CMS SOM App. Z, Tag E-0019

[(b) Policies and procedures. The [facilities] must develop and implement

emergency preparedness policies and procedures, based on the emergency plan set

forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this

section, and the communication plan at paragraph (c) of this section. The policies

and procedures must be reviewed and updated at least every 2 years. At a

minimum, the policies and procedures must address the following:]

*[For homebound Hospice at §418.113(b)(2), PACE at §460.84(b)(4), and HHAs at

§484.102(b)(2):] The procedures to inform State and local emergency preparedness

officials about [homebound Hospice, PACE or HHA] patients in need of evacuation

from their residences at any time due to an emergency situation based on the

patient’s medical and psychiatric condition and home environment.

Interpretive Guidelines applies to: §418.113(b)(2), §460.84(b)(4), §484.102(b)(2).

NOTE: The regulatory language for hospices under §418.113(b)(2) does not include

the terms “emergency preparedness” when describing officials.

NOTE: This only applies to homebound Hospice, PACE and HHAs.

Home bound hospices, HHAs and PACE organizations are required to inform State and

local emergency preparedness officials of the need for patient evacuations. These

policies and procedures must address when and how this information is communicated to

emergency officials and also include the clinical care needed for these patients. For

instance, in the event an in-home hospice, PACE organization or HHA patient requires

evacuation, the responsible agency should provide emergency officials with the

appropriate information to facilitate the patient’s evacuation and transportation. This

should include, but is not limited to, the following:

• Whether or not the patient is mobile.

• What type of life-saving equipment does the patient require?

• Is the life-saving equipment able to be transported? (E.g., Battery operated,

transportable, condition of equipment, etc.)

• Does the patient have special needs? (E.g., electricity-dependent, communication

challenges, language barriers, intellectual disabilities, special dietary needs, etc.)

• Is the patient a person under investigation (PUI), suspected exposure to or a

confirmed case for any communicable diseases?

Since such policies and procedures include protected health information of patients,

facilities must also ensure they are in compliance with, as applicable, the Health

Insurance Portability and Accountability Act (HIPAA) Rules at 45 CFR parts 160 and

164, as appropriate. See (81 FR 63879, Sept. 16, 2016).

A level of pre-coordination activity with state and local emergency officials may be

needed. Facilities should work with their state and local officials to determine how to

coordinate the reporting of staff or patients who cannot be contacted. Emergency

officials may include but are not limited to, emergency management

departments/agencies (such as local FEMA or ASPR representatives), the state health

department, CMS State Survey Agency or local response public emergency officials.

(For additional information, please see standard (c)(2) [Tag E-0031] under the

Communications Plan).

Facilities should also account for contingency planning in the event that some staff are

unaccounted for and how this relates to providing patient care.

Finally, a facility’s policies and procedures should also outline a contingency plan in the

event patients require evacuation but are unable to be transferred due to a community-wide impacted emergency. See also, tag E-0022 for policy and procedure requirements

addressing shelter in place.

Survey Procedures

• Review the emergency plan to verify it includes procedures to inform State and local

emergency preparedness officials about patients in need of evacuation from their

residences at any time due to an emergency situation based on the patient’s medical

and psychiatric condition and home environment.