Birth of a New CoP for Medicare Hospice, Part 2

Part two of the three-part series will focus on the first two standards of the final rule for Medicare and Medicaid Programs; Emergency Preparedness Requirements for Medicare and Medicaid Participating Providers and Suppliers (CMS-3178-F) for hospice providers. 

The Emergency Plan

The first standard in this new hospice Condition of participation (CoP) at §418.113 (a) requires the hospice to develop and maintain an emergency preparedness program that complies with all of the outlined requirements and applicable Federal, State, and local emergency preparedness requirements and is reviewed/updated at least annually.  The basis of the plan rests on the completion and documentation of a facility-based and community-based risk assessment, utilizing an all-hazards approach. Based on the outcomes of this assessment, the hospice will identify strategies for addressing emergency events identified by the risk assessment, including the management of the effects of power outages, natural disasters, and other emergencies that would affect the hospice's ability to provide patient/ family care[i].

The hospice must also address their patient population by determining what type of services they can provide in during an emergency and how the services will be delivered and how continuity of operations will be maintained, including delegation of authority and development of a succession plan.  The hospice provider must also map out their process for coordinating and cooperating with local, tribal, regional, State, or Federal emergency preparedness officials' efforts with the aim of maintaining an integrated response during a disaster or emergency response situation.  The hospice must document their attempts to contact these officials and, when applicable, of their involvement in collaboration and coordination in planning[ii]. 

Hospice providers should check with their state for emergency preparedness resources such as hazard risk assessment tools and emergency plan templates.  There are also Federal risk assessment resources available from the Federal Emergency Management Agency (FEMA).  Ready.gov has a helpful risk assessment tool for providers to use to document their all hazards risk assessment outcomes.  

Policies and Procedures

The second standard of the new CoP at §418.113(b) requires a hospice provider to develop and implement emergency preparedness policies and procedures, based on the emergency plan, the facility-based and community-based risk assessment, the communication plan, and the training and testing program. The communication plan and training and testing program requirements will be discussed in Part three of this blog series. The hospice organization’s policies and procedures must be reviewed and updated at least annually just like the emergency plan.  There are minimal requirements for the policies and procedures including: 

• Processes for follow up with on-duty staff and patients to determine services that are needed, in the event that there is an interruption in services during or due to an emergency and how hospice staff will be used in emergency as well as other emergency staffing strategies.
• Measures to inform State and local officials about hospice patients in need of evacuation from their residences at any time due to an emergency situation based on the patient's medical and psychiatric condition and home environment.
• Structure and processes to preserve patient information and clinical documentation that is HIPAA security compliant and maintains access to records.
• The establishment of arrangements with other hospices and other providers to receive patients if there are limitations or interruption of hospice operations to maintain the continuity of services to patients[iii].

When §418.113 goes into effect in 2017, the current CoP requirements at §418.110 Condition of participation: Hospices that provide inpatient care directly, Standard: Physical environment will be eliminated.  The policies and procedures that are additional requirements for hospice-operated inpatient care facilities only must include the following: 

•  A process to shelter in place for patients, hospice employees who remain in the hospice.
• An evacuation plan from the hospice facility which includes consideration of care and treatment needs of evacuees; staff responsibilities; transportation; identification of evacuation site(s) and principle and alternate modes of communication with external sources for assistance.
• A plan to meet the sustenance need of hospice patients and staff including food, water, medical, and pharmaceutical supplies if they evacuate to an alternative site; the means to provide a temperature controlled environment to protect patient health and safety and for the safe and sanitary storage of provisions; emergency lighting, fire detection, alarms, and management; and sewage and waste disposal.
• Plan for functioning under a Federal 1135 waiver [iv] for the provision of patient care and treatment at an alternate care site identified by emergency management officials.
• Development of a system to track the location of hospice employees' on-duty and sheltered patients in the hospice's care during an emergency.

o   If the on-duty employees or sheltered patients are relocated during the emergency, the hospice must document the specific name and location of the receiving facility or other location[v].

The last two standards of this new CoP will be discussed in Part 3 of this blog series. (Read Part 1.)

Jennifer Kennedy, MA, BSN, RN, CHC
NHPCO Senior Director, Regulatory & Quality 

---

[i] Medicare and Medicaid Programs; Emergency Preparedness Requirements for Medicare and Medicaid Participating Providers and Suppliers; Final Rule. (2016, Sep16). Retrieved from https://www.gpo.gov/fdsys/pkg/FR-2016-09-16/pdf/2016-21404.pdf

[ii] Medicare and Medicaid Programs; Emergency Preparedness Requirements for Medicare and Medicaid Participating Providers and Suppliers; Final Rule. (2016, Sep16). Retrieved from https://www.gpo.gov/fdsys/pkg/FR-2016-09-16/pdf/2016-21404.pdf

[iii] Medicare and Medicaid Programs; Emergency Preparedness Requirements for Medicare and Medicaid Participating Providers and Suppliers; Final Rule. (2016, Sep16). Retrieved from https://www.gpo.gov/fdsys/pkg/FR-2016-09-16/pdf/2016-21404.pdf

[iv] Centers for Medicare and Medicaid Services. (2009, Nov 4). Retrieved from https://www.cms.gov/About-CMS/Agency-Information/H1N1/downloads/requestingawaiver101.pdf

[v] Medicare and Medicaid Programs; Emergency Preparedness Requirements for Medicare and Medicaid Participating Providers and Suppliers; Final Rule. (2016, Sep16). Retrieved from https://www.gpo.gov/fdsys/pkg/FR-2016-09-16/pdf/2016-21404.pdf