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Accreditation and Certification

September 13, 2017

Revised EM standards mesh with CMS final rule on Emergency Management

CMSOn Sept. 8, 2016, the Centers for Medicare and Medicaid Services (CMS) issued its final rule on emergency preparedness for participating providers and suppliers. To correspond with these new rules, The Joint Commission has updated its Emergency Management (EM) standards.

CMS is expected to approve the updated standards soon, with implementation of both the final rule and the corresponding standards scheduled to go into effect on Nov. 15 for Joint Commission deemed status surveys. The affected settings are: hospitals, ambulatory surgery centers, critical access hospitals, home health agencies, and hospices. In addition, enhanced requirements also will be applied to rural health clinics and federally qualified health centers to support consistency of implementation across ambulatory settings.

The aim of the final rule is to establish national emergency preparedness requirements designed to aid health care organizations in properly planning for natural and human-caused disasters and coordinating with federal, state, tribal, regional and local emergency preparedness systems. This also is meant to help prepare providers and suppliers to meet the needs of patients, residents, clients, and participants during emergency events and throughout recovery.

After reviewing current Medicare emergency preparedness requirements for providers and suppliers, CMS determined that its existing regulations weren’t as broad and all-inclusive as needed to cover the complications that can arise with emergency preparedness. Deficiencies identified across various health care settings included lack of contingency planning, personnel training, and communication to coordinate with other systems of care within cities, rural areas and states.

The final rule addresses these and other areas and obligates CMS deemed status organizations to comply with key, best practice standards, including:

  • Emergency plan: After conducting a risk assessment, create an emergency plan employing an all-hazards approach targeting capabilities and capacities essential to preparedness emergencies and disasters particular to the location of a provider or supplier. Policies and procedures support implementation of the emergency plan.
  • Communication planning: As part of emergency planning, create and maintain a communication strategy that conforms to state and federal law, with the goal of patient care being well coordinated within the facility, across health care providers, and with local and state emergency systems and health departments.
  • Training and testing: Develop and implement training programs (initial and annual trainings included), and conduct exercises that test the plan; evaluate the exercises and responses to actual emergencies to inform improvements in preparedness. 
  • Integrated healthcare systems (optional): Health care systems that include multiple facilities (that are each separately certified as a Medicare-participating provider or supplier) have the option of developing a unified and integrated emergency preparedness program that supports coordinated preparedness, response, and recovery across system providers. .
  • Transplant hospitals: The hospital in which a transplant center is located would be responsible for ensuring that the transplant center is incorporated in the hospital’s emergency preparedness program.

The Joint Commission has been reviewing standards and revising key requirements to address the CMS rule through new EPs for the EM chapter. A draft of these new EPs was sent to CMS in June for its official review and approval.

The draft standards indicate that hospices, home health agencies and ambulatory surgical centers will have the most new EPs (25 to 30); hospitals and critical access hospitals will have fewer additional requirements. New EPs have been created that address the following areas:

  • Continuity of operations and succession plans
  • Documentation of collaboration with local, tribal, regional, state and federal EM officials
  • Contact information on volunteers and tribal groups
  • Annual training of all new/existing staff, contractors and volunteers
  • Integrated health care systems
  • Transplant hospitals

Many of the new requirements provide more specificity to expectations that organizations are currently meeting — for example, staff training must be performed annually. Also, several new EPs require documentation of existing or new practices.

The proposed draft of this content is currently available to accredited organizations on their Joint Commission Connect™ extranet site. More information will be shared with organizations as it becomes available. 

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