This federal emergency preparedness regulation requires multiple facility types—including hospices, PRTFs, hospitals, long-term care facilities, PACE organizations, ICFs/IID, critical access hospitals, CMHCs, ESRD facilities, and RNHCIs—to develop and implement policies and procedures for prearranged transfer agreements with other facilities and providers. These arrangements must ensure continuity of services to patients in the event of limitations or cessation of operations, and must be reviewed at least every two years (annually for LTC facilities). Facilities must document agreements in writing (e.g., MOUs, transfer agreements) and account for patient population, volume, and the receiving facility's capacity. Survey procedures require facilities to produce copies of these arrangements and explain transportation plans for evacuation scenarios.
View official sourceE-0025 (Rev. 204, Issued: 04-16-21; Effective: 04-16-21, Implementation: 04-16-21) §403.748(b)(7), §418.113(b)(5), §441.184(b)(7), §460.84(b)(8), §482.15(b)(7), §483.73(b)(7), §483.475(b)(7), §485.625(b)(7), §485.920(b)(6), §494.62(b)(6). [(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:] *[For Hospices at §418.113(b), PRFTs at §441.184,(b) Hospitals at §482.15(b), and LTC Facilities at §483.73(b):] Policies and procedures. (7) [or (5)] The development of arrangements with other [facilities] [and] other providers to receive patients in the event of limitations or cessation of operations to maintain the continuity of services to facility patients. *[For PACE at §460.84(b), ICF/IIDs at §483.475(b), CAHs at §486.625(b), CMHCs at §485.920(b) and ESRD Facilities at §494.62(b):] Policies and procedures. (7) [or (6), (8)] The development of arrangements with other [facilities] [or] other providers to receive patients in the event of limitations or cessation of operations to maintain the continuity of services to facility patients. *[For RNHCIs at §403.748(b):] Policies and procedures. (7) The development of arrangements with other RNHCIs and other providers to receive patients in the event of limitations or cessation of operations to maintain the continuity of non- medical services to RNHCI patients. Interpretive Guidelines applies to: §403.748(b)(7), §418.113(b)(5), §441.184(b)(7), §460.84(b)(8), §482.15(b)(7), §483.73(b)(7), §483.475(b)(7), §485.625(b)(7), §485.920(b)(6), §494.62(b)(6). NOTE: The differences for some providers and suppliers between “and” and “or” are referenced above. Additionally, the there are differences between continuity of “operations” and “services” within the regulatory language. NOTE: This does not apply to ASCs, Transplant Programs, HHAs, CORFs, Clinics, Rehabilitation Agencies and Public Health Agencies as Providers of Outpatient Physical Therapy and Speech-Language Pathology Services, OPOs, RHCs/FQHCs. Facilities are required to have policies and procedures which include prearranged transfer agreements, which may include written agreements or contracted arrangements with other facilities and other providers to receive patients in the event of limitations or cessation of operations to maintain the continuity of services to facility patients. Facilities should consider all needed arrangements for the transfer of patients during an evacuation. For example, if a CAH is required to evacuate, policies and procedures should address what facilities are nearby and outside the area of disaster which could accept the CAH’s patients. Additionally, the policies and procedures and facility agreements should include pre-arranged agreements for transportation between the facilities. The arrangements should be in writing, such as Memorandums of Understanding (MOUs) and Transfer Agreements, in order to demonstrate compliance. When developing transfer agreements, facilities should take into account the patient population and the ability for the receiving facility to provide continuity of services. If a facility has a transfer arrangement with another facility and this facility could not accommodate all patients, then the facility should plan accordingly to provide continuity of services with another facility who could receive the remaining residents. For ICFs/IID and LTC facilities, the facility is also responsible for the tracking of residents, therefore any written arrangements should account for the patient population, number of patients and the ability for the receiving facility or facilities to continue care to the residents/patients. Finally, as the regulation requires policies and procedures to be reviewed every 2 years (annually for LTC), facilities should also consider reviewing their developed arrangements on the same scheduled review timeframe to ensure the contract/agreement/MOU is still applicable and able to be fulfilled to provide continuity of care. For RNHCIs, at § 403.748(b)(7), the term “non-medical” is added in order to accommodate the uniqueness of the RNHCI non-medical care. Survey Procedures • Ask to see copies of the arrangements and/or any agreements the facility has with other facilities to receive patients in the event the facility is not able to care for them during an emergency. • Ask facility leadership to explain the arrangements in place for transportation in the event of an evacuation.