This regulation requires Home Health Agencies (HHAs) to develop and implement emergency preparedness policies and procedures that include individualized emergency plans for each patient, documented as part of the comprehensive patient assessment. HHAs must address potential disasters, patient-specific safety steps, and contingency staffing operations. Plans must be reviewed at least every two years and copies retained in patient files with copies provided to patients and caregivers.
View official sourceE-0017 (Rev. 204, Issued: 04-16-21; Effective: 04-16-21, Implementation: 04-16-21) §484.102(b)(1) Condition for Participation: [(b) Policies and procedures. The HHA must develop and implement emergency preparedness policies and procedures, based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, and the communication plan at paragraph (c) of this section. The policies and procedures must be reviewed and updated at least every 2 years. At a minimum, the policies and procedures must address the following:] (1) The plans for the HHA’s patients during a natural or man-made disaster. Individual plans for each patient must be included as part of the comprehensive patient assessment, which must be conducted according to the provisions at §484.55. Interpretive Guidelines for §484.102(b)(1). HHAs must include policies and procedures in its emergency plan for ensuring all patients have an individualized plan in the event of an emergency. That plan must be included as part of the patient’s comprehensive assessment. For example, discussions to develop individualized emergency preparedness plans could include potential disasters that the patient may face within the home such as fire hazards, flooding, tornados, and EIDs; and how and when a patient is to contact local emergency officials. Discussions may also include patient, care providers, patient representative, or any person involved in the clinical care aspects to educate them on steps that can be taken to improve the patient’s safety. The individualized emergency plan should be in writing and could be as simple as a detailed emergency card to be kept with the patient. HHA personnel should document that these discussions occurred and also keep a copy of the individualized emergency plan in the patient’s file as well as provide a copy to the patient and or their caregiver. Additionally, HHAs should consider potential contingency operations within their policies. For example, how will the HHA ensure the appropriate discipline/staff perform the required initial and comprehensive assessments when access to residences may be hindered due to an emergency? While some contingency plans may include requests for Section 1135(b) emergency waiver flexibility during a declared public health emergency (requiring CMS pre-approval prior to use), HHAs are encouraged to plan ahead for the potential use of alternative staffing options/professions, acting in accordance with their state scope of practice laws. For additional information on 1135 Waivers, please visit: https://www.cms.gov/About- CMS/Agency-Information/Emergency/EPRO/Resources/Waivers-and-flexibilities and also the CMS Frequently Asked Questions, Emergency-Related Policies and Procedures That May Be Implemented Without § 1135 Waivers, at https://www.cms.gov/about- cms/agency- information/emergency/downloads/consolidated_medicare_ffs_emergency_qsas.pdf Survey Procedures • Through record review, verify that each patient has an individualized emergency plan documented as part of the patient’s comprehensive assessment. • Does the HHA have a process related to how to continue to meet the requirements for individualized care plans?