CMS SOM App. Z, Tag E-0034

§460.84(c)(7), §483.73(c)(7), §483.475(c)(7), §484.102(c)(6), §485.68(c)(5),

§485.68(c)(5), §485.727(c)(5), §485.625(c)(7), §485.920(c)(7), §491.12(c)(5),

§494.62(c)(7).

[(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:

(7) [(5) or (6)] A means of providing information about the [facility’s] occupancy,

needs, and its ability to provide assistance, to the authority having jurisdiction, the

Incident Command Center, or designee.

*[For ASCs at 416.54(c)]: (7) A means of providing information about the ASC’s

needs, and its ability to provide assistance, to the authority having jurisdiction, the

Incident Command Center, or designee.

*[For Inpatient Hospice at §418.113(c):] (7) A means of providing information about

the hospice’s inpatient occupancy, needs, and its ability to provide assistance, to the

authority having jurisdiction, the Incident Command Center, or designee.

Interpretive Guidelines applies to: §403.748(c)(7), §416.54(c)(7), §418.113(c)(7),

§441.184(c)(7), §460.84(c)(7), §482.15(c)(7), §483.73(c)(7); §483.475(c)(7);

§484.102(c)(6); §485.68(c)(5), §485.625(c)(7); §485.727(c)(5); §485.920(c)(7);

§491.12 (c)(5), §494.62(c)(7).

NOTE: This does not apply to outpatient hospices or Transplant Programs.

Facilities, except for transplant programs, must have a means of providing information

about the facility’s needs and its ability to provide assistance to the authority having

jurisdiction (local and State emergency management agencies, local and state public

health departments, the Incident Command Center, the Emergency Operations Center, or

designee).

Reporting of a Facility’s Needs

Generally, in small community emergency disasters, reporting the facility’s needs will be

coordinated through developed processes to report directly to local and state emergency

officials. Reporting needs may include but are not limited to: shortages in PPE; need to

evacuate or transfer patients; requests for assistance in transport; temporarily loss of

part or all facility function; and, staffing shortages.

In large scale emergency disasters or pandemics, reporting of needs specific to a facility

may be altered by local, state and federal public health and emergency management

officials due to the potential volume of requests. Some emergency management officials

at all levels of governance may require facilities to report specific data or slow reporting

to manage volume. It is recommended that facilities verify their reporting requirements

with their local Incident Command Structures or State Agencies.

Dependent on the emergency event and the anticipated longevity, facilities may need to

report select criteria such as in an EID outbreak or the number of patients’ positive or

persons under investigation (PUI). The facility’s process should include monitoring by

the facility’s emergency management coordinator or designee of reporting requirements

issued by CMS or other agencies with jurisdiction. Additional monitoring and reporting

may be required by local and state public health agencies due to contact tracing

requirements for extended periods of time or for time specific intervals. Facilities should

identify local and state policies for reporting and contract tracing to ensure they have

appropriate information to address requirements.

Facilities should actively engage with their healthcare coalitions, associations,

accrediting organizations and other stakeholders during the onset of any wide-spread

emergency. As state and federal emergency organizations may become overwhelmed

with requests, these stakeholders may be able to reconcile needs-requests for specific

providers and suppliers. In situations in which a Presidential Declaration and a Public

Health Emergency (PHE) have been declared, and Section 1135 Waivers may be

granted, these stakeholders (healthcare coalitions, associations, accrediting

organizations and others) may have the ability to request and streamline 1135 waiver

requests for their members, dependent on the severity of the emergency.

Reporting of a Facility’s Ability to Provide Assistance

During widespread disasters, reporting a facility’s ability to provide assistance is critical

within a community. Pre-planning and collaborating with emergency officials before an

emergency to determine what assistance may be necessary directly supports surge

planning within a community. For instance, in preparation for a natural disaster such as

a hurricane, pre-planning reporting criteria such as the facility’s response-- e.g. closing

the outpatient services in a forecasted natural disaster-- may facilitate the Incident

Command as they would be aware of the operating status of the facility. Reporting the

ability to provide assistance would also include pre-planning with public health and

emergency officials in the local community to make them aware of what capabilities are

available within the specific facility, e.g. number of beds, critical care equipment,

staffing, etc.

During widespread disasters, facilities may be required to report the following to local

officials:

• Ability to care for patients requiring transfer from different healthcare settings;

• Availability of PPE;

• Availability of staff who may be able to assist in a mass casualty incident;

• Availability of electricity-dependent medical and assistive equipment, such as

ventilators and other oxygen equipment (BiPAP, CPAP, etc.), renal replacement

therapy machines (e.g., home and facility-based hemodialysis, peritoneal

dialysis, continuous renal replacement therapy and other machines, etc.), and

wheelchairs and beds.

Occupancy Reporting

For hospitals, CAHs, RNHCIs, inpatient hospices, PRTFs, LTC facilities, and ICF/IIDs,

they must also have a means for providing information about their occupancy.

Occupancy reporting is considered, but not limited to, reporting the number of patients

currently at the facility receiving treatment and care or the facility’s occupancy

percentage. The facility should consider how its occupancy affects its ability to provide

assistance. For example, if the facility’s occupancy is close to 100% the facility may not

be able to accept patients from nearby facilities. The types of “needs” a facility may have

during an emergency and should communicate to the appropriate authority would include

but is not limited to, shortage of provisions such as food, water, medical supplies,

assistance with evacuation and transfers, etc.

NOTE: The authority having jurisdiction varies by local, state and federal emergency

management structures as well as the type of disaster. For example, in the event of a

multi-state wildfire, the jurisdictional authority who would take over the Incident

Command Center or state-wide coordination of the disaster would likely be a fire-related

agency.

We are not prescribing the means that facilities must use in disseminating the required

information. However, facilities should include in its communication plan, a process to

communicate the required information.

NOTE: As defined by the Federal Emergency Management Administration (FEMA), an

Incident Command System (ICS) is a management system designed to enable effective

and efficient domestic incident management by integrating a combination of facilities,

equipment, personnel, procedures, and communications operating within a common

organizational structure. (FEMA, 2016). The industry, as well as providers/suppliers, use

various terms to refer to the same function and we have used the term ‘‘Incident

Command Center’’ to mean ‘‘Emergency Operations Center’’ or ‘‘Incident Command

Post.’’ Local, State, Tribal and Federal emergency preparedness officials, as well as

regional healthcare coalitions, can assist facilities in the identification of their Incident

Command Centers and reporting requirements dependent on an emergency.

Survey Procedures

• Verify the communication plan includes a means of providing information about the

facility’s needs, and its ability to provide assistance, to the authority having

jurisdiction, the Incident Command Center, or designee by reviewing the

communication plan.

• For hospitals, CAHs, RNHCIs, inpatient hospices, PRTFs, LTC facilities, and

ICF/IIDs, also verify if the communication plan includes a means of providing

information about their occupancy.