Page 27 - Occupational Health & Safety, November 2017

data of most cited standards for EM for 2016, the top five were:
1. EM.03.01.03 Evaluate the effectiveness of the Emergency Operations Plan (EOP)
Two drills annually, activating the EOP at each site (not just the flagship)
2. EM.02.02.13 Granting disaster privileges to Licensed In- dependent Practitioners
3. EM.01.01.01 Foundation
Inventory of resources and assets, conducting Hazard Vulner- ability Assessments (HVA), Leaders and medical staff participate in HVA
4. EM.03.01.01 Evaluations
Annual review of inventory, EOP, and HVA
5. EM.02.01.01 EOP Requirement
Identify 96-hour capabilities; leaders’ participation in develop- ing, maintaining, and updating the EOP as necessary; and process for initiating and terminating response recovery
At a high level, the final rule requires health care facilities to conduct risk assessments using an all-hazards approach; develop emergency preparedness plans, policies, and procedures; create distinct communications plans; and establish training and test- ing programs.
It Starts With the Risk Assessment
Health care facilities are required to conduct risk assessments utilizing an all-hazards approach to develop and maintain a com- prehensive emergency preparedness program. The definition of all-hazards approach is an integrated approach to emergency pre- paredness that focuses on hazard identification and developing emergency preparedness capacities and capabilities that can ad- dress those, as well as a wide spectrum of emergencies or disasters. They must recognize potential hazards, threats and events, and as- sess their impact on the care, treatment, and services they provide for patients. The health care facility must collaborate with its com- munity partners and prioritize the potential emergencies that have been identified by its risk assessment. The health care organization utilizes the risk assessment analysis as grounds for prioritizing its mitigation activities.
Required Elements of an Emergency Operations Plan
The EOP must include eight elements for hospitals and seven ele- ments for CAHs. The main difference is that CAHs do not have Transplant Centers. Also, CAHs have additional training require- ments centered on fire safety, which was specifically mentioned by CMS in the final rule remarks. The elements are listed below:
a. Emergency plan
b. Policies and procedures
c. Communication plan
d. Training and testing
e. Emergency and Standby Power Systems
f. Integrated Health care Systems (optional)
g. Transplant Hospitals (if applicable)
h. Reference Standards
CMS expressed concerns over the lack of consistency when it
came to collaboration between CAHs and their local fire depart- ments and fire marshals. CMS’s intent is to increase the level of ini- tial staff training to be able to appropriately respond to a fire at their
facilities. Initial training requirements are:
■ Prompt reporting and extinguishing of fires
■ Protection and or evacuation of patients, visitors, and staff ■ Fire prevention
■ Cooperation and collaboration with firefighting and disas-
ter authorities
Communication Plan
Communication issues are one of the most identified problem ar- eas of any emergency drill or event. That is why a communication plan is critical to the success of all emergency plans. Health care or- ganizations must develop and maintain a communication plan that is reviewed and updated annually and includes names and contact information for staff, physicians, and volunteers. There should be a succession plan in place that identifies whom to contact when someone in the organization is not available during an emergency event. The names and contact information for federal, state, tribal, regional, and local emergency preparedness staff and means for communicating with these organizations must be included in the plan. The communication plan also must identify the method for sharing medical documentation, how patient information would be released in the event of an evacuation, and means for providing information regarding authorities having jurisdiction about occu- pancy, needs, and ability to provide assistance.
Training and Testing
Each organization is required to develop and maintain training and testing programs that are reviewed annually. Organizations must base their training on the EOP, risk assessment, policies and proce- dures and their communication plan.
The emergency preparedness training program must include initial training on emergency preparedness policies and proce- dures for all new and existing staff, contractors providing services, and volunteers consistent with their roles within the organization. The training must be conducted at least annually, and training re- cords must be documented and maintained.
Annual testing of the emergency plan exercise must be a full- scale exercise that is community based or, depending on availabil- ity of the community groups, may be just facility based. Health care organizations are required to document who the contact was and why the community groups were not available for the exercise. Two exercises are required each year, one community-based, individu- al-based, or it could be a tabletop exercise.
A tabletop exercise involves key personnel discussing simu- lated scenarios in an informal setting. A tabletop exercise is a discussion-based exercise that involves senior staff, elected or ap- pointed officials, and other key decision-making personnel in a group discussion centered on a hypothetical scenario. Tabletop exercises can be used to assess plans, policies, and procedures without deploying resources.
If an actual natural or man-made emergency situation that re- quires the activation of the emergency plan occurs, the health care organization is exempt for one year following the event from hav- ing to conduct training exercises.
The TJC standards do not currently allow for tabletop exercises to count toward one of their two mandated training exercises. This is one of the topics that is under the TJC gap analysis review pro-
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