CMS SOM App. Z, Tag E-0025

§483.73(b)(7), §483.475(b)(7), §485.625(b)(7), §485.920(b)(6), §494.62(b)(6).

[(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:]

*[For Hospices at §418.113(b),

PRFTs at §441.184,(b) Hospitals at §482.15(b), and LTC

Facilities at §483.73(b):] Policies and procedures. (7) [or (5)] The development of

arrangements with other [facilities] [and] other providers to receive patients in the

event of limitations or cessation of operations to maintain the continuity of services

to facility patients.

*[For PACE at §460.84(b), ICF/IIDs at §483.475(b), CAHs at §486.625(b), CMHCs at

§485.920(b) and ESRD Facilities at §494.62(b):] Policies and procedures. (7) [or (6),

(8)] The development of arrangements with other [facilities] [or] other providers to

receive patients in the event of limitations or cessation of operations to maintain the

continuity of services to facility patients.

*[For RNHCIs at §403.748(b):] Policies and procedures. (7) The development of

arrangements with other RNHCIs and other providers to receive patients in the

event of limitations or cessation of operations to maintain the continuity of non-medical services to RNHCI patients.

Interpretive Guidelines applies to: §403.748(b)(7), §418.113(b)(5), §441.184(b)(7),

§460.84(b)(8), §482.15(b)(7), §483.73(b)(7), §483.475(b)(7), §485.625(b)(7),

§485.920(b)(6), §494.62(b)(6).

NOTE: The differences for some providers and suppliers between “and” and “or”

are referenced above. Additionally, the there are differences between continuity of

“operations” and “services” within the regulatory language.

NOTE: This does not apply to ASCs, Transplant Programs, HHAs, CORFs, Clinics,

Rehabilitation Agencies and Public Health Agencies as Providers of Outpatient

Physical Therapy and Speech-Language Pathology Services, OPOs, RHCs/FQHCs.

Facilities are required to have policies and procedures which include prearranged transfer

agreements, which may include written agreements or contracted arrangements with

other facilities and other providers to receive patients in the event of limitations or

cessation of operations to maintain the continuity of services to facility patients.

Facilities should consider all needed arrangements for the transfer of patients during an

evacuation. For example, if a CAH is required to evacuate, policies and procedures

should address what facilities are nearby and outside the area of disaster which could

accept the CAH’s patients. Additionally, the policies and procedures and facility

agreements should include pre-arranged agreements for transportation between the

facilities. The arrangements should be in writing, such as Memorandums of

Understanding (MOUs) and Transfer Agreements, in order to demonstrate compliance.

When developing transfer agreements, facilities should take into account the patient

population and the ability for the receiving facility to provide continuity of services. If a

facility has a transfer arrangement with another facility and this facility could not

accommodate all patients, then the facility should plan accordingly to provide continuity

of services with another facility who could receive the remaining residents. For ICFs/IID

and LTC facilities, the facility is also responsible for the tracking of residents, therefore

any written arrangements should account for the patient population, number of patients

and the ability for the receiving facility or facilities to continue care to the

residents/patients.

Finally, as the regulation requires policies and procedures to be reviewed every 2 years

(annually for LTC), facilities should also consider reviewing their developed

arrangements on the same scheduled review timeframe to ensure the

contract/agreement/MOU is still applicable and able to be fulfilled to provide continuity

of care.

For RNHCIs, at § 403.748(b)(7), the term “non-medical” is added in order to

accommodate the uniqueness of the RNHCI non-medical care.

Survey Procedures

• Ask to see copies of the arrangements and/or any agreements the facility has with

other facilities to receive patients in the event the facility is not able to care for them

during an emergency.

• Ask facility leadership to explain the arrangements in place for transportation in the

event of an evacuation.