Ray Miller 432018

Direct Supply 1

1

CMS EP Regulation

What Have We learned

All Hazards Approach Facility and Community-Based Risk Assessment

Ray Miller

2 copy 2017 Direct Supply Inc all rights reserved

The materials comments and other information contained in

this presentation are intended to provide general information

but not advice about certain regulations and initiatives

This information is not and not intended as legal or other

advice and each situation may vary depending on the

particular facts and circumstances

You should not act upon this information without first

consulting with qualified legal counsel Thank you

Disclaimer

7

Agenda ndash National EP Rule

Concepts 1

Core Components 2

From Your PEERS 3

Questions and Your Answers 4

Waivers Subsistence Volunteers

5

6

For questions regarding EP Rule SCGEmergencyPrepcmshhsgov

ldquoAll Hazards Risk Assessmentrdquo

Ray Miller 432018

Direct Supply 2

12

1 Identification AHRA

2 Preparation Analyze amp

Address facility info amp

capabilities and AHRA

findings + Training

Testing Staff (EP roles)

Residents testing the

plan + MLM

3 Mitigation Eliminate

reduce probability amp

severity Part of Prep amp

Response

4 Response and

Continuity Pre-

During After Event +

Address immediate and

short-term effects

5 Recovery Actions amp

Activities to return the

facility to its ldquoUsual

Staterdquo or a ldquoNew

Normal

R + S + F

Six Steps of Disaster Planning

Ray Miller 432018

Direct Supply 3

EP Module 2 Lesson 1 Topic 3

Patient Population and Collaboration

It is important to note that the new EP requirements focus

on continuity of operations NOT recovery of operations

Facilities can choose to include recovery planning in their

EP plan but CMS does not require recovery of operation

planning as part of this standard

httpssurveyortrainingcmshhsgovpubsEPlayeraspxcid=0CMSEmPrep_ONLampsid=4ffb83eb-ce51-e711-9524-0e63451df8f4ampsv=1amppid=76

Continuity Not Recovery

Agenda ndash National EP Rule

Concepts 1

Core Components 2

3

Questions and Your Answers 4

Waivers Subsistence Volunteers

5

6

For questions regarding EP Rule SCGEmergencyPrepcmshhsgov

ldquoAll Hazards Risk Assessmentrdquo

From Your PEERS

18

sect 48373 Emergency Preparedness

Requirements for LTC Facilities

The EP program must include but not be limited to the

following elements

1 Risk Assessment amp Emergency plan

2 Policies and procedures

3 Communication plan

4 Training and testing

5 Emergency and standby power systems

6 Integrated healthcare systems

4 Core Elements

httpswwwcmsgovMedicareProvider-Enrollment-and-CertificationSurveyCertEmergPrepCore-EP-Rule-Elementshtml

Ray Miller 432018

Direct Supply 3

EP Module 2 Lesson 1 Topic 3

Patient Population and Collaboration

It is important to note that the new EP requirements focus

on continuity of operations NOT recovery of operations

Facilities can choose to include recovery planning in their

EP plan but CMS does not require recovery of operation

planning as part of this standard

httpssurveyortrainingcmshhsgovpubsEPlayeraspxcid=0CMSEmPrep_ONLampsid=4ffb83eb-ce51-e711-9524-0e63451df8f4ampsv=1amppid=76

Continuity Not Recovery

Agenda ndash National EP Rule

Concepts 1

Core Components 2

3

Questions and Your Answers 4

Waivers Subsistence Volunteers

5

6

For questions regarding EP Rule SCGEmergencyPrepcmshhsgov

ldquoAll Hazards Risk Assessmentrdquo

From Your PEERS

18

sect 48373 Emergency Preparedness

Requirements for LTC Facilities

The EP program must include but not be limited to the

following elements

1 Risk Assessment amp Emergency plan

2 Policies and procedures

3 Communication plan

4 Training and testing

5 Emergency and standby power systems

6 Integrated healthcare systems

4 Core Elements

httpswwwcmsgovMedicareProvider-Enrollment-and-CertificationSurveyCertEmergPrepCore-EP-Rule-Elementshtml

Ray Miller 432018

Direct Supply 4

20

1 Written Comprehensive Emergency Plan

Comprehensive Integrated EP approach 1] Identifydocument

hazards impacts gaps (residents facility community geographical region)

2] Develop EP capacities and capabilities to address gaps and

challenges and emergencies or disasters

Natural man-made or facility emergencies 1] care-related

2] equipment power 3] communications (eg cyber-attacks)

4] essential supply interruptions (water and food)

5] total partial facility loss

E-Tags 0004 0006 0007 0009

ldquoFacilities must develop an all-hazards EP program and planrdquo

(1) HVA (2) Related Strategies (3) 247 Resident Needs (4) AHJ Collaboration

22

2 Specific Policies and Procedures

1 Subsistence Needs

2 Supplies

3 Alternate Energy Sources (temps lighting fire detection sewagedisposal)

4 Sewage and waste disposal

5 Resident Staff Tracking

6 Safe Evacuation

E-Tags 0016 0018 0020 0022 0022 0023 0024 0025 0026

ldquoFacilities must develop and implement EP PampP based on hellip EP Plan HVA CP

hellipldquoRampU ALArdquo and at a minimum must addresshelliprdquo

SIDEBAR CMS Differentiates

1 POLICIES formal method course of action to be adhered to

2 PROCEDURES actions needed to implement policies to meet regulations

3 OPERATING GUIDELINES checklists etc that are an integral PART of PampPs

7 Shelter-In-Place

8 Medical Documentation System (Secure available)

9 Surge Events Strategies

10Receiving Facility Arrangements

111135 Facility Waiver Role

ALSO Collaboration

23

3 Defined Communication Plan (1 of 4)

(1amp2) Names and contact information (people partners)

(3) Primary and alternate means for communicating

(4) Method to share necessary resident info and documents

(5) Means to release allowable resident info due to evacuation

(6) Means to provide info regarding resident condition and location info

(7) Means to provide info regarding (occupancy needs ability to assist) to AHJICCDesignee

(8) Method for sharing appropriate EP info with residents families and representatives

E-Tags 0029 0030 0031 0032 0033 0034 0035

The [facility] must develop maintain an EP communication plan hellip

complies with F S L laws hellip RampU ALA and must include hellip

Survey Procedures

1 Ask to reviewhellip

2 Ask to see evidencehellip

3 Ask staff to demonstratehellip

4 Interview Residents Familieshellip

5 Verify the communication plan includeshellip

Ray Miller 432018

Direct Supply 5

24

3 Defined Communication Plan (2 of 4)

Coordination of Resident Care (within facility across healthcare providers w

statelocal public HDs EM agencies systems) Facilities are required to

1 Develop method to share timely information and medical

documentation to maintain continuity of care

2 Ensure that all necessary patient information is readily

available (evacuated or SIP) and 2] sent WITH evacuated patient

(AT LEAST name age DOB allergies current medrsquos diagnoses reason for

admission blood type advance directives next of kinemergency contacts

means NOT specified)

E-Tags 0029 0030 0031 0032 0033 0034 0035

25

3 Defined Communication Plan (3 of 4)

1 Primary and alternate emergency communication system (with staff Federal State tribal regional and local EM agencies)

2 ldquoFacilities have discretionrdquo (EXPECTED CONSIDERATION pagers

cellular satellite phones walkie-talkies NOAA Weather radiohellip)

3 Emerg Comrsquos systems (availability capability compatibility affordability)

Wireless Priority Service (WPS)

SHAred RESources (SHARES) HF Radio

National Communication System (NCS)

Telecommunications Service Priority (TSP) Program

Govrsquot Emergency Telecommunications Services (GETS)

Amateur (HAM) Radio amp ldquoRadio Amateur Civil Emergency Servicesrdquo (RACES)

E-Tags 0029 0030 0031 0032 0033 0034 0035

26

3 Defined Communication Plan (4 of 4)

NOTE 1 ldquoWe are allowing facilities flexibility in how

they formulate and operationalize the requirements of

the communication planrdquo

NOTE 2 Facilities utilizing electronic data storage hellip

provide evidence of data back-up with hard copies

and the capability to reproduce or access data during

emergencies hellip RUALA

E-Tags 0029 0030 0031 0032 0033 0034 0035

Ray Miller 432018

Direct Supply 6

27

4 Training and Testing (1 of 4)

1 Training

I Initial PampP training hellip new existing

staff ldquocontractedrdquo individuals

volunteers roles-based

II ALA

III Documented

IV Demonstrated knowledge (SKILLS)

(ldquoCompetency-based Carerdquo)

E-Tags 0036 0037 0039

The [facility] must develop maintain an EP TampT program hellip based on

Plan HVA CP hellip RampU ALA and must include hellip

28

4 Training and Testing (2 of 4)

2 Testing hellip The LTC facility must do all of the following

i Community-based full scale exercise OR (when not accessible)

a Facility-based OR Actual natural man-made

emergency that requires activation (exempt for 1 year)

AND

E-Tags 0036 0037 0039

29

4 Training and Testing (3 of 4)

2 Testing hellip The LTC facility must do all of the following

ii Additional exercise hellip not limited to

A 2nd full-scale exercise (community or individual based)

OR

B (B) Tabletop exercise (that includes discussion facilitator

narrated clinically-relevant emergency scenario problem statements

directed messages or challenging questions)

iii Analyze facility responses documentation (drills exercises

tabletops actual events) hellip revise EP plan (After Action Report)

E-Tags 0036 0037 0039

The [facility] must develop maintain an EP TampT program hellip based on

Plan HVA CP hellip RampU ALA and must include hellip

(contrsquod)

Ray Miller 432018

Direct Supply 7

32

4 Training and Testing (4 of 4)

1 ldquoDrillrdquo Tests a single function or capability

2 ldquoExerciserdquo Multiple agencies mirrors real event tests EP Plan

3 ldquoCommunity-based hospital exerciserdquo (IF Med Surge Capacity

THEN you must actually establish all components necessary to accept patients)

4 ldquoFacility-based Community-based exerciserdquo (YOU own ldquoITrdquo)

1st Responders + Hospital + Other LTCs communities

DAVE ldquoCMS encourages LTCs to reach out to Coalitions but in

many areas LTCs have VERY LIMITED coalition involvementrdquo

E-Tags 0036 0037 0039

EMAIL From Dave Weidner NJ HCA Sent Wednesday 29 Mar

To Erin Jocelyn Ray Miller Subject ldquoParticipaterdquo vs ldquoPlanrdquo

34

Tabletop Exercises (TTX) (1 of 2)

1 SIMULATION informal reduced-stress discussdecide

2 FOCUSED roles responsibilities procedures

possibilities communications flexibility TEAM

3 INTERACTIVE discussion brainstorming

4 PARTICIPANTS decision makers (who)

DESIGNED TO CHALLENGE AN EMERGENCY PLAN Group discuss

decide + facilitator + narrated clinically-relevant emergency scenario + set

of problem statements + directed messages (ldquoinsertsrdquo) or prepared questions

DISADVANTAGES

1 Can be superficial

2 Difficult to test staff and

system capabilities

3 Tough to simulate staff

and system overload

ADVANTAGES

1 Reality check for the team

2 Good review of plans procedures and policies

3 Modest commitment of time expenses resources

4 Good team building Acquaints key staff with

responsibilities procedures each other Unit 5 The Tabletop Exercise ndash FEMA trainingfemagovis139unit5doc Emergency Management Institute

Agenda ndash National EP Rule

Concepts 1

Core Components 2

From Your PEERS 3

Questions and Your Answers 4

Waivers Subsistence Volunteers

5

6

For questions regarding EP Rule SCGEmergencyPrepcmshhsgov

ldquoAll Hazards Risk Assessmentrdquo

Ray Miller 432018

Direct Supply 5

24

3 Defined Communication Plan (2 of 4)

Coordination of Resident Care (within facility across healthcare providers w

statelocal public HDs EM agencies systems) Facilities are required to

1 Develop method to share timely information and medical

documentation to maintain continuity of care

2 Ensure that all necessary patient information is readily

available (evacuated or SIP) and 2] sent WITH evacuated patient

(AT LEAST name age DOB allergies current medrsquos diagnoses reason for

admission blood type advance directives next of kinemergency contacts

means NOT specified)

E-Tags 0029 0030 0031 0032 0033 0034 0035

25

3 Defined Communication Plan (3 of 4)

1 Primary and alternate emergency communication system (with staff Federal State tribal regional and local EM agencies)

2 ldquoFacilities have discretionrdquo (EXPECTED CONSIDERATION pagers

cellular satellite phones walkie-talkies NOAA Weather radiohellip)

3 Emerg Comrsquos systems (availability capability compatibility affordability)

Wireless Priority Service (WPS)

SHAred RESources (SHARES) HF Radio

National Communication System (NCS)

Telecommunications Service Priority (TSP) Program

Govrsquot Emergency Telecommunications Services (GETS)

Amateur (HAM) Radio amp ldquoRadio Amateur Civil Emergency Servicesrdquo (RACES)

E-Tags 0029 0030 0031 0032 0033 0034 0035

26

3 Defined Communication Plan (4 of 4)

NOTE 1 ldquoWe are allowing facilities flexibility in how

they formulate and operationalize the requirements of

the communication planrdquo

NOTE 2 Facilities utilizing electronic data storage hellip

provide evidence of data back-up with hard copies

and the capability to reproduce or access data during

emergencies hellip RUALA

E-Tags 0029 0030 0031 0032 0033 0034 0035

Ray Miller 432018

Direct Supply 6

27

4 Training and Testing (1 of 4)

1 Training

I Initial PampP training hellip new existing

staff ldquocontractedrdquo individuals

volunteers roles-based

II ALA

III Documented

IV Demonstrated knowledge (SKILLS)

(ldquoCompetency-based Carerdquo)

E-Tags 0036 0037 0039

The [facility] must develop maintain an EP TampT program hellip based on

Plan HVA CP hellip RampU ALA and must include hellip

28

4 Training and Testing (2 of 4)

2 Testing hellip The LTC facility must do all of the following

i Community-based full scale exercise OR (when not accessible)

a Facility-based OR Actual natural man-made

emergency that requires activation (exempt for 1 year)

AND

E-Tags 0036 0037 0039

29

4 Training and Testing (3 of 4)

2 Testing hellip The LTC facility must do all of the following

ii Additional exercise hellip not limited to

A 2nd full-scale exercise (community or individual based)

OR

B (B) Tabletop exercise (that includes discussion facilitator

narrated clinically-relevant emergency scenario problem statements

directed messages or challenging questions)

iii Analyze facility responses documentation (drills exercises

tabletops actual events) hellip revise EP plan (After Action Report)

E-Tags 0036 0037 0039

The [facility] must develop maintain an EP TampT program hellip based on

Plan HVA CP hellip RampU ALA and must include hellip

(contrsquod)

Ray Miller 432018

Direct Supply 7

32

4 Training and Testing (4 of 4)

1 ldquoDrillrdquo Tests a single function or capability

2 ldquoExerciserdquo Multiple agencies mirrors real event tests EP Plan

3 ldquoCommunity-based hospital exerciserdquo (IF Med Surge Capacity

THEN you must actually establish all components necessary to accept patients)

4 ldquoFacility-based Community-based exerciserdquo (YOU own ldquoITrdquo)

1st Responders + Hospital + Other LTCs communities

DAVE ldquoCMS encourages LTCs to reach out to Coalitions but in

many areas LTCs have VERY LIMITED coalition involvementrdquo

E-Tags 0036 0037 0039

EMAIL From Dave Weidner NJ HCA Sent Wednesday 29 Mar

To Erin Jocelyn Ray Miller Subject ldquoParticipaterdquo vs ldquoPlanrdquo

34

Tabletop Exercises (TTX) (1 of 2)

1 SIMULATION informal reduced-stress discussdecide

2 FOCUSED roles responsibilities procedures

possibilities communications flexibility TEAM

3 INTERACTIVE discussion brainstorming

4 PARTICIPANTS decision makers (who)

DESIGNED TO CHALLENGE AN EMERGENCY PLAN Group discuss

decide + facilitator + narrated clinically-relevant emergency scenario + set

of problem statements + directed messages (ldquoinsertsrdquo) or prepared questions

DISADVANTAGES

1 Can be superficial

2 Difficult to test staff and

system capabilities

3 Tough to simulate staff

and system overload

ADVANTAGES

1 Reality check for the team

2 Good review of plans procedures and policies

3 Modest commitment of time expenses resources

4 Good team building Acquaints key staff with

responsibilities procedures each other Unit 5 The Tabletop Exercise ndash FEMA trainingfemagovis139unit5doc Emergency Management Institute

Agenda ndash National EP Rule

Concepts 1

Core Components 2

From Your PEERS 3

Questions and Your Answers 4

Waivers Subsistence Volunteers

5

6

For questions regarding EP Rule SCGEmergencyPrepcmshhsgov

ldquoAll Hazards Risk Assessmentrdquo

Ray Miller 432018

Direct Supply 6

27

4 Training and Testing (1 of 4)

1 Training

I Initial PampP training hellip new existing

staff ldquocontractedrdquo individuals

volunteers roles-based

II ALA

III Documented

IV Demonstrated knowledge (SKILLS)

(ldquoCompetency-based Carerdquo)

E-Tags 0036 0037 0039

The [facility] must develop maintain an EP TampT program hellip based on

Plan HVA CP hellip RampU ALA and must include hellip

28

4 Training and Testing (2 of 4)

2 Testing hellip The LTC facility must do all of the following

i Community-based full scale exercise OR (when not accessible)

a Facility-based OR Actual natural man-made

emergency that requires activation (exempt for 1 year)

AND

E-Tags 0036 0037 0039

29

4 Training and Testing (3 of 4)

2 Testing hellip The LTC facility must do all of the following

ii Additional exercise hellip not limited to

A 2nd full-scale exercise (community or individual based)

OR

B (B) Tabletop exercise (that includes discussion facilitator

narrated clinically-relevant emergency scenario problem statements

directed messages or challenging questions)

iii Analyze facility responses documentation (drills exercises

tabletops actual events) hellip revise EP plan (After Action Report)

E-Tags 0036 0037 0039

The [facility] must develop maintain an EP TampT program hellip based on

Plan HVA CP hellip RampU ALA and must include hellip

(contrsquod)

Ray Miller 432018

Direct Supply 7

32

4 Training and Testing (4 of 4)

1 ldquoDrillrdquo Tests a single function or capability

2 ldquoExerciserdquo Multiple agencies mirrors real event tests EP Plan

3 ldquoCommunity-based hospital exerciserdquo (IF Med Surge Capacity

THEN you must actually establish all components necessary to accept patients)

4 ldquoFacility-based Community-based exerciserdquo (YOU own ldquoITrdquo)

1st Responders + Hospital + Other LTCs communities

DAVE ldquoCMS encourages LTCs to reach out to Coalitions but in

many areas LTCs have VERY LIMITED coalition involvementrdquo

E-Tags 0036 0037 0039

EMAIL From Dave Weidner NJ HCA Sent Wednesday 29 Mar

To Erin Jocelyn Ray Miller Subject ldquoParticipaterdquo vs ldquoPlanrdquo

34

Tabletop Exercises (TTX) (1 of 2)

1 SIMULATION informal reduced-stress discussdecide

2 FOCUSED roles responsibilities procedures

possibilities communications flexibility TEAM

3 INTERACTIVE discussion brainstorming

4 PARTICIPANTS decision makers (who)

DESIGNED TO CHALLENGE AN EMERGENCY PLAN Group discuss

decide + facilitator + narrated clinically-relevant emergency scenario + set

of problem statements + directed messages (ldquoinsertsrdquo) or prepared questions

DISADVANTAGES

1 Can be superficial

2 Difficult to test staff and

system capabilities

3 Tough to simulate staff

and system overload

ADVANTAGES

1 Reality check for the team

2 Good review of plans procedures and policies

3 Modest commitment of time expenses resources

4 Good team building Acquaints key staff with

responsibilities procedures each other Unit 5 The Tabletop Exercise ndash FEMA trainingfemagovis139unit5doc Emergency Management Institute

Agenda ndash National EP Rule

Concepts 1

Core Components 2

From Your PEERS 3

Questions and Your Answers 4

Waivers Subsistence Volunteers

5

6

For questions regarding EP Rule SCGEmergencyPrepcmshhsgov

ldquoAll Hazards Risk Assessmentrdquo

Ray Miller 432018

Direct Supply 7

32

4 Training and Testing (4 of 4)

1 ldquoDrillrdquo Tests a single function or capability

2 ldquoExerciserdquo Multiple agencies mirrors real event tests EP Plan

3 ldquoCommunity-based hospital exerciserdquo (IF Med Surge Capacity

THEN you must actually establish all components necessary to accept patients)

4 ldquoFacility-based Community-based exerciserdquo (YOU own ldquoITrdquo)

1st Responders + Hospital + Other LTCs communities

DAVE ldquoCMS encourages LTCs to reach out to Coalitions but in

many areas LTCs have VERY LIMITED coalition involvementrdquo

E-Tags 0036 0037 0039

EMAIL From Dave Weidner NJ HCA Sent Wednesday 29 Mar

To Erin Jocelyn Ray Miller Subject ldquoParticipaterdquo vs ldquoPlanrdquo

34

Tabletop Exercises (TTX) (1 of 2)

1 SIMULATION informal reduced-stress discussdecide

2 FOCUSED roles responsibilities procedures

possibilities communications flexibility TEAM

3 INTERACTIVE discussion brainstorming

4 PARTICIPANTS decision makers (who)

DESIGNED TO CHALLENGE AN EMERGENCY PLAN Group discuss

decide + facilitator + narrated clinically-relevant emergency scenario + set

of problem statements + directed messages (ldquoinsertsrdquo) or prepared questions

DISADVANTAGES

1 Can be superficial

2 Difficult to test staff and

system capabilities

3 Tough to simulate staff

and system overload

ADVANTAGES

1 Reality check for the team

2 Good review of plans procedures and policies

3 Modest commitment of time expenses resources

4 Good team building Acquaints key staff with

responsibilities procedures each other Unit 5 The Tabletop Exercise ndash FEMA trainingfemagovis139unit5doc Emergency Management Institute

Agenda ndash National EP Rule

Concepts 1

Core Components 2

From Your PEERS 3

Questions and Your Answers 4

Waivers Subsistence Volunteers

5

6

For questions regarding EP Rule SCGEmergencyPrepcmshhsgov

ldquoAll Hazards Risk Assessmentrdquo

Ray Miller 432018

Direct Supply 8

48

What Wersquore Seeing and How Wersquore Preparing

From Elmer Terry [mailtoETerryDVCRcom] Sent Thursday March 29 2018 425 PM To Ray Miller Cc Loren Martin Subject

1 ASSESSMENT FORM

I adapted the ldquoHRArdquo from the CA I modified it

some with respect to the specific hazards I wanted

it simple and relatively quickly

We ranked the top 5 in our HVA policy

So far its fairly well by surveyors

ldquoForum Members I need your helprdquo

50 From Elmer Terry [mailtoETerryDVCRcom] Sent Thursday March 29 2018 425 PM To Ray Miller Cc Loren Martin Subject

2 ELOPEMENT

One surveyor seemed to think ldquoelopementrdquo should

have been higher than we had it rated due to ldquoit is

definitely more likely than othersrdquo

My thought was that yes more likely but wonrsquot

compare to possible life safety property damage or

business continuity with something like tornados

floods hurricanes etc

What Wersquore Seeing and How Wersquore Preparing ldquoForum Members I need your helprdquo

51 From Elmer Terry [mailtoETerryDVCRcom] Sent Thursday March 29 2018 425 PM To Ray Miller Cc Loren Martin Subject

3a SURVEYORS

1 Wide range of perspective with respect to scrutiny of the plan and approach by the surveyors (teaching vs enforcement)

2 One KS surveyor got bent out of shape about the HVA and EOP needing to be more facility specific

3 One thing he brought up was that the HVA had hurricane listed on it and there was no chance of a hurricane in KS

4 The center in question had hurricane rated as a ldquo0rdquo but he still had a problem with it being on the HVA Personally I thought this was a bit picky

What Wersquore Seeing and How Wersquore Preparing ldquoForum Members I need your helprdquo

Ray Miller 432018

Direct Supply 9

52 From Elmer Terry [mailtoETerryDVCRcom] Sent Thursday March 29 2018 425 PM To Ray Miller Cc Loren Martin Subject

3b SURVEYORS

5Common questions from surveyors

a) Did you change your EP plans since the new

requirements went into effect

b) Can I see your plans

6Inconsistencies

a) Nebraska Some surveyors asked to see evidence of

collaboration with local (had to show minutes of the

meeting and sign in sheet)

b) Maine ndash fire marshals are saying they are going easy with

low scopeseverity this year Next year they will increase

to the IJ Level

What Wersquore Seeing and How Wersquore Preparing ldquoForum Members I need your helprdquo

53 From Elmer Terry [mailtoETerryDVCRcom] Sent Thursday March 29 2018 425 PM To Ray Miller Cc Loren Martin Subject

3c SURVEYORS

6 Inconsistencies (contrsquod)

a) Iowa ndash Surveyors

1) Hotcold using a customized corporate template

2) Didnrsquot accept Cell Phone as 2nd communication

and asked for hand held radios (Affordability vs

capabilities)

3) Fire marshal vs health surveyors working E-Tags

4) Most are using the CMS checklist during the

survey

What Wersquore Seeing and How Wersquore Preparing ldquoForum Members I need your helprdquo

54 From Elmer Terry [mailtoETerryDVCRcom] Sent Thursday March 29 2018 425 PM To Ray Miller Cc Loren Martin Subject

4a SURVEY RESULTS

Vetting and Training of Volunteers Surveyors are

all over this and really donrsquot seem to be able to tell you

how to comply Their definition of ldquovolunteerrdquo is much

different than the traditional LTC volunteer

One surveyor in TX asked how we would vet and

provide appropriate training for the volunteer fire

department Another surveyor wanted to know how

we knew that FEMA volunteers or Red Cross

volunteers were qualified and were actually who they

said they were This one is a real pain

What Wersquore Seeing and How Wersquore Preparing ldquoForum Members I need your helprdquo

Ray Miller 432018

Direct Supply 10

55 From Elmer Terry [mailtoETerryDVCRcom] Sent Thursday March 29 2018 425 PM To Ray Miller Cc Loren Martin Subject

4b SURVEY RESULTS

TrainingExercises When it come to surveys this is

our biggest challenge hellip several E-036 E-037 tags

around training

Wersquore developing departmental training templates and

quizzes for all staff volunteers and contractors Wersquoll see

how theyrsquore accepted

Not surprisingly we received several E037 tags around

exercises Exercises will be a big focus for 2018

Some surveyors indicated they are not citing these this

year but will definitely cite it next year if exercises are not

in place

What Wersquore Seeing and How Wersquore Preparing ldquoForum Members I need your helprdquo

56 From Elmer Terry [mailtoETerryDVCRcom] Sent Thursday March 29 2018 425 PM To Ray Miller Cc Loren Martin Subject

4c SURVEY RESULTS

1135 Waiver We received a couple of tags on this I

forgot to add it to our plan I added it no more tags so far

Annual Review Some surveyors have wanted us to have

documentation of an annual review even though we

published our completely revised EOP in the 2nd half of 2017

TOP TAGS (30 of surveyed facilities were cited with E-tags)

E 26 ndash roles waiver

E 15 ndash subsistence needs

E 39 ndash testing requirements

What Wersquore Seeing and How Wersquore Preparing ldquoForum Members I need your helprdquo

57 From Peggy Connorton Sent Thursday March 29 2018 1224 PM To Debra McLain ltDMMclaincovenantretirementorggt Jillian Thomas JLThomascovenantretirementorg

Table Top Exercises We provide 2 table top exercises from

the corporate office each year

After Action Report The centers are mandated to write an

AAR report for each event (incident drill exercise) to document

analyze and identify needed improvements

Surveys Yes IL (2) CT (1) FL (1) -- all have resulted in

zero deficiencies

What Wersquore Seeing and How Wersquore Preparing ldquoForum Members I need your helprdquo

Ray Miller 432018

Direct Supply 11

EP Module 2 Lesson1 Topic 2 Slide 9

Evaluating Potential Interruptions

When evaluating potential SUPPLY interruptions facilities

should consider the likely durations of such interruptions

Utility services ldquoare maintained or re-established during an

emergency should describe

bull The timeframe within which the contractor is required to

initiate services after the start of the emergency

bull How the services will be procured and delivered in the

facilityrsquos local area

bull How the contractor will continue to supply the essential

items throughout and to the end of the emergencies of

varying duration

httpssurveyortrainingcmshhsgovpubsEPlayeraspxcid=0CMSEmPrep_ONLampsid=4ffb83eb-ce51-e711-9524-0e63451df8f4ampsv=1amppid=76

EP Module 2 Lesson1 Topic 2 Slide 10

Survey Procedures EP (General Standard)

When assessing for plan general standard surveyors should

perform the following

bull Ask to see a copy of the facilityrsquos EPP

bull Ask facility leadership to describe potential hazards

identified in the risk assessment including natural man-

made facility-based and geographic emergencies or

disasters and how the facility conducted its risk assessment

bull Verify the emergency preparedness plan contains all the

required elements

bull Verify the facility reviews and updates the plan annually by

checking for documentation of review dates and updates

made to the plan based on the review httpssurveyortrainingcmshhsgovpubsEPlayeraspxcid=0CMSEmPrep_ONLampsid=4ffb83eb-ce51-e711-9524-0e63451df8f4ampsv=1amppid=76

EP Module 2 Lesson1 Topic 3

Survey Procedures Succession Planning

Succession planning is a process for identifying and

developing internal people with the potential to fill key

leadership positions

Through succession planning facilities can increase the

availability of experienced and capable employees prepared

to assume these key roles

At minimum facilities must identify a qualified person

authorized in writing to act in the absence if the administrator

or person legally responsible for the operations of the facility

httpssurveyortrainingcmshhsgovpubsEPlayeraspxcid=0CMSEmPrep_ONLampsid=4ffb83eb-ce51-e711-9524-0e63451df8f4ampsv=1amppid=76

Ray Miller 432018

Direct Supply 12

EP Module 2 Lesson1 Topic 4

Survey Procedures Continuity of Operations

In addition to the facility- and community-based risk

assessments other elements considered in continuity of

operations planning generally include

bull Essential personnel

bull Essential functions and critical resources

bull Vital records and information Technology (IT) data

protection

bull Alternate facility identification and location

bull Financial resources

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EP Module 2 Lesson 1 Topic 3

Survey Procedures Patient Population and Continuity of Operations

When assessing for compliance with the requirements of the

emergency plan standard at part (a) surveyors should

interview leadership and ask them to describe the following

bull The facilityrsquos patient or resident populations that would be

considered at risk during an emergency event

bull Strategies in place to address the needs of at-risk or

vulnerable patient populations

bull Types of services the facility could provide during an

emergency

bull The facilityrsquos plans to continue operation during an

emergency including delegations of authority and

succession plans httpssurveyortrainingcmshhsgovpubsEPlayeraspxcid=0CMSEmPrep_ONLampsid=4ffb83eb-ce51-e711-9524-0e63451df8f4ampsv=1amppid=76

72

Agenda ndash National EP Rule

Concepts 1

Core Components 2

3

Questions and Your Answers 4

Waivers Subsistence Volunteers

5

6

For questions regarding EP Rule SCGEmergencyPrepcmshhsgov

ldquoAll Hazards Risk Assessmentrdquo

From Your PEERS

Ray Miller 432018

Direct Supply 13

Question 1 Is this Compliance or non-compliance

During an survey interview with the DON the surveyor

asked her if a person was designated that would assume her

responsibilities if she is unavailable during an emergency

The DON explained that emergency events are so rare that

the facility decided provided her with a dedicated mobile phone to

ensure that she would be available to manage nursing services at

all times from any location Hence no replacement was necessary

ANSWER The facility EPP is out of compliance The plan

IAW a] the succession planning and b] the delegation of authority

plan standards must designate which staff will assume specific

roles in anotherrsquos absence

In your succession plans which positions

have you delegated authority for

Question 2 True or False

Your EP plan must include a process for

cooperating and collaborating with local tribal

regional state and federal EP officials to

maintain an integrated response during a

disaster or emergency

True

How are you handling ldquocooperating

and collaboratingrdquo in your plan

Question 3 True or False

CMS is silent relative to where you house EP

Preparedness program documents and PampP

False

Where do you store yours

CMS recommends that you house EP

Preparedness program documents and

PampP in a central place to facilitate review

Ray Miller 432018

Direct Supply 14

Question 4 Multiple choice

When assessing for compliance with the general

requirements for the PampP standard surveyors should review

the EP plan to verify that PampPs address and were developed

IAW the risk assessment and _____________________ plan

2Communication

1 Emergency power systems

2 Communication

3 Training and testing

4 Integrated health care

Examples

Question 5 True or False

Community-based risk assessments ensure

that facilities collaborate with other entities

within their community to promote an integrated

response to emergency events

True

What do they mean by ldquocommunity-

based risk assessmentsrdquo

EP Module 2 Lesson1 Topic 2 Slide 13

6Each provider will have its EP regulations incorporated

into its Requirements for Certification

7 An EP plan activation (due to a disaster) exempts the facility

from one full-scale individual-based exercise for that

year The 2nd exercise requirement still applies

8 Surveyor training is available to Providers

Question 6 7 8 Three EP Rule High Lights

httpswwwcmsgovMedicareProvider-Enrollment-and-CertificationSurveyCertEmergPrepEmergency-Prep-Rulehtml

Ray Miller 432018

Direct Supply 14

Question 4 Multiple choice

When assessing for compliance with the general

requirements for the PampP standard surveyors should review

the EP plan to verify that PampPs address and were developed

IAW the risk assessment and _____________________ plan

2Communication

1 Emergency power systems

2 Communication

3 Training and testing

4 Integrated health care

Examples

Question 5 True or False

Community-based risk assessments ensure

that facilities collaborate with other entities

within their community to promote an integrated

response to emergency events

True

What do they mean by ldquocommunity-

based risk assessmentsrdquo

EP Module 2 Lesson1 Topic 2 Slide 13

6Each provider will have its EP regulations incorporated

into its Requirements for Certification

7 An EP plan activation (due to a disaster) exempts the facility

from one full-scale individual-based exercise for that

year The 2nd exercise requirement still applies

8 Surveyor training is available to Providers

Question 6 7 8 Three EP Rule High Lights

httpswwwcmsgovMedicareProvider-Enrollment-and-CertificationSurveyCertEmergPrepEmergency-Prep-Rulehtml

Ray Miller 432018

Direct Supply 15

83

Agenda ndash National EP Rule

Concepts 1

Core Components 2

3

Questions and Your Answers 4

Waivers Subsistence Volunteers

5

6

For questions regarding EP Rule SCGEmergencyPrepcmshhsgov

ldquoAll Hazards Risk Assessmentrdquo

From Your PEERS

85

Risk Assessment All-Hazards Risk Approach (1 of 4) [For LTC facilities at sect48373(a)(1)]

1 A documented facility-based and

community-based all-hazards risk

assessment

The Emergency Plan must be based on and include

2 Strategies for addressing the

identified emergency events

86

Risk Assessment All-Hazards Risk Approach (2 of 4)

httpswwwcmsgovMedicareProvider-Enrollment-and-CertificationSurveyCertEmergPrepHealthCareProviderGuidancehtml

Ray Miller 432018

Direct Supply 16

88

Risk Assessment All-Hazards Risk Approach (4 of 6)

httpwwwcahfdisasterprepcomPreparednessTopicsAllHazardResourcesGuidesaspx

TOPICS IN THIS SECTION

bull Disaster Planning

Guide

bull Media Toolkit

Emergency Food amp Water

bull Planning Templates amp Checklists

bull Ready Set Go Fact Sheets

bull Regulatory

bull Resources for ICFIID

Revised HVA Tool from Kaiser Permanente January 2017

Download the Kaiser Permanente HVA Tool 2014

ADDITIONAL PLANNING TEMPLATES amp CHECKLISTS

CONDUCTING A HAZARD

VULNERABILITY ASSESSMENT

90

91

Ray Miller 432018

Direct Supply 17

92

Agenda ndash National EP Rule

Concepts 1

Core Components 2

3

Questions and Your Answers 4

Waivers Subsistence Volunteers

5

6

For questions regarding EP Rule SCGEmergencyPrepcmshhsgov

ldquoAll Hazards Risk Assessmentrdquo

From Your PEERS

93

1 1135 Waivers ndash Purpose (1 of 2)

httpswwwcmsgovMedicareProvider-Enrollment-and-CertificationSurveyCertEmergPrepDownloadsAll-Hazards-FAQspdf

The purposes of a waiver are to ensure that

1 Sufficient HC suppliesservices are available

2 HC providers that are unable to comply with certain

requirements may still be reimbursed and

exempted from sanction (absent fraud or abuse)

94

1 1135 Waivers ndash Purpose (1 of 1)

1 State Operations Manual Appendix Z- Emergency Preparedness for All Provider and Certified Supplier Types Interpretive Guidance

2 httpswwwaceporgnews-media-top-banneremtala 3

1 Out-of-network providers (Medicare Advantage )

2 EMTALA (Emerg Med Trx amp Labor Act)

3 Licensure (Physicians Others)

4 3-Day stay

5 HIPAA

1st Pres declares a major disaster emergency

(under the Stafford Act OR the National Emergencies Act)

-AND-

2nd HHS Sec declares a public health emergency

-AND-

3rd HHS Sec grants an 1135 Act-waiver (federal requirements)

Examples of 1135 waivers (existing CoPs)

6 Evacuated residents may have no

1] health care records 2]

information on current health status

or 3] verification of the personrsquos

status as a Medicare beneficiary

These actions and flexibilities are

effective retroactively to hellip

Ray Miller 432018

Direct Supply 18

95

4 Subsistence (sect 48373(b)(1)) (1 of 1)

LTC facilities are required to provide subsistence needs for

staff and residents hellip evacuate or shelter in place including

but not limited to

1 Food water medical and pharmaceutical supplies

2 Alternate sources of energyelectrical power

3 Safe and sanitary storage of such provisions

Subsistence Needs food water medical and pharmaceutical supplies

alternate sources of energy to maintain

a] temperatures to protect patientresident health and safety and sanitary

storage of provisions b] emergency lighting c] fire detection

extinguishing and alarm systems and d] sewage and waste disposal

NOTE You can relocate residents to in portion of the facility hellip

rather than the maintaining temperature in the entire facility

96

5 Use of volunteers during an emergency

copy 2014-15 Direct Supply Inc all rights reserved

1 Encourage volunteers hellip varying skills

and training SIP PampP for volunteers

2 Scope of practice training privileging

and credentialing

3 Non-medical volunteers =

Non-medical tasks

3 Flexibility BUT IAW State law scope of practice rules AND

facility policy

4 PRE--EVENT Integrate with State-established volunteer

registries (and where possible) State-based Emergency

System for Advanced Registration of Volunteer Health

Professionals ESAR-VHP

Agenda ndash National EP Rule

Concepts 1

Core Components 2

3

Questions and Your Answers 4

Waivers Subsistence Volunteers

5

6

For questions regarding EP Rule SCGEmergencyPrepcmshhsgov

ldquoAll Hazards Risk Assessmentrdquo

From Your PEERS

Ray Miller 432018

Direct Supply 19

102

A Review Evaluation Strategies

1 Update AHRA

2 Develop an EP plan

3 Ensure it contains

a At least the 11 specified PampP

b Defined Communication plan

c Training and Testing program

d Determine your Essential Electric System needs

4 Learn and Teach Tabletop Exercises

5 Collaborate with officials and join your local HC Coalition

IN CLOSING Implementation Strategies (1 of 2)

For questions regarding EP Rule SCGEmergencyPrepcmshhsgov

104

Thank You