Post Call Update: After the brief CMS National provider Call, we believe the analysis below was spot on. Our two main takeaways from the call not necessarily covered in the written content or analysis below include:
- CMS will define annual in a rolling 12-month fashion from the exercise or onset of a real world incident.
- Surveyors will assess the efficacy of an organization’s training, both initial and annual, via interviews of random staff.
CMS conducted a second Emergency Preparedness Rule Call via the Medicare Learning Network and pre-published the slide deck. Just like with the first CMS webinar in October there are no major surprises, the call mainly clarified some topics and reiterated a sense of urgency.
If we combine the content from the webinar slide deck along with the four rounds of FAQs published by CMS in November and December, you can see some trends that are worth noting.
Key Webinar Topics
- The Interpretive Guidelines (IGs) still are not ready and holding your breath is not advisable. CMS reiterates what it clearly stated in a March 24th memo, providers and suppliers should not delay preparedness activities while waiting on the IGs.
- Building on the ‘don’t delay theme,’ the webinar clearly calls out that the following should be done by November 15, 2017, or risk non-compliance enforcement.
- Completed “All of the staff training requirements”
- “Participation in a full-scale exercise that is community-based or when a community-based exercise is not accessible an individual, facility-based exercise.”
- A second full-scale exercise that is individual, facility-based or a tabletop exercise based on a clinically-relevant emergency scenario.
- The presenters also look to provide some clarity around the types of exercises after the confusion following the last webinar.
- The webinar reiterates some core Emergency Management / Preparedness topics and cycles including:
- The utilization of an “all-hazards” approach, which CMS defines within the webinar.
- The foundational nature of the Risk Assessment and how that drives the development of the emergency plan.
- The importance of continual process improvement and at least annual review of all relevant plans, policies, and procedures.
Other Key Topics from Documents and FAQs.
- Facilities with residential/inpatient consideration will most likely need to plan for an alternate power source for HVAC if they plan to shelter in place during an event with a loss of power. Several FAQs addressed the responsibility of the provider to maintain the environment, including temperature, during a disaster.
- Both the webinar content and the FAQs address and reiterate a Facility-Based approach and the necessity of the organization to plan for each specific facility. The planning process must include a facility-based risk assessment to address specific hazards, geography, and patient population.
Even after this webinar, there is still a lot we don’t know. Providers do not have the luxury of time and if you are wondering where to start, begin by reading: What to do without Interpretive Guidelines? Additionally, if you can’t make the webinar or it is full, feel free to check back on our CMS Resource Page for an update and a link to the recording. We will also be tweeting leading up to the webinar, so follow us on Twitter.
Crisis Focus, LLC has focused expertise in healthcare emergency management, including CMS compliance. Please visit Crisis Focus’ CMS Emergency Preparedness resource page or contact us for more information.