On September 16, 2016 CMS issued their “Final Rule” on their new Emergency Preparedness Program Requirements, and have made it clear that by November 15, 2017 facilities should be compliant. In fact, earlier this year CMS issued S&C 17-21 (click to read) that gave clear direction that provider’s first “annual” training and testing requirements must be complete by the implementation date November 15, 2017 (one year after adoption). No exceptions.
Training, testing and other annual requirements that must be accomplished by November 15, 2017 include:
- Conducting a documented, facility-based and community-based risk assessment, utilizing an all-hazards approach, and collaboration with your community partners (Hazard Vulnerability Assessment [HVA])
- Communicating strategies for addressing emergency events identified by the risk assessment (Mitigation Plans)
- Completing required training (for all staff, consistent with their expected roles; documented; and demonstrating staff knowledge of emergency procedures (Training)
- Completing required exercises: one community-based full scale exercise and one other exercise (Testing) or an actual event replacing one of your exercise requirements
- Reviewing and updating your Emergency Plans (Emergency Plan).
- This review and gap analysis should be done immediately, but it may require you creating an “action plan” that continues past the November compliance date, to do the detailed work of updating your current plans to meet all the new CMS requirements, conduct training on the new plans and to ensure all aspects of the requirements are truly met, for example:
- Address resident/patient population, including, but not limited to, persons at risk and the type of services provided in an emergency,
- Continuity of operations, including delegations of authority and succession plans, e.g., using an incident command system (ICS),
- All the specific policies and procedures detailed in the regulations, including robust “Communications Plans.”