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CMS' new emergency preparedness rules

March 15, 2017
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  • Alternate sources of energy to maintain temperatures to protect resident health and safety, safe storage of provisions, emergency lighting, fire detection, extinguishing and alarm systems, and sewage and waste systems.
  • A system to track the location of on-duty staff and sheltered residents in the LTC facility’s care during and after emergency.
  • If on-duty staff and sheltered residents are relocated during emergency, facilities must document the specific names and location or the receiving facility or other locations.
  • Safe evacuation includes: care and treatment of evacuees; staff responsibilities; transportation; identification of evacuation location(s); primary and alternate means of communication with external sources of assistance.
  • Means to shelter in place for residents, staff, volunteers who remain in the LTC Facility.
  • System of medical documentation that preserves, resident’s information, protects confidentiality of resident information, and secures and maintains the availability of records.
  • Use of volunteers in an emergency or other emergency staffing strategies, including the process and role for integration of state or federally designated health care professionals to address surge needs in emergency.
  • Role of the LTC facility under 1135 waiver in the provision of care and treatment at an alternate care site identified by emergency management officials.

My friend and colleague, Jocelyn Montgomery, Director of Clinical Affairs and Emergency Preparedness at the California Association of Health Facilities (CAHF) and Chairperson of the American Health Care Association’s Emergency Preparedness Committee, has developed an excellent summary document that highlights all the new requirements and includes some interpretive notes and resources that can help ensure compliance.

Communications Plan

Under the new regulations, providers will be required to develop and maintain an emergency preparedness communications plan that complies with federal state and local laws. This means that a specific plan must be developed to effectively communicate during an emergency or disaster within the facility to protect patient health and safety as well as communicate with other stakeholders including:

  • Other health care providers
  • State health departments
  • Local health departments
  • Emergency management systems and agencies

The communications plan needs to identify primary and all alternate modes of communications along with detailed contacts lists for the following:

  • Residents
  • Residents’ family members/responsible parties
  • Staff
  • Providers of all essential services, including supplies, equipment, transportation and other vendors and contractors
  • Residents’ physicians
  • Other LTC facilities
  • Other healthcare providers
  • Emergency Management Agencies (Federal, state, tribal, regional and local)
  • Ombudsman

The communication plan must also provide detailed information on the following:


Stan Szpytek

President, Fire and Life Safety, Inc.

Stan Szpytek

Stan Szpytek is the president of consulting firm Fire and Life Safety, Inc., in Mesa, Arizona,...