CMS SOM App. Z, Tag E-0033

§460.84(c)(4)-(6), §441.184(c)(4)-(6), §460.84(c)(4)-(6), §482.15(c)(4)-(6),

§483.73(c)(4)-(6), §483.475(c)(4)-(6), §484.102(c)(4)-(5), §485.68(c)(4), §485.625(c)(4)-

(6), §485.727(c)(4), §485.920(c)(4)-(6), §491.12(c)(4), §494.62(c)(4)-(6).

[(c) The [facility] must develop and maintain an emergency preparedness

communication plan that complies with Federal, State and local laws and must be

reviewed and updated at least every 2 years [annually for LTC facilities]. The

communication plan must include all of the following:

(4) A method for sharing information and medical documentation for patients

under the [facility's] care, as necessary, with other health providers to maintain the

continuity of care.

(5) A means, in the event of an evacuation, to release patient information as

permitted under 45 CFR 164.510(b)(1)(ii). [This provision is not required for HHAs

under §484.102(c), CORFs under §485.68(c)]

(6) [(4) or (5)]A means of providing information about the general condition and

location of patients under the [facility's] care as permitted under 45 CFR

164.510(b)(4).

*[For RNHCIs at §403.748(c):] (4) A method for sharing information and care

documentation for patients under the RNHCI’s care, as necessary, with care

providers to maintain the continuity of care, based on the written election statement

made by the patient or his or her legal representative.

*[For RHCs/FQHCs at §491.12(c):] (4) A means of providing information about the

general condition and location of patients under the facility’s care as permitted

under 45 CFR 164.510(b)(4).

Interpretive Guidelines applies to: §403.748(c)(4)-(6), §416.54(c)(4)-(6),

§418.113(c)(4)-(6), §441.184(c)(4)-(6), §460.84(c)(4)-(6), §482.15(c)(4)-(6),

§441.184(c)(4)-(6), §460.84(c)(4)-(6), §483.73(c)(4)-(6), §483.475(c)(4)-(6),

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

(6), §491.12(c)(4), §494.62(c)(4)-(6).

NOTE: For RHCs/FQHC’s the regulatory language differs under (c)(4).

Additionally, a method for sharing information and medical documentation for

patients under the RHC/FQHC’s care, as necessary, with other health providers to

maintain the continuity of care and a means of providing information about the

general condition and location of patients does not apply.

NOTE: This does not apply to Transplant Programs.

Facilities are required to develop a method for sharing information and medical (or for

RNHCIs only, care) documentation for patients under the facility's care, as necessary,

with other health care providers to maintain continuity of care. Such a system must

ensure that information necessary to provide patient care is sent with an evacuated patient

to the next care provider and would also be readily available for patients being sheltered

in place. While the regulation does not specify timelines for delivering patient care

information, facilities are expected to provide patient care information to receiving

facilities during an evacuation, within a timeframe that allows for effective patient

treatment and continuity of care. Facilities should not delay patient transfers during an

emergency to assemble all patient reports, tests, etc. to send with the patient. Facilities

should send all necessary patient information that is readily available and should include

at least, patient name, age, DOB, allergies, current medications, medical diagnoses,

current reason for admission (if inpatient), blood type, advance directives and next of

kin/emergency contacts. There is no specified means (such as paper or electronic) for

how facilities are to share the required information.

Facilities (with the exception of HHAs, RHCs/FQHCs, and CORFs) are also required to

have a means, in the event of an evacuation, to release patient information as permitted

under 45 CFR 164.510 and a means of providing information about the general condition

and location of patients under the facility's care as permitted under 45 CFR

164.510(b)(4). Thus, facilities must have a communication system in place capable of

generating timely, accurate information that could be disseminated, as permitted under 45

CFR 164.510(b)(4), to family members and others. Facilities have the flexibility to

develop and maintain their own system in a manner that best meets its needs.

HIPAA requirements are not suspended during a national or public health emergency.

However, the HIPAA Privacy Rule specifically permits certain uses and disclosures of

protected health information in emergency circumstances and for disaster relief purposes.

Section 164.510 ‘‘Uses and disclosures requiring an opportunity for the individual to

agree to or to object,’’ is part of the ‘‘Standards for Privacy of Individually Identifiable

Health Information,’’ commonly known as ‘‘The Privacy Rule.’’ HIPAA Privacy

Regulations at 45 CFR 164.510(b)(4), ‘‘Use and disclosures for disaster relief purposes,’’

establishes requirements for disclosing patient information to a public or private entity

authorized by law or by its charter to assist in disaster relief efforts for purposes of

notifying family members, personal representatives, or certain others of the patient’s

location or general condition.

Survey Procedures

• Verify the communication plan includes a method for sharing information and

medical (or for RNHCIs only, care) documentation for patients under the facility's

care, as necessary, with other health (or care for RNHCIs) providers to maintain the

continuity of care by reviewing the communication plan.

o For RNCHIs, verify that the method for sharing patient information is based on a

requirement for the written election statement made by the patient or his or her

legal representative.

• Verify the facility has developed policies and procedures that address the means the

facility will use to release patient information to include the general condition and

location of patients, by reviewing the communication plan.