A deadline requiring hospitals to meet new requirements for handling patient safety during emergencies is fast approaching.

The federal rule requiring upgrades in facility practice was published in September 2016 requires and went into effect on Nov. 16, 2016, requiring hospitals to be in compliance within one year, or by Nov. 15, 2017.

Meeting the rules stipulations will require increased use of information technology, industry experts say.

Core requirements in the rule include:

  • Developing an emergency plan based on a risk assessment and using an “all-hazards” approach to provide an integrated system for emergency planning that focuses on capacities and capabilities.
  • Developing policies and procedures based on the emergency plan and risk assessment.
  • Developing and maintaining an emergency preparedness communications plan that complies with federal, state and local laws.
  • Developing and maintaining training and testing programs, including initial training in policies and procedures.

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Many hospitals and suppliers not only are unprepared but also may be unaware of the rule and could lose their reimbursements from Medicare and possibly Medicaid, warns Denise Braun, senior manager for healthcare solutions at Evans Incorporated, a software vendor and consultancy.

Information technology tools can help move providers toward compliance, but organizations also will need to develop new processes to support initiatives to meet emergency needs, Braun says. These include use of a hazard vulnerability assessment tool to prioritize risks, as well as collection and analysis of data to demonstrate that requirements have been met.

“Look at ways to create a training module for onboarding new staff, as it will be very important to show you are complying with the requirements,” advises Braun, whose company, among others, markets software and consulting services. Policies and procedures should be maintained on a network, and data backups of should be stored off-site.

Denise Braun

The rule will affect some Medicaid providers. If a Medicaid provider is required to meet the requirements for participation in Medicare to receive Medicaid payment, that provider is required to comply with the emergency preparedness requirements, CMS notes in a frequently asked questions document, available here. “For example, Medicaid only hospitals must meet the Medicare requirements so they must comply with all of the hospital’s conditions of participation, including the Emergency Preparedness requirements.”

Besides hospitals, other providers falling under the requirements include hospices, long-term care facilities, psychiatric residential treatment centers ambulatory surgery centers, transplant facilities and community mental health centers, among others.

The rule does not apply to physician offices that are not part of a certified Medicare participating facility, according to the Centers for Medicare and Medicaid Services. And while the rule does not apply to stand-alone community pharmacies, it does apply to pharmacies considered a department of a Medicare participating facility.

Certain suppliers also are required to meet the emergency requirements. The rule does not affect facilities participating in the Hospital Preparedness Program.

Many of these organizations will be challenged to meet the requirements, which could be “a pretty heavy lift,” according to Braun. Advisory services can help them identify the most critical steps to take and assess various approaches to mitigation. Smaller organizations without expertise will need assistance with an initial assessment.

Surveying for compliance will start in November 2017, according to CMS. “There will be no exceptions for the requirements and non-compliance will follow the same process as non-compliance with any other Conditions of Participation and Conditions for Coverage for the facility at hand.” CMS’s bottom line: “These new regulations are a condition or requirement to participate in Medicare.”

Braun warns against a half-hearted effort. “It can be complicated; the challenge is that many think they can create a document with line items and check boxes, but that’s not acceptable anymore.” For instance, organizations must show interaction with other emergency organizations in the region. The rule is available here.

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