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Disaster Preparedness Update: CMS Surveys and ASPRTRACIE's Home Care and Hospice Surge Project
9/25/2019
1
Disaster Preparedness Update: CMS Survey and ASPR TRACIE’s Home Care
and Hospice Surge Project
Disaster Preparedness Update: CMS Survey
Barbara Citarella RN, MS, CHCE, NHDP- BC
President
RBC Limited Healthcare & Management Consultants
www.rbclimited.com
Copyright 2019 RBC Limited 2
9/25/2019
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Final Rule Emergency PreparednessSeptember 16, 2016
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Why This Regulation?
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Natural Disasters The Worst Natural Disasters Of 2018
• Fall 2018 California Fires. 3 wildfires in California have displaced hundreds of thousands of people and destroyed thousands of homes
• Hurricane Michael• The Indonesia Earthquake And Tsunami.
Events in 2018
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• Transplant Centers
• Long-term Care Facilities
• Intermediate Care Facilities
• Home Health Agencies
• Comprehensive Outpatient Rehab
• Critical Access Hospitals
• Community Health Care Centers
Who Are the Providers
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• Organ Procurement Organizations
• Rural Health Clinics
• Federally Qualified Health Centers
• End-Stage Renal Disease Facilities
• Clinics, Rehabilitation Agencies, and Public Health Agencies as providers of outpatient physical therapy and speech language pathology services
Who Are the Providers
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• Hospitals
• Religious Non Medical Health Care Institutions
• Ambulatory Care Centers
• Hospice
• Psychiatric Residential Treatment Facilities
• PACE
Who Are the Providers
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Each Medicare provider can have its own plan or be part of a system plan as long as the
regulations for each provider can be met.
Integrated HealthCare Systems
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• Ensuring the safety and well being of patients and staff;• Maintaining continuity of care to patients;• Ensuring agency financial viability and continuity of business
operations;• Providing agency legal protection;• Ensuring appropriate utilization of resources; and• Supporting community and community partners during a disaster.
Supporting the critical infrastructure.
Source: CMS Federal Register Disaster Preparedness Rule 2016
Home Care and Hospice Role In The Regulation
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Emergency Preparedness Program
Plan
Policies
Communication
Train/Test
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• Risk assessment
• Establish a plan
• Policies and procedures that address the plan
• Communication plan
• Train and orient staff
• Test the plan
All Providers
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• Conducted by either health surveyors or Life Safety Code (LSC) surveyors
• Surveys are in conjunction with regularly scheduled survey cycles
• Information from November 2017 to September 2018
First Year Survey
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Source: CMS Presentation at 2018 National Healthcare Coalition Preparedness Conference
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Source: CMS Presentation at 2018 National Healthcare Coalition Preparedness Conference
Provider Types By Citation Ranking
• Nursing Facilities• ICF• ESRD• Home Health• Ambulatory Care• Rural Health• Hospice• Outpatient PT/ST• Hospitals
Source: CMS
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• EP Testing• EP Training and Testing• Develop and Maintain EP Program• Development of EP Policies and Procedures• Subsistence needs for staff and patients.
DEFICIENCY
Top 5 Deficiencies Overall
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Source: CMS Presentation at 2018 National Healthcare Coalition Preparedness Conference
• EP Testing
• EP Training Program
• EP Collaboration
• Policies and Procedures for Volunteers
• Maintain and Annual EP Updates
Top 5 Deficiencies for Home Care
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Source: CMS Presentation at 2018 National Healthcare Coalition Preparedness Conference
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Agencies should have a process for the role of integration of state and federally designated health care professionals to address surge needs. Health and Human Services coordinates three programs that maintain registries of health care volunteers.
• Emergency System for Advance Registration of Volunteer Health Professionals (ESAR-VHP)
• Medical Reserve Corps (MRC)
• National Disaster Medical System (NDMS).
Volunteer Use
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• EP Testing
• EP Training Program
• Maintain and Annual EP Updates
• Names and contact information
• Arrangements with other facilities
Top 5 Deficiencies for Hospice
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Source: CMS Presentation at 2018 National Healthcare Coalition Preparedness Conference
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• Lack of plans that meet regulations
• Lack of education and training
• Lack of partnerships
• Role expectation deficits
• Lack of policies as related to HVA
• Surveyors in some states want everything in the “plan”
Deficiencies/Issues
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Staffing Shortages
• Impact our ability to respond and having prepared staff
• Supporting the community
• Impact surge capability
Additional Concerns Home Care and Hospice Industry
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Inclusion in Plan: 1135 Waiver
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Orders of succession are a formal, sequential listing of organization positions (rather than specific names of individuals) that identify who is authorized to assume a particular
leadership or management role under specific circumstances.
Inclusion in Plan: Succession Planning
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2
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Ongoing Analysis Of Citations byCMS and ASPR TRACIE
The purpose of this effort is to:
‒ Identify ways to strengthen emergency preparedness efforts of
health care providers and suppliers at all levels (National; State;
Regional; and Local Healthcare Entity)
‒ Enhance technical assistance efforts
‒ Highlight variances
‒ Create a baseline of information that can be updated and
monitored
Copyright 2019 RBC Limited
ASPR Technical Resources, Assistance Center, Information Exchange (TRACIE)Home Care and Hospice Conference and ExpoOctober 15, 2019
Jennifer Nieratko, MPH, ICF TRACIE Special Projects Managerhttps://asprtracie.hhs.gov/
Unclassified/For Public Use
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ASPR’s Priorities: Building Readiness for 21st Century Threats
Unclassified/For Public Use
ASPR TRACIE: Three Domains
• Self‐service collection of audience‐tailored materials
• Subject‐specific, SME‐reviewed “Topic Collections”
• Unpublished and SME peer‐reviewed materials highlighting real‐life tools and experiences
• Personalized support and responses to requests for information and technical assistance
• Accessible by toll‐free number (1844‐5‐TRACIE), email (askasprtracie@hhs.gov), or web form (ASPRtracie.hhs.gov)
• Area for password‐protected discussion among vetted users in near real‐time
• Ability to support chats and the peer‐to‐peer exchange of user‐developed templates, plans, and other materials
Unclassified/For Public Use
9/25/2019
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ASPR TRACIE‐Developed Resources
ASPRtracie.hhs.gov/tracie‐resources
Unclassified/For Public Use
CMS EP Rule Resource Examples• CMS EP Rule Resource Page
• CMS and Disasters: Resources at Your Fingertips
• CMS EP Rule General Briefing Slides
• CMS Emergency Preparedness Rule: Integrated Healthcare Systems Implications
• Provider and Supplier Types Covered by the CMS Emergency Preparedness Rule
• Facility‐Specific Requirement Overviews (16)
• CMS EP Rule Citation Analysis Project
Unclassified/For Public Use
9/25/2019
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HCCs: Coordinating a Regional Approach to Health Care and Medical ResponseAn HCC is a group of individual health care and response organizations in a defined geographic location. HCCs play a critical role in developing health care preparedness and response capabilities.
Unclassified/For Public Use
Expanding Health Care and Medical Response Coordination
• Urgent Care Centers
• Health Clinics (Federally Qualified Health Centers, Rural Health Clinics)
• Practice‐Based Primary Care Providers
• Accountable Care Organizations
• Home Health and Hospice Agencies
Unclassified/For Public Use
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Medical Surge and the Role of Home Health and Hospice
• Sought to learn what role Medicare‐certified home health and hospice agencies saw for themselves in emergency preparedness and response.
• Recruited convenience sample of home health and hospice agency leaders through outreach by the National Association of Home Care & Hospice.*
* Online survey and telephone interviews were conducted in accordance with the Paperwork Reduction Act under Office of Management and Budget Control Number 0990‐0379, approved February 1, 2019. ICF’s IRB reviewed and determined the project was exempt from IRB review on January 18, 2019.
Unclassified/For Public Use
Project Participants
• Analyzed data from 245 online survey responses and 25 telephone interviews with home health and hospice agency leaders.
• Participants represented 43 states in all 10 HHS regions.
Unclassified/For Public Use
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Services Provided by Survey Participants
89
42
39
30
15
0 10 20 30 40 50 60 70 80 90 100
Home Health Care
Home Hospice Care ‐ in a private residence
Home Hospice Care ‐ in a residential facility
Inpatient Hospice Care ‐ in a hospital or nursing facility
Inpatient or Home Hospice Care ‐ in a hospice agency‐ownedfacility or hospice agency‐owned space in another entity's
facility
% of Participants
n = 245
Unclassified/For Public Use
Participation in Preparedness Activities
• Home health and hospice leaders reported their agencies participated in coordinated emergency preparedness activities with a variety of partners.
• Ranged from active involvement to being unable to establish partnerships.
n=[VALUE], 72%
n=[VALUE], 69%
n=[VALUE], 66%
n=[VALUE], 62%
n=[VALUE], 54%
n=97, 40%
n=[VALUE], 6%
Emergency Management Agency
Healthcare Coalition
Hospital(s) in the Community
Health Department
Nursing or Long‐term Care Facility(ies)
Non‐profit Organizations
Other
Unclassified/For Public Use
n = 245
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Perceived Role in Emergency Response
• The majority of survey respondents believed their agency would have a role in the response to both an infectious disease outbreak and a natural disaster.
• However, some interviewees were unsure exactly what that response role would be.
YESn=[VALUE]
84%
YESn=[VALUE]
88%
NOn=[VALUE]
16%
NOn=[VALUE]
12%
Infectious Disease Outbreak (n=243) Natural Disaster (n=244)
Unclassified/For Public Use
Potential Services in Hospice Agency‐Owned Facility or Space
79%
92%
71%
42%
29%
92%
71%
88%
54%
38%
0% 20% 40% 60% 80% 100%
Medical Care for Low Acuity Patients
Prophlyaxis/Vaccination
Patient Triage
Behavioral Health Support/Treatment forStaff
Behavioral Health Support/Treatment forPatients
Natural Disaster Infectious Disease Outbreak
Unclassified/For Public Use
n = 24
• 15% of survey respondents provide hospice services in facilities or spaces owned by their agencies.
• Most reported they could provide patient triage, prophylaxis or vaccination, or low acuity patient care in the event of an emergency in their community.
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Tested Ability to Implement Emergency Procedures
• Home health and hospice agencies have tested their ability to communicate and implement a variety of procedures and protocols either through preparedness exercises or a real‐life incident.
• Interviewees described elements of their business continuity plans, including having offsite servers, the ability to switch to paper records, access to GETS cards for communications, and agreements with partners for office space or patient care.
n=[VALUE], 76%
n=[VALUE], 74%
n=[VALUE], 73%
n=[VALUE], 71%
n=[VALUE], 64%
n=[VALUE], 59%
n=[VALUE], 56%
n=[VALUE], 56%
n=[VALUE], 52%
n=[VALUE], 40%
n=[VALUE], 28%
n=[VALUE], 32%
n=[VALUE], 54%
n=[VALUE], 18%
n=[VALUE], 14%
n=[VALUE], 26%
n=[VALUE], 25%
n=[VALUE], 48%
Establish incident command
Maintain patient records (i.e., paper‐based) ifelectronic health record is inaccessible
Receive/send notifications to otherpreparedness/response partners
Contact staff during off hours
Evacuate staff and patients
Financial preparedness
Procedures to shut down operations
Procedures to restart operations
Contact patients during off hours
Yes – through an exercise Yes – through a real‐life emergency
Unclassified/For Public Use
n = 243
Previous Experience in Emergency Response
• Nearly two‐thirds of those surveyed have been involved in the response to an emergency or disaster.
• Interviewees reported responding to: hurricanes, fires, flooding, tornadoes, winter weather, shooting/bomb threats, power outages, water breaks, and cybersecurity incidents.
• Based on those experiences, they updated communications systems and plans, revised procedures for power outages, added scenarios to their emergency plans, and worked to improve tracking systems for evacuated patients.
YESn=[VALUE]
63%
NOn=[VALUE]
37%
Unclassified/For Public Use
n = 245
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Factors to Facilitate Participation in Preparedness and Response
• Interviewees mentioned access to communication equipment or technology, funding for time spent on preparedness, a structured system to integrate into community response, better collaboration with community partners, and SME guidance as helpful.
• Tailoring resources and adapting requirements for small or rural agencies were also mentioned.
n=[VALUE], 72%
n=[VALUE], 63%
n=[VALUE], 56%
n=[VALUE], 55%
n=[VALUE], 39%
n=[VALUE], 37%
n=[VALUE], 36%
n=[VALUE], 7%
n=[VALUE], 55%
n=[VALUE], 56%
n=[VALUE], 46%
n=[VALUE], 44%
n=[VALUE], 42%
n=[VALUE], 37%
n=[VALUE], 32%
Access to Additional Training and Exercises
Inclusion in Notification/Information Sharing
Funding/Reimbursement
Guidance/SME Support/Technical Assistance
Access to Additional Personnel
Legal Protections
Access to Supplies/Equipment
Other
Preparedness Activities Response Activities
Unclassified/For Public Use
n = 229
Challenges in Meeting CMS Final Rule Requirements
• Collaborating and engaging with community response partners was the greatest challenge mentioned by survey respondents and interviewees.
• Those who have successfully addressed this challenge reported very positive interactions with partners.
n=[VALUE], 66%
n=[VALUE], 57%
n=[VALUE], 31%
n=[VALUE], 21%
n=[VALUE], 21%
n=[VALUE], 15%
n=[VALUE], 15%
Collaborating and Engaging with other CommunityEmergency Response Partners
Conducting/Participating in Emergency PreparednessExercises
Developing/Maintaining an Emergency PreparednessTraining Program
Developing Emergency Preparedness Plans forPatients
Developing/Maintaining an Emergency PreparednessCommunication Plan
Developing/Implementing Emergency PreparednessPolicies and Procedures
Developing/Maintaining Emergency Plan n = 234
Unclassified/For Public Use
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Barriers Contributing to Challenges in Meeting CMS Final Rule Requirements• Lack of time was
overwhelmingly identified as the greatest barrier to meeting CMS Final Rule requirements.
• Interviewees also mentioned having a geographically dispersed staff, finding partners, uncertainty about their overall role, and preparedness not being a priority for their patients as challenges.
n=[VALUE], 64%
n=[VALUE], 38%
n=[VALUE], 37%
n=[VALUE], 33%
n=[VALUE], 20%
n=[VALUE], 12%
Not Enough Time to Devote to PreparednessGiven Other Competing Responsibilities/Priorities
Unsure of Role/Not Engaged in CommunityPlanning for Emergency Response
Continually Changing Patient Population/CareSetting
Lack of Staff Expertise in Emergency Management
Other
Unsure how to Access Technical Assistance toImprove Understanding of CMS Final Rule
Requirements
Unclassified/For Public Use
n = 236
Key Findings• Home health and hospice have capabilities that could be valuable in responding to
a medical surge, but the overall emergency management role of home health and hospice has not been clearly defined in most communities.
• Wide variation exists in the capacity and infrastructure of home health and hospice with particularly limited resources among those in rural areas or with less established community partnerships.
• Most home health and hospice agencies reported engagement in coordinated emergency preparedness activities with various partners, but also noted collaboration is challenging.
• Awareness of CMS Final Rule requirements is high, but home health and hospice would benefit from training and technical assistance to support their implementation efforts.
Unclassified/For Public Use
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Opportunities to Improve Preparedness
• Better define the role of Medicare‐certified home health agencies and hospices in overall community emergency management efforts.
• Increase the quality of engagement of home health and hospice with healthcare coalitions and other community partners.
• Enhance mechanisms for communication and collaboration among home health and hospice and the other healthcare providers and facilities who provide services to their patients.
• Promote opportunities for knowledge exchange and learning, particularly highlighting the lessons learned of home health agencies and hospices with emergency response experience.
• Support home health and hospice in implementing CMS Final Rule requirements, particularly through targeted training, technical assistance, funding, and other resources.
Unclassified/For Public Use
Available Resources• Full report:
https://files.asprtracie.hhs.gov/documents/aspr‐tracie‐medical‐surge‐and‐the‐role‐of‐home‐health‐and‐hospice‐full‐report.pdf
• Summary: https://files.asprtracie.hhs.gov/documents/aspr‐tracie‐medical‐surge‐and‐the‐role‐of‐home‐health‐and‐hospice‐summary‐final.pdf
• Q&A document: https://files.asprtracie.hhs.gov/documents/aspr‐tracie‐engagement‐of‐home‐health‐and‐hospice‐agencies‐in‐medical‐surge‐activities‐q‐and‐a.pdf
Unclassified/For Public Use
9/25/2019
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ASPR Programs
• Critical Infrastructure Protection Program (CIP): www.phe.gov/Preparedness/planning/cip
• Division for At‐Risk Individuals, Behavioral Health & Community Resilience (ABC): www.phe.gov/Preparedness/planning/abc
• emPOWER: https://empowermap.hhs.gov/
• Hospital Preparedness Program (HPP): www.phe.gov/preparedness/planning/hpp
• Biomedical Advanced Research and Development Authority: https://www.phe.gov/about/barda/Pages/default.aspx
Unclassified/For Public Use
Contact Us
asprtracie.hhs.gov 1‐844‐5‐TRACIE askasprtracie@hhs.gov
Unclassified/For Public Use
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