MDS Alert

Published on Mon Oct 08, 2018 PDF

Check out some of the ways your facility may be affected by this proposed rule and get your comments in before mid-November.

Experience may be a more effective teacher than legislation, but the Centers for Medicare and Medicaid Services (CMS) is still trying to encourage facilities to be prepared for extreme weather situations. Adequate preparation for extreme weather is one aspect of a proposed rule published Sept. 20, 2018, and open for public comment through Nov. 19, 2018.

“CMS states that the proposed rule would reduce burden on healthcare providers and allow them to focus more on patients, part of the agency’s ‘Patients Over Paperwork’ initiative,” says Linda Elizaitis, RN, RAC-CT, BS, CIC, president of CMS Compliance Group in Melville, New York.

Though the rule delves into other issues affecting long-term care facilities, take special note of how facilities and providers should evaluate and adjust their emergency preparedness program (EPP), in order to remain in compliance —  and ready for seemingly increasingly common disasters.

Note Change in Timeline

The burden of annual check-ins to facilities’ EPPs may be adjusted if this proposed rule becomes final rule. However, the burden of documentation obviously doesn’t translate to actual preparations. Make sure your facility does its due diligence in keeping plans current and keeping all staff abreast of their responsibilities, and facility processes and protocols during a disaster.

“Proposed change to Annual Review of Emergency Preparedness Program requirements — CMS has proposed to change the annual review of the EPP to occur every two years versus the annual review that is required now. The caveats are that facilities would still be expected to update their policies and procedures to ensure that they have best practices in place and that the EPP is updated more frequently if there is a real-life emergency or training exercise where lessons learned from the incident would require the plan to be updated,” Elizaitis notes.

Documentation Regulations Lessened

Though the current administration is keen on cutting paperwork and red tape, don’t let new, more lax regulations affected your preparedness. Facilities should still have processes and protocols in place for documentation of communication plans and training initiatives for contacting emergency management folks. This should include a primary and secondary (or contingency) plan for getting in touch with emergency management officials.

“Proposed change to Documentation of Cooperation Efforts requirements — CMS has proposed to eliminate the documentation requirement related to facilities’ efforts to contact emergency management officials (local, state, federal, etc.) and to eliminate the documentation requirement related to facility participation in collaborative/cooperative training initiatives. While the documentation requirements in these areas would be eliminated, facilities would still be expected to have a process in place for how this cooperation will occur,” Elizaitis says.

Keep Staff in Loop

Anyone who works in long-term care knows how high staff turnover can be, so consider taking the new proposed change to the training program requirement as a bare minimum instead of a standard practice.

“Proposed change to Annual Emergency Preparedness Training Program requirement — CMS has proposed that facilities would be required to provide training every two years after the initial training on their Emergency Preparedness programs instead of annually as the regulations requires currently. However, facilities would be required to provide additional training if significant plans to their EPPs were made,” Elizaitis says.

However, if you have team members who join your facility’s staff after your most recent initial training, you need to make sure that they fully understand all protocols and plans for a disaster — including their specific roles and responsibilities. If your facility doesn’t already include emergency preparedness program training as part of your staff onboarding, consider incorporating it into your new staff orientation.

Practice Still Makes Perfect

Don’t forget to refresh established employees’ memories, either. Everyone needs to have the facility’s plans and protocols etched in muscle memory in order to keep everyone safe and as comfortable as possible during a disaster!

The proposed change may affect how your facility can evaluate whether staff are prepared to fulfill their responsibilities in an emergency. More “flexibility” could be a good thing, as long as additional leeway doesn’t affect the thoroughness of your preparations.

“Proposed change to Annual Emergency Preparedness Testing requirement — CMS has proposed to expand the types of exercises for inpatient providers to fulfill the testing requirements while providing more flexibility,” Elizaitis says.

Resource: Read the proposed rule “Medicare and Medicaid Programs; Regulatory Provisions To Promote Program Efficiency, Transparency, and Burden Reduction” in its entirety, here: www.federalregister.gov/documents/2018/09/20/2018-19599/medicare-and-medicaid-programs-regulatory-provisions-to-promote-program-efficiency-transparency-and. Check out CMS Compliance Group’s blog, as well, at www.cmscompliancegroup.com/blog/.