This federal CMS emergency preparedness regulation requires facilities to maintain a communication plan that includes a means of reporting the facility's needs and its ability to provide assistance to the authority having jurisdiction, the Incident Command Center, or designee. Hospitals, CAHs, RNHCIs, inpatient hospices, PRTFs, LTC facilities, and ICF/IIDs must additionally include a means of reporting occupancy information. The plan must be reviewed and updated at least every two years (annually for long-term care facilities). Surveyors will verify these elements are present in the facility's written communication plan.
View official sourceE-0034 (Rev. 204, Issued: 04-16-21; Effective: 04-16-21, Implementation: 04-16-21) §403.748(c)(7), §416.54(c)(7), §418.113(c)(7) §441.184(c)(7), §482.15(c)(7), §460.84(c)(7), §483.73(c)(7), §483.475(c)(7), §484.102(c)(6), §485.68(c)(5), §485.68(c)(5), §485.727(c)(5), §485.625(c)(7), §485.920(c)(7), §491.12(c)(5), §494.62(c)(7). [(c) The [facility] must develop and maintain an emergency preparedness communication plan that complies with Federal, State and local laws and must be reviewed and updated at least every 2 years [annually for LTC facilities]. The communication plan must include all of the following: (7) [(5) or (6)] A means of providing information about the [facility’s] occupancy, needs, and its ability to provide assistance, to the authority having jurisdiction, the Incident Command Center, or designee. *[For ASCs at 416.54(c)]: (7) A means of providing information about the ASC’s needs, and its ability to provide assistance, to the authority having jurisdiction, the Incident Command Center, or designee. *[For Inpatient Hospice at §418.113(c):] (7) A means of providing information about the hospice’s inpatient occupancy, needs, and its ability to provide assistance, to the authority having jurisdiction, the Incident Command Center, or designee. Interpretive Guidelines applies to: §403.748(c)(7), §416.54(c)(7), §418.113(c)(7), §441.184(c)(7), §460.84(c)(7), §482.15(c)(7), §483.73(c)(7); §483.475(c)(7); §484.102(c)(6); §485.68(c)(5), §485.625(c)(7); §485.727(c)(5); §485.920(c)(7); §491.12 (c)(5), §494.62(c)(7). NOTE: This does not apply to outpatient hospices or Transplant Programs. Facilities, except for transplant programs, must have a means of providing information about the facility’s needs and its ability to provide assistance to the authority having jurisdiction (local and State emergency management agencies, local and state public health departments, the Incident Command Center, the Emergency Operations Center, or designee). Reporting of a Facility’s Needs Generally, in small community emergency disasters, reporting the facility’s needs will be coordinated through developed processes to report directly to local and state emergency officials. Reporting needs may include but are not limited to: shortages in PPE; need to evacuate or transfer patients; requests for assistance in transport; temporarily loss of part or all facility function; and, staffing shortages. In large scale emergency disasters or pandemics, reporting of needs specific to a facility may be altered by local, state and federal public health and emergency management officials due to the potential volume of requests. Some emergency management officials at all levels of governance may require facilities to report specific data or slow reporting to manage volume. It is recommended that facilities verify their reporting requirements with their local Incident Command Structures or State Agencies. Dependent on the emergency event and the anticipated longevity, facilities may need to report select criteria such as in an EID outbreak or the number of patients’ positive or persons under investigation (PUI). The facility’s process should include monitoring by the facility’s emergency management coordinator or designee of reporting requirements issued by CMS or other agencies with jurisdiction. Additional monitoring and reporting may be required by local and state public health agencies due to contact tracing requirements for extended periods of time or for time specific intervals. Facilities should identify local and state policies for reporting and contract tracing to ensure they have appropriate information to address requirements. Facilities should actively engage with their healthcare coalitions, associations, accrediting organizations and other stakeholders during the onset of any wide-spread emergency. As state and federal emergency organizations may become overwhelmed with requests, these stakeholders may be able to reconcile needs-requests for specific providers and suppliers. In situations in which a Presidential Declaration and a Public Health Emergency (PHE) have been declared, and Section 1135 Waivers may be granted, these stakeholders (healthcare coalitions, associations, accrediting organizations and others) may have the ability to request and streamline 1135 waiver requests for their members, dependent on the severity of the emergency. Reporting of a Facility’s Ability to Provide Assistance During widespread disasters, reporting a facility’s ability to provide assistance is critical within a community. Pre-planning and collaborating with emergency officials before an emergency to determine what assistance may be necessary directly supports surge planning within a community. For instance, in preparation for a natural disaster such as a hurricane, pre-planning reporting criteria such as the facility’s response-- e.g. closing the outpatient services in a forecasted natural disaster-- may facilitate the Incident Command as they would be aware of the operating status of the facility. Reporting the ability to provide assistance would also include pre-planning with public health and emergency officials in the local community to make them aware of what capabilities are available within the specific facility, e.g. number of beds, critical care equipment, staffing, etc. During widespread disasters, facilities may be required to report the following to local officials: • Ability to care for patients requiring transfer from different healthcare settings; • Availability of PPE; • Availability of staff who may be able to assist in a mass casualty incident; • Availability of electricity-dependent medical and assistive equipment, such as ventilators and other oxygen equipment (BiPAP, CPAP, etc.), renal replacement therapy machines (e.g., home and facility-based hemodialysis, peritoneal dialysis, continuous renal replacement therapy and other machines, etc.), and wheelchairs and beds. Occupancy Reporting For hospitals, CAHs, RNHCIs, inpatient hospices, PRTFs, LTC facilities, and ICF/IIDs, they must also have a means for providing information about their occupancy. Occupancy reporting is considered, but not limited to, reporting the number of patients currently at the facility receiving treatment and care or the facility’s occupancy percentage. The facility should consider how its occupancy affects its ability to provide assistance. For example, if the facility’s occupancy is close to 100% the facility may not be able to accept patients from nearby facilities. The types of “needs” a facility may have during an emergency and should communicate to the appropriate authority would include but is not limited to, shortage of provisions such as food, water, medical supplies, assistance with evacuation and transfers, etc. NOTE: The authority having jurisdiction varies by local, state and federal emergency management structures as well as the type of disaster. For example, in the event of a multi-state wildfire, the jurisdictional authority who would take over the Incident Command Center or state-wide coordination of the disaster would likely be a fire-related agency. We are not prescribing the means that facilities must use in disseminating the required information. However, facilities should include in its communication plan, a process to communicate the required information. NOTE: As defined by the Federal Emergency Management Administration (FEMA), an Incident Command System (ICS) is a management system designed to enable effective and efficient domestic incident management by integrating a combination of facilities, equipment, personnel, procedures, and communications operating within a common organizational structure. (FEMA, 2016). The industry, as well as providers/suppliers, use various terms to refer to the same function and we have used the term ‘‘Incident Command Center’’ to mean ‘‘Emergency Operations Center’’ or ‘‘Incident Command Post.’’ Local, State, Tribal and Federal emergency preparedness officials, as well as regional healthcare coalitions, can assist facilities in the identification of their Incident Command Centers and reporting requirements dependent on an emergency. Survey Procedures • Verify the communication plan includes a means of providing information about the facility’s needs, and its ability to provide assistance, to the authority having jurisdiction, the Incident Command Center, or designee by reviewing the communication plan. • For hospitals, CAHs, RNHCIs, inpatient hospices, PRTFs, LTC facilities, and ICF/IIDs, also verify if the communication plan includes a means of providing information about their occupancy.