Facilities must develop and implement policies and procedures that support the successful execution of the emergency plan and risks identified during the risk assessment process.  They should make provisions for the subsistence of staff and residents, whether they evacuate or shelter in place.  Policies and procedures also should include a system of medical documentation that preserves resident information, protects confidentiality, and secures and maintains the availability of records.

A core tenant of the rule that hasn't changed, requires the development of policies and procedures that are based on an all-hazards risk assessment and support the emergency plan as well as the communications plan. This is intended to help healthcare providers identify gaps and realistically develop a response that best leverages staff and resources.

• These policies will ensure a system to track all on-duty staff and sheltered patients/clients during and after a crisis event.
• Strategies should align with the risk assessment to ensure the continuation of care.

During an emergency, it is critical that all providers and suppliers have a system to contact appropriate staff, as well as patients' treating physicians and other necessary persons in a timely manner to ensure a continuation of patient care safely throughout the facilities.  The plan must be well-coordinated within the facility, across health care providers, and with state and local public health departments.

How hospitals and healthcare providers communicate during an emergency―from contacting all staff and patients and coordinating care to collaborating with emergency personnel and state and local health officials―will define the immediate and long-term impact on a hospital and the surrounding community and patients it serves.         

Per the Rule, facilities should continue to develop and maintain an emergency communication plan to coordinate patient care within the facility, across healthcare providers and with state and local public health departments and emergency management systems. This includes:

• Assurances that even during tenuous times, there’s a method of sharing information and medical documentation between providers in accordance with HIPAA and all pertinent rules.
• Attention should be given to patient care/occupancy throughout the facility(s) and with any transportation of patients.

Training and Testing

Facilities must develop a well-organized, effective training program that includes initial training for new and existing staff in emergency preparedness policies and procedures, as well as annual refresher training.  The facility must offer annual emergency preparedness training so that staff can demonstrate knowledge of emergency procedures. 

CMS continues to emphasize the following as part of their training and testing efforts to ensure a coordinated, collaborative response:

• Develop and maintain a training and testing program for all new and existing employees.
• All employees must demonstrate knowledge of emergency procedures, evacuation routes/location, and patient instructions.
• Coordinate drills with local, tribal, regional, state, or federal emergency preparedness officials to ensure an integrated approach during a disaster or emergency.

In addition, the following updates have been made to the training and testing requirement per the Omnibus Reduction Final Rule.

• The training requirement is lessened from annual to biennial for providers and suppliers with the exception of LTCs, which are still required to provide annual training.
• Inpatient providers/suppliers may choose the type of emergency preparedness test they conduct – either a community-based full-scale test, or a facility-based test. These facilities must administer two emergency preparedness tests per year.
• Outpatient providers/suppliers may test for emergency preparedness once, rather than twice, a year.