Compliance with new Conditions of Participation (CoPs) for emergency preparedness has proven very difficult for many home health agencies. The Centers for Medicare and Medicaid Services (CMS) issued draft Interpretive Guidelines for the new CoPs for home health agencies on October 27, 2017. The draft provides information about what surveyors will be looking for when they survey agencies based on the new CoPs for emergency preparedness.
Below is the remainder of the list of the activities in which surveyors will engage during surveys with regard to emergency preparedness. In addition to the activities included in part one of this series, providers may wish to use this list as a checklist for preparation for surveys.
Here is the remainder of what surveyors will do:
Verify that all required contacts are included in communication plans by asking to see a list of contacts, including information about how to contact them
Verify that all contact information has been reviewed and updated at least annually by asking to see evidence of annual reviews
Review communication plans, including methods for sharing information and medical documentation for patients under agencies' care, as necessary, with other health providers to maintain continuity of care
Verify that agencies have developed policies and procedures that address the means agencies will use to release patient information, including the general condition and location of patients by reviewing communication plans
Verify communication plans, including the means of providing information about agencies' needs and their ability to provide assistance to authorities with jurisdiction, Incident Command Centers or designees
Verify that agencies have written training and testing programs that meet the requirements of applicable regulations
Verify that programs have been reviewed and updated on at least an annual basis by asking for documentation of annual reviews and any updates
Ask for copies of agencies' initial emergency preparedness training and annual educational programs thereafter
Interview various staff and ask questions about agencies' initial and annual training to verify staff knowledge of emergency procedures
Review a sample of staff training files to verify that staff members have received initial and annual emergency preparedness training thereafter
Ask to see documentation of annual tabletop and full scale exercises
Ask to see documentation of agencies' efforts to identify full-scale community based exercises, if they did not participate in such exercises, including date, personnel and agencies contacted and reasons for the inability to participate in community based exercises
Request documentation of agencies' analysis and response, and how agencies updated emergency programs based on these analyses
So, there it is: the complete "checklist" of what surveyors will do with regard to emergency preparedness during surveys. It's a tall order, but home care providers have done a lot of hard things!