CMS SOM App. Z, Tag E-0020

§482.15(b)(3), §483.73(b)(3), §483.475(b)(3), §485.68(b)(1), §485.625(b)(3),

§485.727(b)(1), §485.920(b)(2), §491.12(b)(1), §494.62(b)(2)

[(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 [annually for

LTC facilities]. At a minimum, the policies and procedures must address the

following:]

[(3) or (1), (2), (6)] Safe evacuation from the [facility], which includes consideration

of care and treatment needs of evacuees; staff responsibilities; transportation;

identification of evacuation location(s); and primary and alternate means of

communication with external sources of assistance.

*[For RNHCIs at §403.748(b)(3) and ASCs at §416.54(b)(2):]

Safe evacuation from the [RNHCI or ASC] which includes the following:

(i) Consideration of care needs of evacuees.

(ii) Staff responsibilities.

(iii) Transportation.

(iv) Identification of evacuation location(s).

(v) Primary and alternate means of communication with external sources of

assistance.

* [For CORFs at §485.68(b)(1), Clinics, Rehabilitation Agencies, OPT/Speech at

§485.727(b)(1), and ESRD Facilities at §494.62(b)(2):]

Safe evacuation from the [CORF; Clinics, Rehabilitation Agencies, and Public

Health Agencies as Providers of Outpatient Physical Therapy and Speech-Language

Pathology Services; and ESRD Facilities], which includes staff responsibilities, and

needs of the patients.

* [For RHCs/FQHCs at §491.12(b)(1):] Safe evacuation from the RHC/FQHC, which

includes appropriate placement of exit signs; staff responsibilities and needs of the

patients.

Interpretive Guidelines applies to: §403.748(b)(3), §416.54(b)(2), §418.113(b)(6)(ii),

§441.184(b)(3), §460.84(b)(3), §482.15(b)(3), §483.73(b)(3), §483.475(b)(3),

§485.68(b)(1), §485.625(b)(3), §485.727(b)(1), §485.920(b)(2), §491.12(b)(1),

§494.62(b)(2)

NOTE: This does not apply to HHAs, OPOs, and Transplant Programs.

NOTE: The requirements under §418.113(b)(6)(ii) is not a requirement for

outpatient hospice providers.

Evacuations & Patient Population Considerations

Facilities must develop policies and procedures that provide for the safe evacuation of

patients from the facility and include all of the requirements of this standard. RHCs and

FQHCs must also place exit signs to guide patients and staff in the event of an evacuation

from the facility.

Facilities must have policies and procedures which address the needs of evacuees. The

facility should also consider in development of the policies and procedures, the

evacuation protocols for not only the evacuees, but also staff members and

families/patient representatives or other personnel who sought potential refuge at the

facility. Additionally, the policies and procedures must address staff responsibilities

during evacuations. Facilities must consider the patient population needs as well as their

care and treatment. For example, if an evacuation is in progress and the facility must

evacuate, leadership should consider the needs for critically ill patients to be evacuated

and accompanied by staff who could provide care and treatment enroute to the designated

relocation site, in the event trained medical professionals are unavailable by the

transportation services.

Facilities must consider in their development of policies and procedures, the needs of

their patient population and what designated transportation services would be most

appropriate. For instance, if a facility primarily cares for critically ill patients with

ventilation needs and life-saving equipment, the transportation services should be able to

assist in evacuation of this special population and be equipped to do so. Additionally,

facilities may also find it prudent to consider alternative methods for evacuation and

patient care and treatment, such as mentioned above to have staff members evacuate with

patients in given situations.

Triaging Considerations

Additionally, facilities should consider their triaging system when coordinating the

tracking and potential evacuation of patient/residents/clients. For instance, a triaging

system for evacuation may consider the most critical patients first followed by those less

critical and not dependent on life-saving equipment. Considerations for prioritization

may be based on, among other things, acuity, mobility status (stretch-

bound/wheelchair/ambulatory), and location of the unit, availability of a known transfer

destination or some combination thereof. Included within this system should be who

(specifically) will be tasked with making triage decisions.

Following the triaging system, staff should consider the communication of patient care

requirements to the in-taking facility, such as attaching a hard copy of a standard

abbreviated patient health condition/history, injuries, allergies, and treatment rendered.

Another method for communicating this information, a facility could consider color

coordination of triage levels (i.e. green folder with this information is for less critical

patients; red folders for critical and urgent evacuated patients, etc.). Additionally, this

hard copy could include family member/representative contact information.

This standard requires facilities to have policies and procedures which address safe

evacuation from the facility. It would be prudent for facilities to consider how they would

addresses a situation where a patient/resident refuses to evacuate and how they would

handle the situation. In most cases, any reasonable person would likely choose to

evacuate if ordered by the state/local community or if necessary as determined by the

facility in a facility-specific event. It is expected that facilities provide care in a safe

setting, therefore any existing guidance on patient rights and safe setting (e.g.

§482.13(c)(2) for hospitals) should be continued. Patient safety should be the number

one priority, therefore leaving a patient in an unsafe environment is not acceptable.

The facilities policies and procedures must outline primary and alternate means for

communication with external sources for assistance. For instance, primary methods may

be via regular telephone services to contact transportation companies for evacuation or

reporting evacuation needs to emergency officials; whereas alternate means account for

loss of power or telephone services in the local area. In this event, alternate means may

include satellite phones for contacting evacuation assistance.

Triage and coordination of evacuation requires planning and communication of plans

within the facility and with entities that assist in providing services such as

transportation and life-saving equipment.

Survey Procedures

• Review the emergency plan to verify it includes policies and procedures for safe

evacuation from the facility and that it includes all of the required elements.

• When surveying an RHC or FQHC, verify that exit signs are placed in the appropriate

locations to facilitate a safe evacuation.

• Ask staff to describe how they would handle a situation in which a patient refused to

evacuate.