CMS SOM App. Z, Tag E-0021

[(b) Policies and procedures. The HHA 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:]

(3) The procedures to follow up with on-duty staff and patients to determine

services that are needed, in the event that there is an interruption in services during

or due to an emergency. The HHA must inform State and local officials of any on-duty staff or patients that they are unable to contact.

Interpretive Guidelines for §484.102(b)(3).

HHAs must include in its emergency plan, procedures required of this standard.

During an emergency, if a patient requires care that is beyond the capabilities of the

HHA, there is an expectation that care of the patient would be rearranged or suspended

for a period of time, as most HHAs in general would not necessarily transfer patients to

other HHAs during an emergency.

HHAs policies and procedures should clearly outline what surrounding facilities, such as

a hospital or a nursing home, it has a transfer arrangement with to ensure patient care is

continued. Additionally, these policies and procedures should outline timelines for

transferring patients and under what conditions patients would need to move. For

instance, if the emergency is anticipated to have one or two days of disruption and does

not pose an immediate threat to patient health or safety (in which then the HHA should

immediately transfer the patient); the HHA may rearrange services, whereas if a disaster

is anticipated to last over one week or more, the HHA may need to initiate transfer of a

patient as soon as possible. The policies and procedures should address these events.

Additionally, the HHAs’ policies and procedures must address what actions would be

required due to the inability to make contact with staff or patients and reporting

capabilities to the local and State emergency officials.

Since HHAs must inform local and state officials of any on-duty staff or patients that they

are unable to contact, the policies and procedures should align with the facility’s

communication plans outlined under §418.113(c). These policies and procedures should

outline the timeframes for check-in with the facility’s designated individual (e.g. staff

check-in’s every 2 or 4 hours while on shift, and every 8 while off-duty).

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

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

coordinate the reporting of staff or patients who cannot be contacted. HHAs should also

accordingly account for contingency planning in the event that some staff are

unaccounted for and how this relates to providing patient care.

Survey Procedures

• Verify that the HHA has included in its emergency plan procedures to follow-up with

staff and patients and to inform state and local authorities when they are unable to

contact any of them.

• Verify that the HHA has procedures in its emergency plan to follow up with on‐duty

staff and patients to determine the services that are needed, in the event that there is

an interruption in services during or due to an emergency.

• Ask the HHA to describe the mechanism to inform State and local officials of any on‐

duty staff or patients that they are unable to contact.