What Have We Learned So Far About the New EP Survey Process in 2018?
By CORTNEY KESTERSON, DPP COORDINATOR
Are you approaching your Fire-Life Safety/EP Survey window? Check out what CAHF DPP has learned so far from provider feedback about the EP Survey process! Read on to find out which E-tags surveyors have dinged providers on the most, and what you can do to become more prepared.
E-tag 0006: All Hazards Approach
This E-tag states that your Emergency Preparedness Program (EPP) must be based on and include a "documented, facility-based and community-based risk assessment, utilizing an all hazards approach, including missing residents." We have seen surveyors mark down providers for not including "missing resident" in their top five hazards after concluding their Hazard Vulnerability Assessment (HVA). The CMS Rule is specifically calling on SNFs to make policies and procedures for elopement. In addition, the CMS Rule is stating you must combine two different Hazard Vulnerability Assessments into one document for your Emergency Preparedness Program (EPP). Not only do you need to do an assessment for your own facility, where you will consider situations like elopement or utility failure, but you also need to reach out to your community partners for their Hazard Vulnerability Assessment as well. Your county's healthcare coalition is ultimately where you will get the most relevant information for the medical health sector. You can also reach out to your City Manager's office, the local Office of Emergency Services, or your local acute hospital.
E-tag 0009: Planning with Response Authorities
As you build your Emergency Preparedness Program, make sure to keep a paper trail of any communication you have with your county's Medical Health Operational Area Coordinator (MHOAC), Public Health or EMS personnel, and ambulance transport companies regarding your emergency operations plans. When attending your healthcare coalition meetings, make sure you save those agendas and stick them in your EOP binder as well. This E-tag states that you will need a "process" for cooperation and collaboration with local response authorities - meaning it won't be enough to show a County phone number, the surveyor wants to hear you articulate how you are involved in your county's planning efforts. The healthcare coalitions spend much of the year planning for the Statewide Medical Health Exercise (SWMHE), so describing your coalition's timeline leading up to this exercise is a great way to demonstrate to the surveyor your "process" for collaborating with response authorities. Additionally, we have seen surveyors mark providers down for the "collaboration process" not being written into the Communications section of their emergency operations plan.
E-tag 0015: Subsistence Needs (in regards to Sewage and Waste Disposal)
This E-tag lists the requirements for subsistence needs for residents and staff in the event of an evacuation or shelter-in-place scenario. Items now required include: emergency food, water, and pharmaceutical supplies, fuctioning fire/life safety systems and emergency lighting, methods for sewage and waste disposal, and any other supplies needed to properly care for any unique resident needs, or to address any additional hazards you may have identified in your Hazard Vulnerability Assessment. Surveyors have been instructed to specifically ask about the sewage and waste disposal portion of this tag, and this is a new requirement for LTC providers. You will need a policy and procedure for continuity of operations in case you have a utility failure - will you contract with a port-a-potty service, use trashbags in the toilets, or another method? Make sure you have a policy stating in which situations you would implement these emergency procedures for managing waste. Check out our EOP template for a sample policy on sewage/waste disposal.
E-tag 0024: Emergency Staffing Strategies & Volunteer Management
There are often Good Samaritans that make all the difference during a disaster - but an effective strategy for staffing and volunteer management should not be overlooked when building your Emergency Preparedness Program. When writing your policy and procedure for emergency staffing, think of the different resources available: do you have sister facilities that you could share staff with? What is your county's method for requesting resources such as additional staff? Could you contact the Disaster Health Volunteers or Medical Reserve Corps, and what is that contact information? Furthermore, who at your building has the authority to do an emergency staff recall? For volunteer management, surveyors have made it clear that providers need to have a policy on how they will integrate emergent/spontaneous volunteers - saying you will turn away volunteers is not a viable option because during emergencies, people will find SOME way to try to help. It is much better to have a procedure for screening volunteers and assigning them a task instead of having random people on your property "helping." For sample policies for volunteer management, visit our website.
