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Date ArticleType
7/18/2017 Regulatory
Lowdown with Lori: Emergency Preparedness (EP) and the Requirements of Participation – Action Toward Compliance and Next Steps

I'm a greater believer in luck, and I find the harder I work the more I have of it.
~Thomas Jefferson

It was wonderful to see a room full of participants at the Emergency Preparedness Workshop on July 13th. It was a day of learning and information for all, however our task is far from complete to meet all the CMS standards specified within requirements for Emergency Preparedness by November. To be completely honest, I am not sure everything listed in the EP rule can be accomplished by November, but we must show a good faith effort along with perseverance and creativity toward our progress to compliance.

Perseverance is the hard work you do after you get tired of doing the hard work you already did.
~Newt Gingrich~

First, we all know that providers are required to develop an emergency preparedness program and the program must describe a facility’s comprehensive approach to meeting the health, safety, and security needs of staff, and resident population during a disaster or emergency. We must also look beyond our own four walls and coordinate with other healthcare facilities and the whole community but first we must ensure that our “house” or facility is ready for internal emergencies and disasters. We have conducted our business related to emergency and disasters pretty much the same way for years and now we must get it right and move forward. Getting it right means we need to honestly evaluate our internal processes for needed improvement in the areas of fire drills, tornado drills and resident elopement, etc. Conducting business as usual is definitely not enough to meet the standards in the new EP rule, but it is a starting point. Improvement with internal processes will help us see the big picture of compliance and expand Emergency Operational plans by November.

I recommend each facility step up their game. Ensure expectations are meeting or exceeding standards related to internal response to fire, tornadoes, severe weather etc.

• Conduct drills and truly evaluate internal response to your already established plan.
• Ensure education is provided upon hire and annually.
• Conduct and document timely generator checks and maintenance.
• Evaluate competency during daily operations.
• Develop action plans for identified areas for improvement.

Will your facility be ready to serve current residents, staff, visitors and possible incoming residents throughout a hazard or emergency? Will your facility be ready, if your facility would lose power or connectivity? Are you prepared to evacuate your residents, if needed, and keep track of them? Keep in mind a hazard or emergency may impact your suppliers and employees too. Who will be in command during an emergency or hazard? How will you communicate if phone and cell towers are not operational? How will you provide food and water to residents and staff? These questions along with others will help you develop a solid plan.

Follow the link to the CMS Emergency Preparedness Checklist. I personally recommended this tool for effective health care facility planning. This tool will challenge your team to ask the tough questions.

Next Steps:

• Review your current Emergency Disaster Plan / Emergency Operation Plan (EOP).
     o Does it reflect the high-risk hazards/emergencies for your area and the population you serve? Your plan will need to be individualized for your facility.
     o No better time than the present to conduct the annual assessment of the mandatory Emergency Operational Plan. Review of the EOP is required annually and must be documented. I recommend documenting the EOP review on the QAPI calendar. By doing so, all changes you make over the next few months will be documented and visible improvement. It’s always positive to see documented progress toward compliance. “A work in Progress”

• Contact your local fire department, police department, and discuss your EOP (Emergency Operational Plan) and ask them for their input and assistance with training staff for fire, tornado and open shooters.

• Contact your local public health department and discuss your plan and ask them for their input and assistance with training related to flu, GI and other community illnesses.

• Contact your District Emergency Preparedness and Response agency and to speak to the contact for the medical-health emergency planning in your area. Ask for a copy of the local hazard vulnerability analysis so you can be aware of the hazards identified for your surrounding community. Inform the District of your desire and request to be involved in the district meetings and education including drills.

• Document dates and times of all contacts and the response you receive. Facilities will need to include documentation of efforts to contact officials and of their participation in collaboration and cooperation efforts. Here again, the QAPI calendar is ideal for documenting touchpoints.
     o It is very likely that the individuals you contact may not know what you are talking about related to the emergency preparedness and might not have received information about the inclusion of LTC providers. Be patient with them, however be persistent in your communications and always document the touchpoint.

I have found a resource for Region 5 related to hazards and disasters. Please open the link and use the information in your approach to a comprehensive assessment. This will give you an overview of the types of risks in our region.

• The term “comprehensive” in the EP requirement is to ensure that each facility/provider consider a multitude of events that could happen.

• A preliminary list of emergencies / disasters most prevalent in Indiana are below:   
     o Fires
     o Floods (in some Indiana locations)
     o Chemical spills (in some Indiana locations)
     o Loss of power/utilities
     o Tornadoes
     o Earthquake (in some Indiana locations)
     o Snow Storms and Ice Storms
     o Extreme temperatures
     o Open Shooter and/or violence
     o Missing residents

Depending on your location and specific variables, additions or deletions to the list may be appropriate.

Stay tuned for follow-up information related to the next recommended steps toward compliance. We have a long way to go but every step counts.

If you have questions, please contact me at  ldavenport@ihca.org.