Birth of a New CoP for Medicare Hospice, Part 3

This is part three of a three part series focusing on 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.  This article will discuss the last two standards of this new Condition of participation (CoP) for hospice providers. 

The Communication Plan

The third standard in this new hospice CoP at §418.113 (c) requires a hospice to develop and maintain an emergency preparedness communication plan that that complies with Federal, State, and local laws and is reviewed and updated at least annually.  The communication plan outlines the names and contact information for hospice staff, contracted partners, and patient physicians as well as Federal, State, tribal, regional, and local emergency preparedness staff.  The plan must outline primary and secondary means for communication with hospice staff and Federal, State, tribal, regional, and local emergency management agencies to ensure optimal coordination of care and services during a disaster[i].

The communication plan must also delineate the process of how a hospice will share information and clinical documentation for patients under their care with other health care providers and Federal, State, tribal, regional, and local emergency management agencies to preserve continuity of care.  The release of patient information is critical in the event of patient evacuation and is permitted under 45 CFR 164.510(b)(1)(ii) which discusses when a covered entity may use or disclose protected health information without the written consent or authorization of an individual.  For hospices with an inpatient facility, this process would also include how information about a hospice's inpatient occupancy, needs, and its ability to provide assistance would be communicated to Federal, State, tribal, regional, and local emergency management agencies.  The process of patient information exchange during a disaster response serves as a means to discern the general condition and location of patients under a hospice facility's care[ii].

Training and Testing
The final standard in the CoP at §418.113(d) requires a hospice provider to develop and maintain an emergency preparedness training and testing program that is based on the emergency plan, policies and procedures, and the communication plan and is reviewed and updated at least annually.  Depending on the size of the hospice and their geographic location, elements in this part of the requirement may be the most difficult to implement. 

The training program:   The emergency preparedness training program must educate new staff, existing staff, and contracted partners about the emergency plan, policies and procedures, and communication plan consistent with their expected roles at least annually. As with all training, staff competency needs to be assessed and documentation of training needs to be maintained[iii].

Testing the program: A hospice must conduct two exercises to test their emergency plan at least annually.  One of the exercises requires ‘boots on the ground’ participation in a full-scale exercise that is community-based or individually facility-based.  The second exercise may include, but is not limited to a second full-scale exercise that is community-based or individually facility-based or a tabletop exercise that includes a group discussion led by a facilitator who utilizes a narrated, clinically-relevant emergency scenario, and a set of problem statements, designed to test an emergency plan.  The hospice must analyze their response to the exercise and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the hospice's emergency plan, as needed based on the outcomes of the exercises.  If the hospice activates their emergency plan related to an actual natural or man-made emergency, they are exempt from engaging in a community-based or individually facility-based full-scale exercise for 1 year following the actual event[iv].

A hospice may be part of a healthcare system which includes multiple separately certified healthcare facilities.  If this is the case, that system may opt to have a combined and integrated emergency preparedness program and the hospice may choose to participate in the healthcare system's coordinated emergency preparedness program. In this scenario, the integrated emergency preparedness program must demonstrate that each provider within the system actively participated in the development of the unified emergency preparedness program and that it was developed and maintained related to the unique conditions, patient populations, and services offered by each provider.  This approach to compliance would need to include all of the required elements outlined in the CoP (emergency plan, policies and procedures, communication plan, and training and testing)[v].

(Read part one and part two.)

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

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[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] 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

[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