Section 1600
Emergency Preparedness
CEMP Policy
LifeCare will comply with all applicable Federal, State and local emergency preparedness requirements. Consistent with applicable regulations, a Comprehensive Emergency Management Plan (CEMP) is to be developed, maintained and updated whenever indicated. The Plan will be reviewed at least annually. The CEMP will:
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Be based on a written facility-based and community-based Risk Assessment that is created utilizing an all-hazards approach.
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Include strategies and policies for addressing Emergency Events identified by the risk assessment.
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Address Patient Population, including, but not limited to, the type of services LifeCare has the ability to provide in an emergency; and continuity of operations, including delegations of authority and succession plans.
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Address the location and use of alarm systems and signals; and methods of containing fire.
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Include a process for cooperation and collaboration with local, tribal, regional, State, and Federal emergency preparedness officials’ efforts to maintain an integrated response during a disaster or emergency situation.
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Be developed and maintained with assistance from fire, safety, and other appropriate experts.
Standards Met
15-D-1
The Provider/Supplier must comply with all applicable Federal, State, and local emergency preparedness requirements. The Provider/Supplier must establish and maintain an emergency preparedness program that meets the requirements of this section. The emergency preparedness program must include, but not be limited to, the following elements:
485.727 Condition
5-D-2
Emergency plan. The Provider/Supplier must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least every two years.
5-D-3
The plan must be based on and include a documented, facility-based and community based risk assessment, utilizing an all-hazards approach. 485.727.a.1 Standard
Please Reference CEMP Policy
Standards Met
5-D-4
The plan must include strategies for addressing emergency events identified by the risk assessment. 485.727.a.2 Standard
5-D-5
The plan must address patient population, including, but not limited to, the type of services the Provider/Supplier has the ability to provide in an emergency; and continuity of operations, including delegations of authority and succession plans. 485.727.a.3 Standard
5-D-6
The plan must address the location and use of alarm systems and signals; and methods of containing fire. 485.727.a.4 Standard
5-D-7
The plan must include a process for cooperation and collaboration with local, tribal, regional, State, and Federal emergency preparedness officials' efforts to maintain an integrated response during a disaster or emergency situation.
5-D-8
The plan must be developed and maintained with assistance from fire, safety, and other appropriate experts. 485.727.a.6 Standard
Please Reference Disaster Preparedness Plan
Standards Met
5-D-9
Policies and procedures.
The Provider/Supplier must develop and implement emergency preparedness policies and procedures, based on the emergency plan set forth in Standard 5-D-2, risk assessment in Standard 5-D-3 and the communication plan in Standard 5-D-21. s The policies and procedures must be reviewed and updated at least every two years.
Please Reference Emergency Preparedness Plan for Review.
Standards Met
5-D-11
At a minimum, the policies and procedures must address safe evacuation from the Provider/Supplier.
5-D-12
Safe evacuation from the Provider/Supplier must include consideration of care and treatment needs of evacuees.
5-D-13
Safe evacuation from the Provider/Supplier must include staff responsibilities.
Please Reference Emergency Plans which include Plan for Safe Evacuation.
Standards Met
5-D-17
At a minimum, the policies and procedures must address a means to shelter in place for patients, staff, and volunteers who remain in the Provider/Supplier.
Please Reference Emergency Plans which include a Plan for Shelter in Place
Standard Met
5-D-18
At a minimum, the policies and procedures must address a system of medical documentation that preserves patient information, protects confidentiality of patient information and secures and maintains the availability of records.
Please Reference Communication Plan & Case Record Policies
Standard Not Applicable
5-D-19
At a minimum, the policies and procedures must address the use of volunteers in an emergency and other staffing strategies, including the process and role for integration of State and Federally designated health care professionals to address surge needs during an emergency.
LifeCare policy is to not utilize volunteers in emergency situation.
Standards Applied
5-D-21
Communication plan.
The Provider/Supplier must develop and maintain an emergency preparedness communication plan that complies with Federal, State, and local laws and must be reviewed and updated at least every two years.
5-D-22
The communication plan must include names and contact information for the following: (i) Staff (ii) Entities providing services under arrangement (iii) Patients' physicians (iv) Volunteers (v) Other Provider/Suppliers within the same Medicare type.
5-D-23
The communication plan must include contact information for the following: (i) Federal, state, tribal, regional, and local emergency preparedness staff (ii) Other sources of assistance.
5-D-24
The communication plan must include primary and alternate means for communicating with the following: (i) Provider/Supplier's staff (ii) Federal, State, tribal, regional, and local emergency management agencies.
5-D-25
The communication plan must include a method for sharing information and medical documentation for patients under the Provider/Supplier's care, as necessary, with other health care providers to maintain the continuity of care.
5-D-28
The communication plan must include a means of providing information about the Provider/Supplier's needs, and its ability to provide assistance, to the authority having jurisdiction or the Incident Command Center, or designee.
Please Reference Communication Plan
Standards Met
5-D-29
Training and testing. The Provider/Supplier must develop and maintain an emergency preparedness training and testing program that is based on the emergency plan set forth in standard 1600.010.002 of this section, risk assessment in standard 1600.010.003 of this section, policies and procedures in standard 1600.010.009 of this section, and the communication plan in standard 1600.010.023 of this section. The training and testing program must be reviewed and updated at least every two years.
5-D-30
The training program must consist of initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing on-site services under arrangement, and volunteers, consistent with their expected roles.
5-D-31
The training program must provide emergency preparedness training at least every two years.
5-D-32
The training program must maintain documentation of all emergency preparedness training.
5-D-33
The training program must demonstrate staff knowledge of emergency procedures.
5-D-34
If the emergency preparedness policies and procedures are significantly updated, the Provider/Supplier must conduct training on the updated policies and procedures.
Please reference Training Plan
Please also reference Personnel Records for documentation
Standards Applied
5-D-35
Testing. The Provider/Supplier must conduct exercises to test the emergency plan at least annually.
5-D-36
The Provider/Supplier must participate in a full-scale exercise that is community-based every two years; or
When a community-based exercise is not accessible, conduct a facility based functional exercise every two years; or
If the Provider/Supplier experiences an actual natural or manmade emergency that requires activation of the emergency plan, the Provider/Supplier is exempt from engaging in its next required community-based or individual, facility based functional exercise following the onset of the emergency event.
5-D-37
The Provider/Supplier must conduct an additional exercise at least every two years opposite the year the full-scale or functional exercise (standard 1600.010.038) is conducted that may include, but is not limited to the following:
A) A second full-scale exercise that is community-based or an individual facility-based functional exercise;
B) A mock disaster drill; or
C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion using a narrated, clinically relevant scenario, and a set of problem statements, directed messages or prepared questions designed to challenge an emergency plan.
5-D-38
The Provider/Supplier must analyze the Provider/Supplier's response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the Provider/Supplier's emergency plan, as needed.
Please reference Emergency Preparedness Plan for policy
Please see documentation of tests and drills in this Section
Standard Not Applicable
Sub-Section E: Integrated HealthCare Systems
Integrated Healthcare Systems
This section only applies to those providers/suppliers participating in Integrated Health Systems