Homebound hospice agencies, PACE organizations, and home health agencies (HHAs) must develop and implement policies and procedures for informing state and local emergency preparedness officials about patients who need evacuation from their residences during an emergency, based on each patient's medical and psychiatric condition and home environment. These procedures must detail when and how patient information is communicated to emergency officials, including mobility status, life-sustaining equipment needs, special needs, and communicable disease status. Facilities must also ensure compliance with HIPAA when sharing protected health information with emergency officials, and must plan for contingencies such as staff unavailability or community-wide emergencies that prevent patient transfer.
View official sourceE-0019 (Rev. 204, Issued: 04-16-21; Effective: 04-16-21, Implementation: 04-16-21) §418.113(b)(2), §460.84(b)(4), §484.102(b)(2) [(b) Policies and procedures. The [facilities] 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:] *[For homebound Hospice at §418.113(b)(2), PACE at §460.84(b)(4), and HHAs at §484.102(b)(2):] The procedures to inform State and local emergency preparedness officials about [homebound Hospice, PACE or HHA] patients in need of evacuation from their residences at any time due to an emergency situation based on the patient’s medical and psychiatric condition and home environment. Interpretive Guidelines applies to: §418.113(b)(2), §460.84(b)(4), §484.102(b)(2). NOTE: The regulatory language for hospices under §418.113(b)(2) does not include the terms “emergency preparedness” when describing officials. NOTE: This only applies to homebound Hospice, PACE and HHAs. Home bound hospices, HHAs and PACE organizations are required to inform State and local emergency preparedness officials of the need for patient evacuations. These policies and procedures must address when and how this information is communicated to emergency officials and also include the clinical care needed for these patients. For instance, in the event an in-home hospice, PACE organization or HHA patient requires evacuation, the responsible agency should provide emergency officials with the appropriate information to facilitate the patient’s evacuation and transportation. This should include, but is not limited to, the following: • Whether or not the patient is mobile. • What type of life-saving equipment does the patient require? • Is the life-saving equipment able to be transported? (E.g., Battery operated, transportable, condition of equipment, etc.) • Does the patient have special needs? (E.g., electricity-dependent, communication challenges, language barriers, intellectual disabilities, special dietary needs, etc.) • Is the patient a person under investigation (PUI), suspected exposure to or a confirmed case for any communicable diseases? Since such policies and procedures include protected health information of patients, facilities must also ensure they are in compliance with, as applicable, the Health Insurance Portability and Accountability Act (HIPAA) Rules at 45 CFR parts 160 and 164, as appropriate. See (81 FR 63879, Sept. 16, 2016). A level of pre-coordination activity with state and local emergency officials may be needed. Facilities should work with their state and local officials to determine how to coordinate the reporting of staff or patients who cannot be contacted. Emergency officials may include but are not limited to, emergency management departments/agencies (such as local FEMA or ASPR representatives), the state health department, CMS State Survey Agency or local response public emergency officials. (For additional information, please see standard (c)(2) [Tag E-0031] under the Communications Plan). Facilities should also account for contingency planning in the event that some staff are unaccounted for and how this relates to providing patient care. Finally, a facility’s policies and procedures should also outline a contingency plan in the event patients require evacuation but are unable to be transferred due to a community- wide impacted emergency. See also, tag E-0022 for policy and procedure requirements addressing shelter in place. Survey Procedures • Review the emergency plan to verify it includes procedures to inform State and local emergency preparedness officials about patients in need of evacuation from their residences at any time due to an emergency situation based on the patient’s medical and psychiatric condition and home environment.