The Center for Clinical Standards and Quality/Quality, Safety & Oversight Group updated guidance for surveyors in QSO-21-15-ALL which revised emergency preparedness considering the Public Health Emergency (PHE).

We have all seen how emerging infectious disease (EID) outbreaks can affect any agency in any location across the country, therefore your emergency preparedness program needs to include EID and pandemics. The goal is that the Emergency Preparedness program (EP) program will include how an agency will plan, coordinate and respond to a localized and widespread pandemic, such as with the 2019 Novel Coronavirus (COVID-19) PHE. In addition, Agencies should ensure their emergency preparedness programs are aligned with their State and local emergency plans/pandemic plans.

With lessons learned during the pandemic, Agencies should ensure revisions to their EP plans. As we have seen, EID outbreaks are a potential threat which can impact the operations and continuity of care for long periods of time.


Emergency Preparedness Plan


As was revised November 2019, The EP plan must be reviewed every 2 years. However, agencies would have had to review and update their EP plans- and train their staff as the plan changes, which it likely has during the pandemic.

Since the EP program is comprehensive and includes all potential natural or man-made disasters or EID outbreaks, your agency may have had to deal with not only the pandemic, but also a polar vortex knocking out power and water for weeks. The more you can do to be prepared for emergencies and disasters, the better you will do when they occur.


Essential Services and Continuity of Care


Business continuity is the agency’s ability to continue operations or services related to patient care and to ensure patient safety and quality of care is continued in an emergency event.

  • To accomplish this, during EID outbreaks, you may have to update your agency facility protocols to protect the health and safety of patients, such as isolation and personal protective equipment (PPE) measures.
  • Since contractors and suppliers may be subject to the same hardships as the community they serve, there are no guarantees in the event of a disaster that the contractor would be able to fulfill their duties. Therefore, the emergency plan should reflect contingency planning.


Risk Assessments Using All-Hazards Approach


The risk assessment does not have to be a specific format but does include pandemics and EID, unforeseen widespread communicable diseases, as well as natural and man-made disasters. A risk assessment is facility-based and community-based and considers an agency’s patient population and vulnerabilities.

For public health emergencies, such as a pandemic, planning should include a process to evaluate the facility’s needs based on the specific characteristics of an EID that includes things we have done during COVID-19, such as, need for PPE, considerations for screening and/or testing patients and staff, transfers or discharges of patients; physical environment, including but not limited to changes needed for distancing, quarantine and masking.

At-risk populations, in the event of emerging infectious diseases and communicable diseases, may also include older adults and people of any age with underlying medical conditions or who are immunocompromised, in which exposure may place them at higher risk for severe illnesses. As we know home health and hospice agencies have a large percentage of high-risk patients.


Surge & Staffing


Ensuring continuity of operations, which includes staffing, should be a major part of an agency’s EP. In the event of short staffing, as in an EID outbreak, where staff themselves are in quarantine, means that active patients may have to be transferred, and referrals stopped. By including these in your emergency plan, you will have identified options and action items before an actual dire staffing shortage occurs.

Delegations of authority and succession plans should also be documented so that operations go uninterrupted and patient care and safety are maintained.


Collaboration with Community, State and Federal Partners


Coordination with the community healthcare systems and local and state health departments is important while in a PHE, therefore, needs to be part of your EP planning and testing. Agencies have to ensure that their EP includes delegating an individual to monitor guidance by public health agencies and issuing directives and recommendations to staff such as use of PPE when entering the building; isolation of patients under investigation (PUIs); and any other applicable guidance in a public health emergency.


Hospice Specifics in the QSO Memo


Hospices must develop policies and procedures that address the use of hospice employees in an emergency and the hospices’ potential surge needs. EP would include policies and procedures to maintain the continuity of services to hospice patients and for the IDG to discuss patient transfers, contact community partners accordingly.

Policies and procedures include the requirement to follow up with on duty staff and patients to determine services that are needed, should an interruption in services occur during or due to an emergency. These include staffing shortages, staff ability to provide safe care, to include any potential needs such as PPE. In addition, policies regarding screening phone calls prior to arrival and prior to entering a home as well as ways to decontaminate equipment and procedures to limit equipment taken into homes.


Home Health Specifics


Each patient’s written plan of care specifies the care and services necessary to meet the patient specific needs identified in the comprehensive assessment. Therefore, the communication plan contact information should also include patient’s physicians or allowed practitioners, as well as additional practitioners, so they can be notified. This reflects the interdisciplinary, coordinated approach to home health care delivery consistent with the HHA regulations.

HHAs need potential contingency operations within their policies in their EP. An example for surveyors in the QSO memo is, “How will the HHA ensure the appropriate discipline/staff perform the required initial and comprehensive assessments when access to residences may be hindered due to an emergency?” While some contingency plans are in the 1135 Waivers due to the PHE, such as allowing telephone calls for the initial assessments, HHAs must look at other issues, such as the comprehensive assessment must be onsite in the patient’s home, and identify alternative staffing options, of course acting in accordance with their state scope of practice laws. Some planning can include for example, if patients are unable to be seen in the home for comprehensive assessment, then the HHA must inform the physician that home health cannot admit the patient at this time, which will require the physician to find alternate care options for the patient.

Home health must report staff or patients who cannot be contacted, as well as patients in need of evacuation. Therefore, the agency may need to do pre-coordination activities with state and local emergency officials as part of the EP. It is important for the policies and procedures to align with the agency’s communication plans. In addition, the QSO memo states that “The policies and procedures for this must outline timeframes for check-in with the agency; e.g., staff check-ins every 2 or 4 hours while on shift and every 8 when off duty”.

The EP needs to address an agency’s primary and alternate means of communication. For instance, a primary means of communication may be cell phone and hard wire lines, but what happens when the power ends… so, alternate means such as satellite phones, radio, and shortwave radio need to be addressed by agencies.


Hospice and Home Health Training


The training program must be based on the Agency’s risk assessment and incorporate its policies and procedures, as well as its communication plan within training for staff.

Training should include individual-based response activities in the event of a natural disasters, such as what the process is for staff in the event of a forecasted hurricane. It should also include the policies and procedures on how to shelter-in-place or evacuate. Training should include how the facility manages the continuity of care to its patient population, such as triage processes and transfer/discharge during mass casualty or surge events.

In addition, the facility must train staff based on the facility’s risk assessment. Training for staff should mirror the facility’s emergency plan and should include training staff on procedures that are relevant to the hazards identified. For example, for EID outbreaks, this may include proper use of PPE, assessing needs of patients and how to screen patients and provide care based on the facility’s capacity and capabilities and communications regarding reporting and providing information on patient status with caregiver and family members.

Facilities must also be able to demonstrate additional training when the emergency plan is significantly updated.

Ensure that when a surveyor asks them, the staff can state their role in the agency’s EP – rather than giving the “Deer in the Headlight” look I get often during mock surveys.


Home Health and Hospice Testing


Agencies are required to conduct one testing exercise on an annual basis, which may be either one community-based full-scale exercise, if available, or an individual facility-based functional exercise. The opposite year, the agency may choose the testing exercise of their choice, which can include either another full-scale, individual facility-based, a mock disaster drill (using mock patients), tabletop exercise or workshop which includes a facilitator. Testing must be based on the Agency’s risk assessment, policies and procedures and communication plan customized to support the patient population it serves. Testing should include EID outbreaks.

The intent is to provide comprehensive testing and training for staff, volunteers, and individuals providing services under arrangement as well community partners.

After the testing, the agency must analyze the HHA’s response and revise the HHA’s emergency plan, as needed. The intent is to identify gaps in the EP as it relates to responding to various emergencies and ensure staff are knowledgeable of the EP program. In the event gaps are identified, Agencies should update their EP programs as outlined within the requirements for After-Action Report (AAR).


Participation in Testing


The regulations do not specify a minimum number of staff, or the roles of staff that must participate in the exercises. HHAs can review which members of staff participated in the previous exercise and include those who did not participate in the subsequent exercises to ensure all staff members have an opportunity to participate and gain insight and knowledge.

When an agency has an actual emergency event or response of sufficient magnitude that requires activation of the emergency plans to meet the full-scale exercise requirement, this would exempt them from engaging in their next required community-based full-scale exercise or individual, facility-based exercise following the actual event. Facilities must be able to demonstrate this through written documentation. As agencies are required to conduct full-scale exercises only every other year, opposite of their exercises of choice, these facilities are exempt from their next required full-scale or individual facility-based exercise. The intent is to ensure that facilities conduct at least one exercise per year.

HHAs must document that they had activated their emergency program based on an actual emergency. Documentation may include, but is not limited to, 1135 waiver (time limited and event-specific), documentation alerting staff of the emergency, and/or meeting minutes which addressed the time and event specific information. The HHA must also have completed an after-action review and integrated corrective actions into their emergency preparedness program. It is recommended that HHAs retain, at a minimum, the past 2 cycles (4 years) of emergency testing exercise documentation. This would allow surveyors to assess compliance on the cycle of testing required for HHAs.


Healthcare Provider Solutions is prepared to assist agencies in review or development of their Emergency Preparedness Plans and Updates.

HPS Alliance members have access to Emergency Preparedness Tools on our website that do include the updates for 2021. If you are not an HPS Alliance member Join Today!

If you need additional information feel free to Contact Us, HPS is always here to support you.