This federal emergency preparedness regulation requires healthcare facilities to develop and implement policies and procedures addressing the use of volunteers and other emergency staffing strategies during a surge, including integration of State and Federally designated health care professionals. Facilities must plan for surge scenarios arising from natural disasters, infectious disease outbreaks, and pandemics, and must address credentialing and privileging of volunteer healthcare professionals. Policies must be reviewed at least every two years (annually for long-term care facilities) and aligned with the facility's risk assessment and communication plan. This tag applies across a broad range of CMS-regulated provider types as listed in the cited CFR sections.
View official sourceE-0024 (Rev. 204, Issued: 04-16-21; Effective: 04-16-21, Implementation: 04-16-21) §403.748(b)(6), §416.54(b)(5), §418.113(b)(4), §441.184(b)(6), §460.84(b)(7), §482.15(b)(6), §483.73(b)(6), §483.475(b)(6), §484.102(b)(5), §485.68(b)(4), §485.625(b)(6), §485.727(b)(4), §485.920(b)(5), §491.12(b)(4), §494.62(b)(5). [(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:] (6) [or (4), (5), or (7) as noted above] The use of volunteers in an emergency or other emergency staffing strategies, including the process and role for integration of State and Federally designated health care professionals to address surge needs during an emergency. *[For RNHCIs at §403.748(b):] Policies and procedures. (6) The use of volunteers in an emergency and other emergency staffing strategies to address surge needs during an emergency. *[For Hospice at §418.113(b):] Policies and procedures. (4) The use of hospice employees in an emergency and other emergency staffing strategies, including the process and role for integration of State and Federally designated health care professionals to address surge needs during an emergency. Interpretive Guidelines applies to: §403.748(b)(6), §416.54(b)(5), §418.113(b)(4), §441.184(b)(6), §460.84(b)(7), §482.15(b)(6), §483.73(b)(6), §483.475(b)(6), §484.102(b)(5), §485.68(b)(4), §485.625(b)(6), §485.727(b)(4), §485.920(b)(5), §491.12(b)(4), §494.62(b)(5). NOTE: This does not apply to Transplant Programs, or OPOs. Surge Planning Emergencies, whether natural disasters, man-made disasters or infectious disease outbreaks, stress our healthcare systems through challenges with capacity and capability. While it is not possible to predict every scenario which could result in surge situations, healthcare facilities must have policies and procedures which include emergency staffing strategies and plan for emergencies. These strategies encompass procedures to preserve the healthcare system while continuing to provide care for all patients, at the appropriate level (e.g., home-based care, outpatient, urgent care, emergency room, or hospitalization). Facilities must have policies which address their ability to respond to a surge in patients requiring care. As required, these policies and procedures must be aligned with a facility’s risk assessment, and should include planning for EIDs. Concentrated efforts will be required to mobilize all aspects of the healthcare system to reduce transmission of disease, direct people to the right level of care, and decrease the burden on the healthcare system. Surge Planning During Natural Disasters In most circumstances, staffing strategies and surge planning surrounding natural disasters such as hurricanes are generally event specific and focus on evacuations, transfers, and staffing assistance from areas which are not impacted by the emergency. For instance, in response to Hurricane Sandy and Hurricane Katrina, while these events were considered large-scale natural disasters, assistance was more accessible in relation to staffing assistance, response assistance from local, state and federal partners as well as management of supplies. Surge Planning for Infectious Diseases/Pandemics Infectious diseases by nature may rise to the level of pandemic, causing severe impact on response and staffing strategies within the healthcare system. The primary goals in planning for infectious disease pandemics are to: • Reduce morbidity and mortality • Minimize disease transmission • Protect healthcare personnel • Preserve healthcare system functioning Surge Planning Considerations Facilities are encouraged to consider development of policies and procedures that could be implemented during an emergency to reduce non-essential healthcare visits and slow surge within the facility, such as: • Instructing patients to use available advice lines, patient portals, and/or on-line self-assessment tools; • Call options to speak to an office/clinic staff and identification of staff to conduct telephonic interactions with patients; • Development of protocols so that staff can triage and assess patients quickly; • Determine algorithms to identify which patients can be managed by telephone and advised to stay home, and which patients will need to be sent for emergency care or come to your facility. NOTE: Facilities are required to have a risk assessment in accordance with E-0004, however we recommend that facilities also consider implications or evaluation of staffing needs. For instance, if a facility identifies a particular hazard, the facility should consider what staffing needs are required to ensure patients continue to receive care. Volunteers- Medical and Non-Medical During an emergency, a facility may also need to accept volunteer support from individuals with varying levels of skills and training. The facility must have policies and procedures in place to facilitate this support. In order for volunteering healthcare professionals to be able to perform services within their scope of practice and training, facilities must include any necessary privileging and credentialing processes in its emergency preparedness plan policies and procedures. Non-medical volunteers would perform non-medical tasks. Facilities have flexibility in determining how best to utilize volunteers during an emergency as long as such utilization is in accordance with State law, State scope of practice rules, and facility policy. These may also include federally designated health care professionals, such as Public Health Service (PHS) staff, National Disaster Medical System (NDMS) medical teams, Department of Defense (DOD) Nurse Corps, Medical Reserve Corps (MRC), or personnel such as those identified in federally designated Health Professional Shortage Areas (HPSAs) to include licensed primary care medical, dental, and mental/behavioral health professionals. Facilities are also encouraged to collaborate with State-established volunteer registries, and where possible, State-based Emergency System for Advanced Registration of Volunteer Health Professionals (ESAR-VHP). Facilities are expected to include in its emergency plan a method for contacting off-duty staff during an emergency and procedures to address other contingencies in the event staff are not able to report to duty which may include, but are not limited to, utilizing staff from other facilities and state or federally-designated health professionals. We would recommend that facilities include policies and procedures on the use of volunteers including if a facility chooses not to use volunteers, however at a minimum, the facility must have policies and procedures which address emergency staffing strategies. Providers and suppliers should have policies and guidelines for sheltering volunteers and any State and Federally designated health care professionals to address surge needs during an emergency. Facilities must determine their policies based on the emergency and the types of volunteers that may be present during and after an emergency (81 FR at 63881). Resources Facilities are recommended to review the tools available related to planning for surge. ASPR TRACIE has developed multiple documents which could provide additional assistance during the development of policies and procedures, which include but are not limited to https://asprtracie.s3.amazonaws.com/documents/aspr-tracie-considerations- for-the-use-of-temporary-care-locations-for-managing-seasonal-patient-surge.pdf Survey Procedures • Ask facility leadership to explain their staffing strategies. Do they use volunteers? Do they have other emergency staffing strategies, if no volunteers are used? • Verify the facility has included policies and procedures for the use of volunteers and other emergency staffing strategies in its emergency plan. • Verify that the facility’s program includes a policy and procedure which addresses surge needs during an emergency.