Emergency Preparedness Conditions of Participation

September 26, 2016

Gatz_JackieAuthor: Jackie Gatz
Vice President of Grant Management and Safety

New rules governing hospital preparedness have been promulgated and, for the first time, the Centers for Medicare & Medicaid Services is requiring hospitals to attain specific levels of preparedness to meet Medicare Conditions of Participation. A webinar series from MHA can help hospitals understand the rule, assess their level of compliance and prepare for implementation in November 2017.

There’s some good news. Although this is a new regulatory requirement, it recognizes and formalizes hospitals’ role as the center of community-based medical response. In addition, because of the investments Missouri hospitals have made since 2002, a significant majority of the state’s hospitals report that they are already meeting the new CoP standards.

Let me provide some background and explain what is available.

It’s no accident that most hospitals are well prepared. MHA has been working to coordinate Missouri’s hospital preparedness and response activities and investments since 2002. The Sept. 11, 2001, terrorist attacks brought significant new resources to hospitals through the Health Resources and Services Administration’s Bioterrorism Hospital Preparedness efforts, which largely focused on front-line staff protection and interoperable communications. As the program matured and incorporated lessons learned from Hurricane Katrina, the Assistant Secretary for Preparedness and Response Hospital Preparedness Program was launched. The HPP prioritized building medical surge capacity, operational sustainability, regional communication and coordination networks between providers.

Missouri’s approach to all-hazard, ESF-8 (health and medical) preparedness has centered around the development of overarching frameworks to include, but not limited to: standardized, plain language emergency codes; a statewide hospital mutual aid agreement; alignment of mobile medical response assets; and the statewide adoption of EMResource®, an electronic platform for health care organization reporting, data collection and notification. This model has promoted consistency, reduced variation and administrative burden, and proved effective in several statewide responses. Further, it has positioned our health care providers to focus on organizational preparedness and the development and refinement of regional health care coalitions.

Missouri’s approach has proven successful. In 2016, a survey of Missouri’s hospitals on emergency preparedness and safety topics found that almost 80 percent of the 124 participants believed that their current emergency preparedness program met the requirements of the then proposed CMS rule (Table 1). Missouri’s hospitals are in a good position for the newly released CoPs. This is important, as CMS notes their recognition of hospitals as focal points for health care in their communities and, as such, are best served to coordinate emergency preparedness planning with other community providers, i.e. health care coalitions.

Despite these national voluntary preparedness efforts, after comprehensive analysis, the Centers for Medicare & Medicaid Services concluded that “current requirements are not comprehensive enough to address the complexities of actual emergencies.” This resulted in the proposal and subsequent finalization of a rule for emergency preparedness conditions of participation. The rule was published September 16 in the Federal Register with a 60-day effective date of Nov. 16, and an implementation date of Nov. 16, 2017.

Although a significant majority of the state’s hospitals indicate that they are prepared for the CoPs, MHA has developed a webinar series to provide hospital emergency preparedness staff and other HCC members with an understanding of the rule and prepare for implementation. This includes, but is not limited to, how the rule interrelates with Missouri hospital licensing and regulations, codes and standards of the National Fire Protection Agency, and requirements of deemed accrediting agencies.

The webinars were developed by MHA, through a subcontract with the Missouri Department of Health and Senior Services, and grant funding through the ASPR Hospital Preparedness Program’s Missouri Cooperative Agreement CFDA 93.889.

In the immediate future and through the implementation period, MHA staff will identify and develop the necessary resources to assist Missouri hospitals with this new compliance.Blog 11_Table 1
Table 1: Self-reported compliance of current hospital emergency preparedness programs, related to the CMS proposed rule for emergency preparedness.