Helping Healthcare Client Facilities become CMS Rule Ready™

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Helping Healthcare Client Facilities become CMS Rule Ready™

By: Kevin McIntyre, MSc. (LtCol, USAF, ANG, Ret), Senior Consultant Strategies and Programs, Firestorm and Jim Satterfield, CEO, Firestorm

On September 8, 2016, the Federal Register posted the final rule Emergency Preparedness Requirements for Medicare and Medicaid Participating Providers and Suppliers. The regulation went into effect on November 16, 2016. Healthcare providers and suppliers affected by this rule must comply and implement all regulations by November 16, 2017.

Jim Satterfield Firestorm President and COO

Jim Satterfield Firestorm CEO, President and Co-Founder

The Centers for Medicare & Medicaid Services (CMS) reviewed existing Medicare emergency regulatory preparedness requirements for both providers and suppliers. CMS found that while many providers and suppliers have emergency preparedness requirements, those requirements do not go far enough in ensuring that these providers and suppliers are equipped and prepared to help protect those they serve during emergencies and disasters.

There is consensus that these existing emergency preparedness requirements are generally insufficient in the face of the needs of the patients, staff and communities, and do not address inconsistency in the level of emergency preparedness amongst all types of healthcare providers. Some providers have no emergency preparedness requirements at all, and current emergency preparedness requirements are not sufficient to handle the complexities of actual emergencies.

The purpose of the Rule then, is to establish consistent, measurable healthcare facility national emergency preparedness requirements to ensure adequate planning for both natural and man-made disasters, and coordination with federal, state, tribal, regional and local emergency preparedness systems.

This rule establishes a consistent framework that mandates incorporation of best practices and lessons learned in emergency preparedness. The rule details the 17 types of healthcare facilities that are covered under the regulation. This final rule will be enforceable as of November 15, 2017. Failure to comply will cause loss of all Medicare and Medicaid reimbursement. No extensions are anticipated.

While the CMS Emergency Preparedness Final Rule may seem like another overzealous regulation, it’s not. There are facilities caring for patients with no plans at all. This puts patients, families, caregivers, employees and livelihoods at risk. There is a movement in recent years to bring all healthcare providers and facilities up to the same level of readiness and this is a good thing.

As an example, healthcare facilities have found success in stopping patient falls by simply focusing attention and support on the topic. Many facilities have established an organized fall-prevention program that identifies unique fall risk factors associated with each patient.

In January of 2015, Grady Health Memorial Hospital in Atlanta was awarded the Quality and Patient Safety Award by the Partnership for Health and Accountability for a program that significantly reduced patient falls.

Grady found that with leadership support and organizational awareness directed toward determining the risk factors associated with patient falls, their fall rates declined, sometimes significantly. In the first quarter of 2014, following the rollout of a revamped fall prevention program, Grady reported a 75% decline compared to baseline measurements from 2011.

Conversely, in South Georgia this year, a long-term care facility was considering moving patients due to a smoke zone resulting from wildfires in the area. The facility notified state authorities that they planned to transfer patients to a local hospital. The local hospital and the long-term care facility had no formal or informal agreement in place, and as such, and when the long-term care facility prepared to transfer the patients, notifying the local hospital on the day of evacuation, they learned the hospital had no room for them. These are the types of situations and outcomes that have created the need for the CMS final rule.

While there are many resources available to assist facilities achieve Rule compliance, they are complex, exceptionally detailed and potentially resource-draining for less than enterprise-level facilities. Items such as command control, communication, safety and security, triage, surge capacity and continuity of operations in preparation and during an emergency within a hospital setting are all critical components.

Moreover, the focus shift is important: the CMS emergency preparedness regulations focus on continuity of operations rather than recovery of operations. Recovery is an important part of emergency management, but for healthcare facilities especially, continuity is the planning priority. This requirement includes continuing to provide care for current patients and continuing to meet the medical needs of the community, while also treating a patient surge caused by an emergency. Hospitals and other facilities may find it helpful to support their Emergency Operations Plan (EOP) with a Continuity of Operations Plan (COOP) to be sure that their emergency preparedness program addresses this new CMS focus.

Kevin McIntyre , MSc. (LtCol, USAF, ANG, Ret), Firestorm Senior Consultant

The Four Core Elements of an Effective Emergency Preparedness Framework are:

Risk Assessment and Emergency Planning
Policies and Procedures
A Communication Plan
Training and Testing

Three Key Essentials for Providing Healthcare in Emergencies are:

Safeguarding human resources
Ensuring business continuity
Protecting physical resources

By example, Hospitals, one of the seventeen types of facilities, must follow the following high-level requirements:

Develop a plan-based on a risk assessment using an “all hazards” approach, which is an integrated approach focusing on capacities and capabilities critical to preparedness for a full spectrum of emergencies and disasters. The plan must be updated annually.
Develop and implement policies and procedures based on the emergency plan, risk assessment, and communication plan which must be reviewed and updated at least annually.
Develop a System to track on -duty staff & sheltered patients during the emergency.
Develop and maintain an emergency preparedness communication plan that complies with both federal and state laws.

Additionally, patient care must be well-coordinated within the facility, across health care providers and with state and local public health departments and emergency systems. The plan must include contact information for other hospitals and CAHs; a method for sharing information and medical documentation for patients.

Facilities must also develop and maintain training and testing programs, including initial training in policies and procedures and demonstrate knowledge of emergency procedures and provide training at least annually.

Also, annually participate in:

A full -scale exercise that is community – or facility -based
An additional exercise of the facility’s choice.

Last, all facilities must have back-up power capabilities and develop policies and procedures that address the provision of alternate sources of energy to maintain:

temperatures to protect patient health and safety and for the safe and sanitary storage of provisions;
emergency lighting; and
fire detection, extinguishing, and alarm systems.

It is critical that we assist our healthcare facility clients comply with the Emergency Preparedness Requirements for Medicare and Medicaid Participating Providers and Suppliers Rule. Failure to do so will mean the immediate loss of major funding sources.

When a facility loses its Certificate of Participation from CMS, other private insurers may also make the decision to stop making payments to that facility. This goes far beyond CMS reimbursement only.

This is not just about regulation and compliance but about patient safety and facility preparedness. Lives can be saved or lost depending on how prepared a facility is. History bears this out.

Related: Join Mac for a CMS preparedness webinar.

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