How to Comply with the CMS Conditions

for Coverage on Emergency Preparedness

Bob Loeper, VP Operations Support

Business Continuity/Disaster Response

Fresenius Kidney Care

November 9, 2018

Facilities Impacted by the

Emergency Preparedness Rule

• Hospitals

• Religious Nonmedical Health Care

Institutions (RNHCIs)

• Ambulatory Surgical Centers (ASCs)

• Hospices

• Psychiatric Residential Treatment

Facilities (PRTFs)

• All Inclusive Care for the Elderly

(PACE)

• Transplant Centers

• Long Term Care (LTC) Facilities

• Intermediate Care Facilities for

Individuals with Intellectual

Disabilities (ICF/IID)

• Home Health Agencies (HHAs)

• Comprehensive Outpatient

Rehabilitation Facilities (CORFs)

• Critical Access Hospitals (CAHs)

• Clinics, Rehabilitation Agencies, and

Public Health Agencies as Providers of

Outpatient

• Physical Therapy and Speech

• Language Pathology Services

• Community Mental Health Centers

(CMHCs)

• Organ Procurement Organizations

(OPOs)

• Rural Health Clinics (RHCs) and

Federally Qualified Health Centers

(FQHCs)

• End Stage Renal Disease (ESRD)

Facilities

Developing a Facility Emergency Plan

Hazard Vulnerability

Assessment (HVA)

• Define Hazards expected in your community

• Rank hazards by probability, risks and

preparedness

• Define Mitigation Strategies for top 5 to 10

hazards

• Show proof of mitigation strategies

• IDT must participate in completing the HVA,

including the Medical Director

Hazardous Vulnerability Analysis

Type of Disasters

• Hurricane• Tornado• Wild Fires• Earthquake• Winter Weather• Flood• Drought• Chemical Spill• Water Main

Break

• Power Outage• Equipment Failure (RO)• Pandemic• Civil Unrest / Riots• Volcano• Nuclear Incident• Ransomware

Hazardous Vulnerability

Analysis

Hazardous Vulnerability Analysis

(HVA)

Type of Disaster Probability of

Occurring?

Impact on Persons,

Property or

Business

Preparedness level or

Internal & External

Resources

Total

3 - High 3 - High 0 - Very Good

2 - Medium 2 - Medium 1 - Good

1 - Low 1 - Low 2 - Fair

0 - None 0 - None 3 - Poor

HAZARD VULNERABILITY ASSESSMENT TOOL

SEVERITY

EVENTPROBABILITY RISK PREPARED-NESS Total

Likelihood this will occur

Possibility of death or injury / Physical

Damage / Dialysis Interruption

Preplanning

Those events with a higher score should be prioritized; as these events

will require additional planning and preparation.

SCORE

0 = N/A 1 = Low 2 = Moderate 3 = High

0 = N/A 1 = Low 2 = Moderate 3 = High

3 = Low / None 2 = Moderate 1 = High 0 = N/A

0 - 9

Volcano 0 0 0 0Hurricane 0 0 0 0Tornado 0 0 0 0

Fire 0 0 0 0Ice Storm 0 0 0 0

Earthquake 0 0 0 0Floods 0 0 0 0Blizzard 0 0 0 0

Electrical Failure 0 0 0 0Water Interruption 0 0 0 0

Drought 0 0 0 0Hazardous Material Spill 0 0 0 0

Terrorism Act 0 0 0 0Bomb Threat 0 0 0 0

Active Shooter 0 0 0 0Nuclear Plant Accident 0 0 0 0

Civil Disturbance 0 0 0 0Pandemic 0 0 0 0

Cyberterrorism / Ransomware 0 0 0 0

Other Local Event 0 0 0 0

Facility Name: Facility #:Preparer: Date:

Only values of 0, 1, 2 or 3 will be accepted for Probability, Risk and Preparedness.

• Procedures to determine the need to evacuate prior

to a hurricane have been established.

• A Memorandum of Understanding with an

engineering firm to complete a Building Damage

Assessment is in place. Ensure you have contact

information for the engineering firm.

• Plastic sheeting and duct tape are on hand to cover

up equipment and windows if necessary.

Hurricane Mitigation StrategiesType of Disasters

• Portable pumps and sandbags are available

• Secure all items susceptible to blowing away, bring these items inside if possible.

• Store and secure all critical records at least 2’ above the floor in the event flooding occurs.

• Fill up the fuel tanks in vehicles and generators prior to landfall.

• Hotel accommodations are available to house staff if necessary.

• Frozen cool packs are available to place in medication refrigerators if needed.

Hurricane Mitigation StrategiesType of Disasters

• Medical equipment, dialysis machines and computers are

secure, elevated and covered in plastic.

• Regulated medical waste is collected, secured and stored in

locked Medical Waste room

• Weather Radio with a warning alarm tone and battery backup

is available.

• Facility shutdown procedures are in place.

• Warning and evacuation plans and procedures are in place.

• Transportation assistance is available if needed.

• Hurricane shutters are in place or 5/8” marine plywood is on

hand to protect windows.

Hurricane Mitigation Strategies

Components of the Facility Emergency Plan

Emergency Operations Center

• Contact your local EoC and discuss your capabilities during a

disaster and understand their role in emergency preparedness

and response

• Seek and join local healthcare coalitions

• Surveyors will ask: Which Coalition do you belong to?

• Determine location of medical/special needs shelters;

• Determine if patient registration is required;

• Determine re-entry requirements post mandatory

evacuation;

• Participate in community drills

Components of the Facility

Emergency Plan• Create a facility manual to provide an overview of the facility emergency plan

and depository for all documents

• Define roles and responsibilities for each staff member:

• Facility Administrator as Incident Commander; complete authority over the

event, authorizes resources, declares the disaster and when event is over

• Social Worker: Contact missing patients and arrange transportation

• Administrative Assistant: Coordinate staffing needs and transfer/admit patients

• Registered Dietitian: Coordination with local hospital and other external

agencies

• Direct Patient Care staff: RNs and PCTs to assist with patient emergency

education, participate in facility evacuation drills, assisting patients

• Medical Director and attending physicians : help in locating your patients after

a disaster, provide orders for patients who present to clinic with no medical

records

Components of the Facility

Emergency Plan

• Create Facility Emergency Contact Information Form

• Hierarchal contact information; Admin/Area/Regional,

Med Dir

• Facility: Landlord, Electrician, Plumber, HVAC, Fuel

• Community: Police, Fire, Telephone, Water, Power

• Regulatory: FEMA, EOC, Network, Red Cross, NKF,

National Guard

• Emergency Housing: Hotels, Campgrounds

• Back up Facilities

• Volunteer groups or local agencies that may provide

assistance

Components of the Facility

Emergency Plan

• Create Staff Emergency Contact Information

Form

• List all staff contact information including cell and emails

• Know staff driving distance form facility

• Include secondary contact information

• Pull electronically from exiting data fields

• Print quarterly for review and compliance

‘If we don’t take care of our staff,

we can’t take care of our patients’

Tracking Patient Emergency

Contact Information

• Create Patient Emergency Contact Information Form and

update at least quarterly

• Know how to get in touch with your patients, include

family members and alternate contact information

• Know their expected evacuation plan

• Identify who will go to special needs shelter during

evacuation

• Register for shelter if required

• Review/update with patients prior to event if possible

• All patients must be accounted for during a disaster

Homeland Security Re-Entry Authorization

Know what your EoC Requires

Facility Authorization Letter

To Whom It May Concern:

The individual carrying this letter is authorized by the National Incident Commander for

Fresenius Medical Care North America to respond to the medical and infrastructure needs

of patients who require life sustaining medical treatment in a Fresenius Medical Care

facility. As such, this individual should be allowed to travel freely and without interruption

or interdiction to and from whatever location that requires his/her assistance.

If you require any further authorization or information, please contact me immediately at

813-843-4423.

Robert P Loeper

National Incident Commander

Fresenius Medical Services

Disaster Response Team

Vice President of FMS Strategic Project Management

Facility Emergency

Supplies and Equipment

• Does facility have a back up analog phone and line

available?

• Emergency equipment to include AED (checked daily), O2

tanks, suction, Ambu bag, IV solutions, back board, oral

airways

• Are emergency medications checked monthly or after use

for expiration dates, cleanliness and proper function

Agreements to include in your Facility

Emergency Plan• Facility Back up Agreement, with multiple facilities

• Alternate water source agreement

• Alternate power source/emergency generator agreement

• HVAC maintenance and repair agreement

• Emergency response agreements with electricians, plumbers,

contractors

• Emergency transportation agreements

• Rental car/van/truck agreements

• Security services agreements

• Environmental testing agreements, Arcadis

• Physical Pant Mitigation Agreements; ServPro, ACT, Service Master

• Debris removal services

Develop Facility Policy and Procedures

to follow Emergency Plan

• Gap Analysis to review current Policies versus CfC:

• Policies and procedures must include emergencies regarding fire

equipment, power failures, care related emergencies, water supply

interruption & natural disasters (existing requirement).

• Tracking during and after the emergency applies to on-duty staff and

sheltered patients.

• Facility Emergency Preparedness Policy/Operations Manuals

• Facility Physical Plant Preparation Assessment and Return to

Operations

Patient Training and Communication Plan

• Quarterly incenter fire drills / facility evacuation

• Emergency disconnect, hand crank blood pump, document patient

verbally understands the process demonstration verbally;

• Dialysis facility staff should show patients what to do if on a dialysis

machine in an emergency. The instructions should include where an

emergency pack is kept and how to disconnect themselves from the

dialysis machine.

• Facility evacuation, know which doorways to exit if patient in chair

Disaster Response• Provide patient with their copy of the

printed information (Care Transition

Report). Keep one copy at the facility

for reference as needed.

• Verify emergency contact information

for patient and location.

• Provide patients with facility phone

number and other emergency

contact information.

Care Transition Report• Treatment orders

• Dietary orders

• Current in-center and home

medications

• Latest laboratory results

• Trends in vital signs

• Hepatitis status

• Allergies

• Active co-morbids

• Demographic Information Sheet

• EPO conversion charts

Disaster Response

Training and Testing requirements due

Annually

• Completed at least one tabletop exercise annually with IDT

• Seek out and to participate in a full-scale, community-based

exercise annually with your local and/or state emergency

agencies and health care coalitions, or if not available in your

community:

• Complete an individual facility-based exercise and document the

circumstances as to why a full -scale, community-based exercise was

not completed

• Document what emergency agencies and/or health care coalitions

you contacted to partner in a full-scale community exercise and the

specific reason(s) why a full-scale exercise was not possible.

Actual Disaster or Emergency

• If your facility was involved in a actual disaster or emergency

where your facility emergency plan was activated where you

interacted with other providers and agencies in the

community you must:

• Complete the After Action Review

• Include pictures, news articles

• Present in QAI

• Facility is exempt from Community Wide drill for 12 months

After Action Report/Improvement Plan

• Brief overview of the exercise

• Major strengths demonstrated during the exercise

• Areas that require improvement

• Complete the After Action Review

Report/Improvement Plan (AAR/IP) to document.

• File the completed AAR/IP in the designated

Disaster/Emergency Response binder.

• Report exercise and outcome in QAI.

Training and Testing Requirements

Due Annually

• Documentation that all staff completed annual emergency

training

• Documentation that all patients completed annual

emergency training

• Documentation that all facility credentialed providers

completed annual emergency training

• Medical Director, Attending Physicians and Extenders ( PAs,

ARNPs)

Patient Emergency Plan

• WHO will I keep in touch with if there is an

emergency?

• WHAT will I pack in my emergency kit?

• WHERE will I go if I need to evacuate my home?

• WHEN will I share my plan with others?

• HOW will I get treatment in a disaster or emergency?

Emergency Medication/Medical Supply List

• First aid kit

• 5-7 day supply of all your medicine(s)

• 5-day supply of antibiotics (if you use peritoneal dialysis

and recommended by your doctor)

• Diuretics (fluid pills), sorbitol, and Kayexalate for potassium

control (if recommended by your doctor)

If diabetes or heart disease keep 5-7 days of all blood

pressure, diabetes, heart, or anticlotting medications.

Medication/Medical Supply List

Kidney Center Emergency Response

(KCER)

The Kidney Community Emergency Response (KCER) Program provides technical

assistance to End Stage Renal Disease (ESRD) Networks, kidney organizations, and

other groups to ensure timely and efficient disaster preparedness, response, and

recovery for the kidney community.

Mission

Collaboratively develop, disseminate, implement, and maintain a coordinated

preparedness and response framework for the kidney community.

Vision

KCER serves as the leading authority on emergency preparedness and response for

the kidney community by providing organization and guidance that seamlessly bridges

the needs of emergency management stakeholders and the ESRD community

nationwide.

www.kcercoalition.com/

Chronic Ambulatory Peritoneal Dialysis

• Patients who use an ultraviolet device should

be advised to keep the battery charged at all

times. The fully charged battery pack should

last for 3 days.

• Patients should keep a 5-7 day supply of

peritoneal dialysis supplies at home. Check

expiration dates and replace as needed or

every 6 months.

Continuous Cyclic Peritoneal Dialysis

• Patients who use a cycler, may want to

purchase a gasoline powered generator that

makes 110 volt AC alternating current.

Patients who have a car can run their cycler

off the cigarette lighter by using a 12 volt DC

to a 110 volt AC invertor (available at

electronics stores). If the car is in a garage,

make sure there is plenty of fresh air and

good ventilation.

• CCPD patients should learn manual CAPD. In

the event of a power loss and don’t have a

generator, switch from CCPD to manual

CAPD.

• If prolong period of no power, facilities can

allow the patient to bring their cycler into

the facility 3 times a week

CAPD and CCPD

Patient Emergency Plans

PD or Home Hemodialysis

• Contact your water and power company ahead of time to

register for special priority to restore your lost services.

• Keep their phone numbers up-to-date and easy to find.

• Keep a flashlight and batteries near your dialysis machine.

• Prepare an Emergency Stock of Supplies,

Medicines/Medical Supplies, and Food

• Keep a 5-7 day supply of peritoneal dialysis supplies and

medications at home.

• Check expiration dates and replace as needed or every 6 months.

Water

• Keep distilled or bottled water on hand for

drinking. If the patient runs out of stored

water, they may disinfect available water for

drinking, brushing their teeth, or for other

uses.

Do not use disinfected water for dialysis

Overall Best Practices

• Post Back Up clinic location when closing a clinic

• Hand out medical records to all patients prior to

closing

• Display the 3 day renal diet during Lobby Day

• Have copies of all staff and patients emergency

contact info in emergency evacuation box

• Contact electrical/plumber vendors (2 deep) day

before closing to ensure availability

• Coordinate closures among facilities along storm

path

Overall Best Practices

• Standardize reporting times and content of clinic closure reports

• Properly prepare clinic for closure

• RMW off the floor and out of shed, locked in RMW room if not picked up

• All records/document off low level shelves/drawers, sealed in water tight containers

• Machines doubled bagged top down, bottom up

• Equipment away from windows

• Secure all outside fixtures, outbuildings

Overall Best Practices

• Opening a clinic after storm, use buddy system

• Walk the exterior first, check for building cracks; sink holes

• One person remain outside while inside is inspected

• Open close windows/doors, check of jams, floor cracks

• Report any damage to leadership and claims adjuster

• Develop of Incident Command teams ready to deploy

• Standardize roles and responsibilities of the team leads

Surveyor E Tag Worksheet

Surveyor E Tag Worksheet

Surveyor E Tag Worksheet

Surveyor E Tag Worksheet

E Tags and P&PsETAGS Emergency Preparedness for ESRD Policy and Procedure Reference Policy Hyperlink

E-0001

Written Emergency Preparedness (EP) program

• Interview the facility leadership and ask him/her/them to

describe the facility’s emergency preparedness program.

• Ask to see the facility’s written policy and documentation on

the emergency preparedness program.

FMS-CS-IC-II-130-014A Guidelines for

Emergency Preparedness Policy

E-0003

Dialysis facility complies with all federal, state and local EP

requirements.

The emergency preparedness program must describe a

facility's comprehensive approach to meeting the health and

safety needs of their patient population during an emergency;

as well as the whole community during and surrounding an

emergency event (natural or man-made).

• Ask to see written or electronic documentation of the

program.

FMS-CS-IC-II-130-014A Guidelines for

Emergency Preparedness Policy

E-0004

Emergency plan developed and updated annually

• See a copy of facility emergency plan and review for

required elements

• Verify documentation that plan has been reviewed and

updated annually by looking for documentation of the date of

the review and updates that were made to the plan based on

the review

FMS-CS-IC-II-130-014D3 Emergency and

Disaster Staff Contact Information Sheet

FMS-CS-IC-II-130-014D4 FKC Emergency

Disaster Patient Contact Information Sheet

FMS-CS-IC-II-130-014D5 FKC Facility Emergency

Information Directory

E-0006

Document a risk assessment using an all-hazards approach

• Hazards common to the state you are in (natural, man-

made, facility, infectious disease, etc.)

• Ask to see documentation of facility risk assessment and

associated strategies.

• Interview the facility leadership and ask which hazards (e.g.

natural, man-made, facility, geographic) were included in the

facility’s risk assessment, why they were included and how the

risk assessment was conducted.

• Verify the risk-assessment is based on an all-hazards

approach specific to the geographic location of the facility and

encompasses potential hazards.

FMS-CS-IC-II-130-014A Guidelines for

Emergency Preparedness Policy

QIP Exemptions

• CMS does have a rule which can be used to apply for a facility

exemption from Quality Incentive Program (QIP) calculations during

emergency/disaster conditions. More information regarding the

completion of exemption requests for QIP calculations during an

emergency/disaster can be found at this link:

• For emergency closures during 2016 and beyond, facilities can request an

Emergency Exemption Form (ECE) from ESRDQIP@cms.hhs.org via email,

and file it through http://www.qualitynet.org , within 90 days after the end of

the emergency event.

• Upon review of application and the supporting documents, CMS can exempt

a facility from QIP scoring for the affected month(s) without impact on the

QIP Total Performance Score.

Clinics do not have to be closed to apply f

or the QIP Exemption.

Want To Learn More

Directly From CMS?

CMS is offering an additional learning session through the

Medicare Learning Network regarding the final rule for

Emergency Preparedness Requirements

Thursday, April 27, 2017

from 2:30 PM to 3:30 PM

To register or for more information visit:

MLN Connects Event Registration