CMS SOM App. Z, Tag E-0024

§482.15(b)(6), §483.73(b)(6), §483.475(b)(6), §484.102(b)(5), §485.68(b)(4),

§485.625(b)(6), §485.727(b)(4), §485.920(b)(5), §491.12(b)(4), §494.62(b)(5).

[(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:]

(6) [or (4), (5), or (7) as noted above] The use of volunteers in an emergency or other

emergency staffing strategies, including the process and role for integration of State

and Federally designated health care professionals to address surge needs during an

emergency.

*[For RNHCIs at §403.748(b):] Policies and procedures. (6) The use of volunteers in

an emergency and other emergency staffing strategies to address surge needs during

an emergency.

*[For Hospice at §418.113(b):] Policies and procedures. (4) The use of hospice

employees in an emergency and other emergency staffing strategies, including the

process and role for integration of State and Federally designated health care

professionals to address surge needs during an emergency.

Interpretive Guidelines applies to: §403.748(b)(6), §416.54(b)(5), §418.113(b)(4),

§441.184(b)(6), §460.84(b)(7), §482.15(b)(6), §483.73(b)(6), §483.475(b)(6),

§484.102(b)(5), §485.68(b)(4), §485.625(b)(6), §485.727(b)(4), §485.920(b)(5),

§491.12(b)(4), §494.62(b)(5).

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

Surge Planning

Emergencies, whether natural disasters, man-made disasters or infectious disease

outbreaks, stress our healthcare systems through challenges with capacity and capability.

While it is not possible to predict every scenario which could result in surge situations,

healthcare facilities must have policies and procedures which include emergency staffing

strategies and plan for emergencies. These strategies encompass procedures to preserve

the healthcare system while continuing to provide care for all patients, at the appropriate

level (e.g., home-based care, outpatient, urgent care, emergency room, or

hospitalization).

Facilities must have policies which address their ability to respond to a surge in patients

requiring care. As required, these policies and procedures must be aligned with a

facility’s risk assessment, and should include planning for EIDs. Concentrated efforts

will be required to mobilize all aspects of the healthcare system to reduce transmission of

disease, direct people to the right level of care, and decrease the burden on the

healthcare system.

Surge Planning During Natural Disasters

In most circumstances, staffing strategies and surge planning surrounding natural

disasters such as hurricanes are generally event specific and focus on evacuations,

transfers, and staffing assistance from areas which are not impacted by the emergency.

For instance, in response to Hurricane Sandy and Hurricane Katrina, while these events

were considered large-scale natural disasters, assistance was more accessible in relation

to staffing assistance, response assistance from local, state and federal partners as well

as management of supplies.

Surge Planning for Infectious Diseases/Pandemics

Infectious diseases by nature may rise to the level of pandemic, causing severe impact on

response and staffing strategies within the healthcare system. The primary goals in

planning for infectious disease pandemics are to:

• Reduce morbidity and mortality

• Minimize disease transmission

• Protect healthcare personnel

• Preserve healthcare system functioning

Surge Planning Considerations

Facilities are encouraged to consider development of policies and procedures that could

be implemented during an emergency to reduce non-essential healthcare visits and slow

surge within the facility, such as:

• Instructing patients to use available advice lines, patient portals, and/or on-line

self-assessment tools;

• Call options to speak to an office/clinic staff and identification of staff to conduct

telephonic interactions with patients;

• Development of protocols so that staff can triage and assess patients quickly;

• Determine algorithms to identify which patients can be managed by telephone

and advised to stay home, and which patients will need to be sent for emergency

care or come to your facility.

NOTE: Facilities are required to have a risk assessment in accordance with E-0004,

however we recommend that facilities also consider implications or evaluation of staffing

needs. For instance, if a facility identifies a particular hazard, the facility should

consider what staffing needs are required to ensure patients continue to receive care.

Volunteers- Medical and Non-Medical

During an emergency, a facility may also need to accept volunteer support from

individuals with varying levels of skills and training. The facility must have policies and

procedures in place to facilitate this support. In order for volunteering healthcare

professionals to be able to perform services within their scope of practice and training,

facilities must include any necessary privileging and credentialing processes in its

emergency preparedness plan policies and procedures. Non-medical volunteers would

perform non-medical tasks. Facilities have flexibility in determining how best to utilize

volunteers during an emergency as long as such utilization is in accordance with State

law, State scope of practice rules, and facility policy. These may also include federally

designated health care professionals, such as Public Health Service (PHS) staff, National

Disaster Medical System (NDMS) medical teams, Department of Defense (DOD) Nurse

Corps, Medical Reserve Corps (MRC), or personnel such as those identified in federally

designated Health Professional Shortage Areas (HPSAs) to include licensed primary care

medical, dental, and mental/behavioral health professionals. Facilities are also

encouraged to collaborate with State-established volunteer registries, and where possible,

State-based Emergency System for Advanced Registration of Volunteer Health

Professionals (ESAR-VHP).

Facilities are expected to include in its emergency plan a method for contacting off-duty

staff during an emergency and procedures to address other contingencies in the event

staff are not able to report to duty which may include, but are not limited to, utilizing

staff from other facilities and state or federally-designated health professionals.

We would recommend that facilities include policies and procedures on the use of

volunteers including if a facility chooses not to use volunteers, however at a minimum,

the facility must have policies and procedures which address emergency staffing

strategies. Providers and suppliers should have policies and guidelines for sheltering

volunteers and any State and Federally designated health care professionals to address

surge needs during an emergency. Facilities must determine their policies based on the

emergency and the types of volunteers that may be present during and after an

emergency (81 FR at 63881).

Resources

Facilities are recommended to review the tools available related to planning for surge.

ASPR TRACIE has developed multiple documents which could provide additional

assistance during the development of policies and procedures, which include but are not

limited to

https://asprtracie.s3.amazonaws.com/documents/aspr-tracie-considerations-

for-the-use-of-temporary-care-locations-for-managing-seasonal-patient-surge.pdf

Survey Procedures

• Ask facility leadership to explain their staffing strategies. Do they use volunteers? Do

they have other emergency staffing strategies, if no volunteers are used?

• Verify the facility has included policies and procedures for the use of volunteers and

other emergency staffing strategies in its emergency plan.

• Verify that the facility’s program includes a policy and procedure which addresses

surge needs during an emergency.