Christus St. Mary's Hospital evacuated their patients to other hospitals, due to the Hurricane Evacuation orders preparing for Hurricane Lili. (Source: Lauren Hobart/FEMA News Photo, 01 October 2002, Port Arthur, LA)

New Emergency Rule: Challenge for Some, Good for All

The Centers for Medicare and Medicaid Services (CMS) implemented a comprehensive emergency preparedness rule in 2016 that applies to nearly every healthcare provider in the nation, and outlines steps those providers must take to improve their preparedness and ensure sustainability in the face of a disaster. The rule compels healthcare providers to devote resources – human and fiscal – to emergency planning. This may be seen as burdensome by some but should effectively improve their levels of readiness and improve the quality of healthcare for all. This rule will make providers – from general hospitals to transplant centers and long-term care facilities – safer for patients and visitors.

Although most people outside healthcare have little awareness of the rule or its requirements, there are good reasons everyone should understand, as they and their loved ones will benefit from enforcement of the rule. Describing the effects of Hurricanes Harvey and Maria in a November 2017 HomeCare Magazine article, Healthcare Ready Executive Director Nicolette Louissaint wrote, “the devastating and significant impact these events had on health care systems reminds us why it is imperative to have emergency preparedness systems in place to ensure the well-being of patients and providers during a disaster.”

Her group, along with others, has spent the past months promoting the emergency rule and encouraging healthcare providers to expand their planning to ensure compliance. Sessions on the rule at a November 2017 National Healthcare Coalition Preparedness Conference in San Diego, California, were popular draws, with more than 60 people attending a half-day workshop co-sponsored by Louissant’s Healthcare Ready, FEMA’s Center for Domestic Preparedness (CDP), and Bio-Defense Network. A panel discussion later in the conference – featuring representatives of CMS, the California Department of Public Health, and Healthcare Ready – drew a standing-room-only crowd.

Key Elements of the Rule

The FEMA CDP has become a chief source of information on the rule, scheduling dozens of comprehensive and complimentary onsite two-day workshops around the nation for providers and healthcare coalitions. In addition to CDP and CMS, significant support for providers has been made available through the U.S. Department of Health and Human Services (HHS) Assistant Secretary for Preparedness and Response’s Technical Resources, Assistance Center, and Information Exchange (TRACIE) service. TRACIE has also produced a series of frequently asked questions and conducted webinars designed to answer questions being raised by providers across the nation.

The rule contains four primary elements, each of which feeds into an organization’s overall emergency preparedness program:

  • Risk Assessment and Planning – Requires providers to assess specific and general risks they face and create plans to respond to those risks.
  • Policies and Procedures – Must be written, approved, and reviewed on a regular basis, at least annually.
  • Communications Plan – Must be created and outline how a healthcare provider will communicate both internally and externally, especially when normal means may be unavailable.
  • Training and Testing – Requires providers to train their staff and conduct periodic testing and exercises to ensure they can do what they must do in the event of a disaster.

These elements sound familiar to business continuity and emergency preparedness professionals, but are not second nature to many healthcare providers, whose backgrounds are focused on healing and medical treatment, not preparedness. This may be why so many providers find themselves in a quandary when faced with complying with the rule. Many providers already do much of what is being required, but full compliance is still necessary, and failure could eventually jeopardize a provider’s Medicare and Medicaid funding.

Different Providers, Varying Requirements

CMS has taken significant steps to promote and explain the requirements by conducting numerous webinars and having representatives speak at multiple events. However, many recipients remain unclear about the steps they must take, how they should document those steps, and what full compliance will look like for them.

Part of the lack of clarity is because 17 different provider and supplier types (see Table 1) are covered and, although there must be general compliance, nuances exist among them, for example:

  • Outpatient providers are not required to have policies and procedures for the provision of subsistence needs;
  • Home health agencies and hospices must inform officials of patients in need of evacuation; and
  • Long-term care and psychiatric residential treatment facilities must share information from the emergency plan with residents and family members or their representatives.
1 Hospitals
2 Religious Nonmedical Healthcare Institutions
3 Ambulatory Surgical Centers
4 Hospices
5 Psychiatric Residential Treatment Facilities
6 All-Inclusive Care for the Elderly
7 Transplant Centers
8 Long-Term Care Facilities
9 Intermediate Care Facilities for Individuals with Intellectual Disabilities
10 Home Health Agencies
11 Comprehensive Outpatient Rehabilitations Facilities
12 Critical Access Hospitals
13 Clinics, Rehabilitation Agencies, and Public Health Agencies as Providers of Outpatient Physical Therapy and Speech-Language Pathology Services
14 Community Mental Health Centers
15 Organ Procurement Organizations
16 Rural Health Clinics (RHCs) and Federally Qualified Health Centers
17 End-Stage Renal Disease Facilities

These requirements are not universal for the 17 provider types. Adding to the complexities, advance copies of the all-important Interpretive Guidelines and Survey Procedures were released in the middle of 2017 – just five months before all recipients were expected to be in full compliance.

Healthcare coalitions have become key players in promoting the rule. Many have seen increases in membership from providers seeking help in their planning efforts and involvement, especially in the areas of policies and exercises. In addition, the overall interest in the rule has become clear to national leaders such as Jennifer Pitcher, executive director of the MESH Coalition in Indianapolis, a lead organizer of the National Healthcare Coalition.

“MESH Coalition has continually experienced an increase in national contacts with regard to resources and calls for assistance,” Pitcher said in an email, citing what she called an “incredibility encouraging” level of interest apparent last November 2017 at the group’s annual preparedness conference. “We are excited for the energy that the rule has brought within our healthcare community and look forward to the successful response as a direct result to those collaborations.”

A key requirement of the rule deals with temperature controls and emergency and standby power for hospitals, critical access hospitals (smaller facilities, often located in rural areas), and long-term care facilities. The importance of such controls and backups was made clear in South Florida in 2017, when a dozen people from a Hollywood Hills nursing home died after Hurricane Irma – as the result of what police termed “environmental heat exposure.” The facility’s emergency generators operated as expected when utility company power was lost, but they were powerful enough to provide only light and other basic power. Since it did not generate enough power to keep the air conditioning system running, residents suffered in the stifling heat for three days following the storm.

Most facilities must include evacuation procedures as part of their emergency program, but some smaller facilities do not have this requirement. As such, the staff at the nursing home monitored the residents for heat exhaustion and attempted to keep them comfortable. However, three days lapsed – and nine residents died – before the decision was made to move the patients to a hospital trauma center directly across the street. The deaths of three more residents also were attributed to the heat after they were moved to the hospital.

Additional Training & Reviews

In the HomeCare Magazine article, Louissant cited the past hurricane season as a powerful teacher, which “highlighted the challenges the health care community faces during natural disasters, and underscored why in today’s integrated health care system, it is essential to know and trust community partners before disaster strikes.” The rule encourages providers to create partnerships through the training and exercise component, which “creates an opportunity for health care coalitions to assist their members in compliance.”

As periodic reviews for compliance are undertaken in 2018, it is likely that gaps in emergency planning and execution will be noted, and corrective actions required. It is also likely that some CMS recipients will decry the requirements that they improve their efforts. Nevertheless, it is clear that preparedness will be enhanced, healthcare will be improved, and lives will be saved.

David Reddick

David Reddick is chief strategy officer and co-founder of Bio-Defense Network, a public health preparedness consultancy which has worked with more than 40 local public health departments over the past nine years.  He also was co-founder of PandemicPrep.Org, a non-profit organization that conducted dozens of public workshops and programs on preparing for pandemics such as COVID-19.

Justin Snair

Justin Snair, M.P.A., CBCP, is the founder and principal consultant with SGNL Health Security Solutions and co-founder of Naseku Goods. Formerly, he was a senior program officer with the National Academy of Sciences, Engineering, and Medicine and directed the Forum on Medical and Public Health Preparedness for Disasters and Emergencies and the Standing Committee on Medical and Public Health Research During Large-Scale Emergency Events. In 2012-2015, he served as a senior program analyst for critical infrastructure and environmental security at the National Association of County and City Health Officials. For six years, he was the local preparedness director and environmental health agent with the Acton Public Health Department in Massachusetts. In 2001-2006, he served as a corporal and combat engineer in the U.S. Marine Corps Reserves and is a veteran of the Iraq war. He holds a Master of Public Administration degree from Northeastern University’s School of Public Policy and Urban Affairs, a Bachelor of Science degree in Health Science from Worcester State University, and is an executive fellow with Harvard University’s National Preparedness Leadership Initiative.



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