1. Working with Community Partners to Achieve Regulatory Compliance
Kathie Dumais, Safety Officer. Environmental Safety & Emergency Mgmt.
Gila River Health Care

2. Who We Are 638 facility 5 Campuses GRHC employs nearly 1,600 staff
Sacaton
15-bed CAH
Dialysis Center
100-bed SNF
Laveen
65,000 sq ft CHC
Laveen*
60-bed Residential Treatment Center
Chandler
140,000 sq ft CHC
Ak-Chin Indian Community
Primary Care Clinic
GRHC employs nearly 1,600 staff
Accredited by both TJC and CMS

3. CMS Final Rule
Emergency Preparedness Requirements for Medicare and Medicaid Participating Providers and Suppliers
Published September 16, 2016
Applies to all 17 provider and supplier types
Implementation date November 15, 2017
Compliance required for participation in Medicare
Emergency Preparedness is one new Condition of Participation of many already required

4. Provider Types What’s a “Provider Type”? Ambulatory Surgical Center
Acute Care Hospital
Clinics
Rehabilitation and Therapy
Immediate Care Facility –Intellectual Disability
Community Mental Health Center
Long Term Care Facility
Comprehensive Outpatient Rehab Organ Procurement Organization
Critical Access Hospital
Program for the All Inclusive Care for the Elderly
End Stage Renal Disease
Psychiatric Residential Treatment Facility
Home Health Agency
Religious Non‐Medical Healthcare Institution
Hospice
Rural Health Care‐FQHC
Transplant Center

5. Four Provisions for All Provider Types
Risk Assessment and Planning
Policies and Procedures
Communication Plan
Training and Testing
Emergency Preparedness Program 8

6. Risk Assessment and Planning
Develop an emergency plan based on a risk assessment.
Perform risk assessment using an “all-hazards” approach, focusing on capacities and capabilities.
Include strategies to address events identified in the risk assessment, plans for evacuating or sheltering in place, working with other providers in the area.
Address patient population; continuity of operations; succession planning.
A process for cooperation/collaboration with local, tribal, regional, state or Federal EP officials to ensure an integrated response
Update emergency plan at least annually. 9

7. Risk Assessment and Planning
Emergency Operations Plan
For TJC, categorized by the 6 Critical Areas (Communications, Resources & Assets, Safety & Security, Staff Responsibilities, Utilities, Patient Clinical Support Activities.)
Hazard Vulnerability Analysis (HVA)
RISK = PROBABILITY * SEVERITY
Got Templates?
Hold that thought! It’s coming!

8. Risk Assessment and Planning
Risk Assessment / HVA should include:
Key Facility Stakeholders (ED, Facilities, Security, IP, IT, etc.)
Local Fire Dept.
Local Police Dept.
Local Emergency Management
Local/County Public Health Dept.
Representative from a nearby “hazard” (factory, etc.)
Other??

9. Gila River Examples HVA Meeting 09/25/17 GRHC EOP
GRHC Stakeholders (7 Facilities)
GRIC OEM
Pinal County Public Health Service Dist.
GRHC EOP
7 EOP’s – 1 per facility
Copies to GRIC OEM

10. All-Hazards Approach:
An all-hazards approach is an integrated approach to emergency preparedness planning that focuses on capacities and capabilities that are critical to preparedness for a full spectrum of emergencies or disasters, including internal emergencies and a man-made emergency (or both) or natural disaster. This approach is specific to the location of the provider or supplier and considers the particular type of hazards most likely to occur in their areas.
These may include, but are not limited to, care-related emergencies, equipment and power failures, interruptions in communications, including cyber-attacks, loss of a portion or all of a facility, and interruptions in the normal supply of essentials such as water and food. 7

11. Policies and Procedures
Develop and implement policies and procedures based on the emergency plan and risk assessment.
Policies and procedures must address a range of issues including subsistence needs, evacuation plans, procedures for sheltering in place, tracking patients and staff during an emergency.
Review and update policies and procedures annually. 10

12. Gila River Examples
All EM Program Management and response Policies are included in EOP.

13. Communication Plan
Develop a communication plan that complies with both Federal and State laws.
Coordinate patient care within the facility, across health care providers, and with state and local public health departments and emergency management systems.
Review and update plan annually.
Templates for policies and Comm Plan will be discussed later! 11

14. Training and Testing Program
Develop and maintain training and testing programs, including initial training in policies and procedures.
Demonstrate knowledge of emergency procedures and provide training at least annually.
Conduct drills and exercises to test the emergency plan. 12

15. Training & Testing Program Definitions
Facility-Based: “facility-based” means that the emergency preparedness program is specific to the facility. Facility-based includes, but is not limited to, hazards specific to a facility based on the geographic location; Patient/Resident/Client population; facility type and potential surrounding community assets (i.e. rural area versus a large metropolitan area).
Full-Scale Exercise: A full scale exercise is a multi-agency, multijurisdictional, multi-discipline exercise involving functional (for example, joint field office, emergency operation centers, etc.) and ‘‘boots on the ground’’ response (for example, decontaminating mock victims). 15

16. Training & Testing Program Definitions
Table-top Exercise (TTX): A table-top exercise is a group discussion led by a facilitator, using narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. It involves key personnel discussing simulated scenarios, including computer-simulated exercises, in an informal setting. TTXs can be used to assess plans, policies, and procedures. 16

17. Training & Testing Requirements
Facilities were expected to meet all Training and Testing Requirements by the implementation date (11/15/17).
Participation in a full-scale exercise that is community-based or when a community-based exercise is not accessible, an individual, facility-based exercise.
Conduct an additional exercise that may include, but is not limited to the following:
A second full-scale exercise that is individual, facility-based.
A tabletop exercise that includes a group discussion led by a facilitator, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. 17

18. Training & Testing Requirements
The Joint Commission in EM requires two emergency response exercises (at least one to include an escalating event where the local community is unable to support the event), and at least one to include participation in a community-wide exercise. One of the exercises must include a patient surge.
For TJC Hospitals, a Tabletop Exercise does NOT count as one of the 2 required exercises.
If a facility experienced an actual natural or manmade emergency that required activation of its emergency plan, it will be exempt from engaging in a community or individual, facility-based full-scale exercise for 1 year following the onset of the actual event

19. Training & Testing Program Definitions
Term “Community”:
CMS did not define community to afford providers and supplies the flexibility to develop emergency exercises that reflect their risk assessments. This can mean multi-state regions. The goals behind the full-scale exercises and broad term of community is to ensure healthcare providers collaborate with other entities, when possible, to promote an integrated response to disasters.
By allowing this flexibility, especially taking into account rural areas, facilities are able to more realistically reflect the risks and composition of their communities.

20. Training & Testing Requirements
Community Partners
OEM
Fire Dept.
Police dept.
Schools
Public Health
EMS
Non-Affiliated Health Care Center
High Hazard Neighbor
CERT
Non-Profit Organizations / NGO’s
Etc.

21. GRHC Examples
11/15/2018 AzCHER Central 2017 Medical Surge Full Scale Exercise.
Community Partners involved in Planning Meetings and on day of Exercise.

22. Training & Testing Requirements
How to Connect with Community Partners
In Person!
Phone Call
Meetings (LEPC’s, Fire Chiefs, EMS, etc.)
Personal Contacts (Child’s Teacher, etc.)
Through Healthcare Coalitions
No Dice?
Save /communications to prove that you attempted to connect. Some Surveyors have allowed – but probably not for long..

23. 7 Health Care Coalitions in AZ
AzCHER Central Region
AzCHER Northern
Arizona Health Care Coalition (AzHCC) South Region
AzCHER Western Region
Arizona Pediatric Disaster Coalition
Coyote Crisis Collaborative
Arizona Tribal Health Care Coalition

24. Requirements Which Vary by Provider Type
Outpatient providers are not required to have policies and procedures for the provision of subsistence needs.
Home health agencies and hospices required to inform officials of patients in need of evacuation.
Long-term care and psychiatric residential treatment facilities must share information from the emergency plan with residents and family members or representatives. 14

25. Requirements Which Vary by Provider Type
Dialysis Centers and LTC’s must have a policy that discusses Tracking on-duty staff and sheltered patients during and after the emergency.
Dialysis Centers must train staff annually on
Who to call and where to go during an emergency
How to disconnect patients (patients disconnect themselves)
Staff current CPR certification.
Nursing staff use of emergency equipment & emergency drugs, patient orientation.

26. Emergency and Standby Power Systems for LTC’s
LTC’s must implement emergency and standby power systems (emergency generators) based on the emergency plan and in the policies and procedures
Emergency generator location: The generator must be located in accordance with the location requirements found in the Health Care Facilities Code NFPA 99 and Life Safety Code (NFPA 101)

27. Emergency and Standby Power Systems for LTC’s
Emergency generator inspection and testing: The facility must implement inspection, testing and maintenance requirements found in the Health Care Facilities Code (NFPA ) and Life Safety Code (NFPA ).
Facilities that maintain an onsite fuel source to power emergency generators must have a plan for how it will keep emergency power systems operational during the emergency, unless it evacuates.

28. Compliance
Facilities were expected to be in compliance with the requirements as of 11/15/2017.
In the event facilities are non-compliant, the same general enforcement procedures will occur as is currently in place for any other conditions or requirements cited for non-compliance. 18

29. Compliance
42 E-Tags
The Joint Commission is currently in the process of reviewing/revising the 100+ Emergency Management Standards to match CMS. New EP’s go in to effect July 1, 2018.

30. Compliance
EP 12 EOP Succession / Delegation of Authority Plans
EP Waiver process
EP 15 EOP describes shelter in place for patients, staff, volunteers
EP 16 Policies based upon the EOP, HVA, and Comm Plan and are updated annually
EP 20 Maintain names and contact information of staff, LIP’s etc.
EP 21 Communicate information. about condition of patients. (Release of Information/HIPAA)
EP 22 Maintain documentation of completed and attempted contact with local, state, etc. preparedness officials.

31. Compliance
EP 3 How to obtain food, bedding, and other provisions
EP 2 Patient management - and evacuation
EP 11 System to track on duty staff during an emergency
EP 13 initial and annual ongoing training for staff
EP 14 Use of volunteers during emergency staffing

32. Compliance 02.02.09 EP 2. Electricity and lighting
EP 7 Maintain temperature to protect health and safe and sanitary storage of provisions 
EP 9 Generator must be located in accordance with NFPA 99 and Tentative Agreements TIA 12-2, 12-3, 12-4, 12-5, 12-6 and NFPA 101 Tentative Agreements TIA 12-1, 12-2, 12-3, 12-4 and NFPA 10 when a new structure is built or when existing is renovated
EP 12 Track the location of patients sheltered on site. Name and location of receiving facility or ACS
EP 2 The medical staff identifies in its bylaws  those individuals for granting privileges
integrated emergency preparedness program

33. Compliance Common Regulatory Citations (from discussions):
1135 Waiver Policy/Process
Drills (number of and Community Partnership)
Unique EOP/HVA per Facility
?????

34. The CMS Website
Refer to the resources on the CMS website for information regarding the EP Rule 19

35. The CMS Website

36. Collaboration with ASPR TRACIE
CMS has been collaborating with the ASPR TRACIE (Assistant Secretary of Preparedness & Response Technical Resources, Assistance Center, and Information Exchange) (whew!!!)
ASPR TRACIE was created to meet the information and technical assistance needs of partners across the healthcare spectrum.

37. Collaboration with ASPR TRACIE

38. Collaboration with ASPR TRACIE

39. Thank You
Thank You!

40. To learn more, visit Gila River Health Care GRHC.ORG
Gila River Indian Community mygilariver.com
/gilariverhealthcare
/gilariverhealthcare
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Information about the people and culture of the Gila River Indian Community was obtained with expressed permission from the Gila River Indian Community / Communications & Public Affairs Office.