This federal CMS interpretive guideline requires a broad range of Medicare/Medicaid-certified facility types to develop and implement emergency preparedness policies and procedures specifically addressing safe evacuation, including consideration of patient care and treatment needs, staff responsibilities, transportation, identification of evacuation locations, and primary and alternate means of external communication. Facilities must also establish triage systems for prioritizing evacuation of patients based on acuity, mobility, and other factors, and must communicate patient care requirements to receiving facilities. Policies must be reviewed and updated at least every two years (annually for long-term care facilities). This regulation governs facility operations across numerous provider types but does not apply to HHAs, OPOs, or Transplant Programs.
View official sourceE-0020 (Rev. 204, Issued: 04-16-21; Effective: 04-16-21, Implementation: 04-16-21) §403.748(b)(3), §416.54(b)(2), §418.113(b)(6)(ii), §441.184(b)(3), §460.84(b)(3), §482.15(b)(3), §483.73(b)(3), §483.475(b)(3), §485.68(b)(1), §485.625(b)(3), §485.727(b)(1), §485.920(b)(2), §491.12(b)(1), §494.62(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 [annually for LTC facilities]. At a minimum, the policies and procedures must address the following:] [(3) or (1), (2), (6)] Safe evacuation from the [facility], which includes consideration of care and treatment needs of evacuees; staff responsibilities; transportation; identification of evacuation location(s); and primary and alternate means of communication with external sources of assistance. *[For RNHCIs at §403.748(b)(3) and ASCs at §416.54(b)(2):] Safe evacuation from the [RNHCI or ASC] which includes the following: (i) Consideration of care needs of evacuees. (ii) Staff responsibilities. (iii) Transportation. (iv) Identification of evacuation location(s). (v) Primary and alternate means of communication with external sources of assistance. * [For CORFs at §485.68(b)(1), Clinics, Rehabilitation Agencies, OPT/Speech at §485.727(b)(1), and ESRD Facilities at §494.62(b)(2):] Safe evacuation from the [CORF; Clinics, Rehabilitation Agencies, and Public Health Agencies as Providers of Outpatient Physical Therapy and Speech-Language Pathology Services; and ESRD Facilities], which includes staff responsibilities, and needs of the patients. * [For RHCs/FQHCs at §491.12(b)(1):] Safe evacuation from the RHC/FQHC, which includes appropriate placement of exit signs; staff responsibilities and needs of the patients. Interpretive Guidelines applies to: §403.748(b)(3), §416.54(b)(2), §418.113(b)(6)(ii), §441.184(b)(3), §460.84(b)(3), §482.15(b)(3), §483.73(b)(3), §483.475(b)(3), §485.68(b)(1), §485.625(b)(3), §485.727(b)(1), §485.920(b)(2), §491.12(b)(1), §494.62(b)(2) NOTE: This does not apply to HHAs, OPOs, and Transplant Programs. NOTE: The requirements under §418.113(b)(6)(ii) is not a requirement for outpatient hospice providers. Evacuations & Patient Population Considerations Facilities must develop policies and procedures that provide for the safe evacuation of patients from the facility and include all of the requirements of this standard. RHCs and FQHCs must also place exit signs to guide patients and staff in the event of an evacuation from the facility. Facilities must have policies and procedures which address the needs of evacuees. The facility should also consider in development of the policies and procedures, the evacuation protocols for not only the evacuees, but also staff members and families/patient representatives or other personnel who sought potential refuge at the facility. Additionally, the policies and procedures must address staff responsibilities during evacuations. Facilities must consider the patient population needs as well as their care and treatment. For example, if an evacuation is in progress and the facility must evacuate, leadership should consider the needs for critically ill patients to be evacuated and accompanied by staff who could provide care and treatment enroute to the designated relocation site, in the event trained medical professionals are unavailable by the transportation services. Facilities must consider in their development of policies and procedures, the needs of their patient population and what designated transportation services would be most appropriate. For instance, if a facility primarily cares for critically ill patients with ventilation needs and life-saving equipment, the transportation services should be able to assist in evacuation of this special population and be equipped to do so. Additionally, facilities may also find it prudent to consider alternative methods for evacuation and patient care and treatment, such as mentioned above to have staff members evacuate with patients in given situations. Triaging Considerations Additionally, facilities should consider their triaging system when coordinating the tracking and potential evacuation of patient/residents/clients. For instance, a triaging system for evacuation may consider the most critical patients first followed by those less critical and not dependent on life-saving equipment. Considerations for prioritization may be based on, among other things, acuity, mobility status (stretch- bound/wheelchair/ambulatory), and location of the unit, availability of a known transfer destination or some combination thereof. Included within this system should be who (specifically) will be tasked with making triage decisions. Following the triaging system, staff should consider the communication of patient care requirements to the in-taking facility, such as attaching a hard copy of a standard abbreviated patient health condition/history, injuries, allergies, and treatment rendered. Another method for communicating this information, a facility could consider color coordination of triage levels (i.e. green folder with this information is for less critical patients; red folders for critical and urgent evacuated patients, etc.). Additionally, this hard copy could include family member/representative contact information. This standard requires facilities to have policies and procedures which address safe evacuation from the facility. It would be prudent for facilities to consider how they would addresses a situation where a patient/resident refuses to evacuate and how they would handle the situation. In most cases, any reasonable person would likely choose to evacuate if ordered by the state/local community or if necessary as determined by the facility in a facility-specific event. It is expected that facilities provide care in a safe setting, therefore any existing guidance on patient rights and safe setting (e.g. §482.13(c)(2) for hospitals) should be continued. Patient safety should be the number one priority, therefore leaving a patient in an unsafe environment is not acceptable. The facilities policies and procedures must outline primary and alternate means for communication with external sources for assistance. For instance, primary methods may be via regular telephone services to contact transportation companies for evacuation or reporting evacuation needs to emergency officials; whereas alternate means account for loss of power or telephone services in the local area. In this event, alternate means may include satellite phones for contacting evacuation assistance. Triage and coordination of evacuation requires planning and communication of plans within the facility and with entities that assist in providing services such as transportation and life-saving equipment. Survey Procedures • Review the emergency plan to verify it includes policies and procedures for safe evacuation from the facility and that it includes all of the required elements. • When surveying an RHC or FQHC, verify that exit signs are placed in the appropriate locations to facilitate a safe evacuation. • Ask staff to describe how they would handle a situation in which a patient refused to evacuate.