By Brian Williams, MBA, MHA
It seems like only yesterday that the Centers for Medicare & Medicaid Services (CMS) updated its regulations to improve life safety in facilities that care for beneficiaries. The final rule, titled “Medicare and Medicaid Programs; Fire Safety Requirements for Certain Health Care Facilities” and published on May 4, 2016, requires long-term care facilities, inpatient hospices, and similar organizations to meet the requirements of the 2012 edition of National Fire Protection Association (NFPA) 101, the Life Safety Code®, and the 2012 edition of NFPA 99, the Health Care Facilities Code. In the same year, CMS published the emergency preparedness requirements final rule, which requires facilities to establish and regularly update their own emergency preparedness plans.
While these regulations impact facilities nationwide, an incident in New York has shed a light on the difficulties that many are experiencing. In a series of unannounced compliance audits, the Office of Inspector General found that among 20 surveyed nursing homes, all had severe deficiencies. These included 205 issues related to life safety and 219 issues related to emergency preparedness. In an August 2019 report, the department cited inadequate management and lack of standardized training as the main causes for noncompliance.
However, the problem is not limited to New York. CMS finds that nursing homes across the United States often have six to seven deficiencies per inspection. While noncompliance can result in substantial fines, the consequences can also prove deadly for patients. Facilities with a pattern of serious problems over the span of three years or longer may be placed in a Special Focus Facility (SFF) program, meaning more frequent inspections, public disclosure of their status, and, if the problems are not corrected, termination from Medicare and/or Medicaid. Currently, there are between five and 30 SFF-enrolled facilities in each state nationwide.
While unfortunate, what’s happened in New York and other states provides a chance for self-examination among not only nursing homes, but also all medical care facilities. It’s an opportunity to review how well equipped and prepared each facility is to protect patients and residents. For those looking at evaluating or updating their life safety and emergency preparedness plans, here are five steps to keep in mind:
- Conduct a comprehensive risk assessment
An effective emergency preparedness plan begins with an all-hazards risk assessment. This ensures that there are plans in place for any and all types of emergencies that may occur. Beyond a potential building fire, this assessment should also account for regional dangers. For instance, a facility in a flood-prone area, such as Louisiana or Texas, will need a plan for evacuating patients and getting them to higher ground. In addition to natural risks, there may also be manmade ones, such as the presence of a local power plant or prison. An all-hazards risk assessment weighs the probability of danger from any applicable incident and determines whether your facility can respond accordingly.
- Digitize policies and procedures
An all-hazards risk assessment also helps define appropriate policies and procedures based on the identified risks. These items tell staff what to do in case of an emergency, such as the provision of supplies and subsistence (e.g., food, water and medical supplies) or whether they should evacuate or find shelter. Better still, consider digitizing these policies and procedures to make them accessible during a disaster. When policies and procedures are available in a digital format, access is not limited to wherever a physical binder might be stored. Managers can assign policies to staff, specific departments, or certain roles—plus require digital signatures for people to acknowledge that they have read and know how to access the policies. This keeps everyone accountable and well informed. Preparing and training staff on the parts of the plan that correspond to their role is also key.
- Create an effective communication plan
CMS also requires facilities to have a communication plan as part of emergency preparedness—i.e., an organized process for whom to contact in case of an event. This includes notice to first responders, resident families, and employee families. Facilities should also think broadly about available emergency resources on the county, state, and federal levels, and nearby hospitals or other facilities where patients might need to be relocated. Notably, all communication and release of patient information should also comply with the Health Insurance Portability and Accountability Act (HIPAA) and federal, state, and local laws. The communication plan can outline how to apply HIPAA when sharing patient information to assist in disaster relief efforts, and to assist patients in receiving the care they need.
- Utilize online training to bolster readiness
CMS requires that organizations create a well-organized, effective program that includes both initial training for new staff and recurring updates for existing staff to maintain a high level of awareness and exposure to the most current emergency preparedness policies and procedures. Notably, online training helps staff be informed and engaged during required drills and actual events. Staff can complete courses at times convenient to them. Managers can track who has completed required training and forgo having to schedule learning sessions during busy patient care activities. Plus, online courses are delivered in a consistent, standardized way. Look for a learning management solution that comes with a comprehensive suite of courses useful for emergency and disaster situations, as well as the ability to create custom training.
- Monitor and document equipment maintenance
As part of life safety compliance, facilities need to monitor and document maintenance on life safety equipment, such as emergency power generators. Ongoing documentation is another area where going digital is a smart choice. Look for a compliance management solution that includes an equipment lifecycle management module, providing the ability to upload digital policies that match up with equipment manufacturers’ user manuals. Such a module would also provide a place to log and track the maintenance work done by third-party contractors. These proactive measures help ensure that all equipment is in working order when it’s needed most—to protect patients as well as staff in any unforeseen emergency or disaster.
Brian Williams serves as director of compliance and regulatory affairs at MedTrainer. He has more than 25 years of director-level healthcare management experience, specializing in staff management, process improvements, infection prevention, performance measurement metrics, and healthcare compliance.