REGULATORY REVIEW: Citation Trends in Emergency Preparedness

Regulatory Review

Citation Trends in Emergency Preparedness

New CMS requirements list 22 E-tags on which ASCs can be cited

Regulatory Review

ASCA is tracking E-tag citations to see if there is a spike in citations due to the new, more robust requirements.

Regulatory Review

Citation Trends in Emergency Preparedness

New CMS requirements list 22 E-tags on which ASCs can be cited

Medicare-certified ASCs have been required to have a disaster preparedness plan since 2009. As noted in State Operations Manual Appendix L—Guidance for Surveyors: Ambulatory Surgical Centers, the intent was for an ASC to “have in place a disaster preparedness plan to care for patients, staff and other individuals who are on the ASC’s premises when a major disruptive event occurs.” The governing body of the ASC was responsible for the development of this plan, which is why the requirement fell under §416.41 Condition for Coverage: Governing Body and Management.

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ASCs have some flexibility as to the focus of their annual training, as long as it aligns with the emergency plan and risk assessment. CMS recommends annual training be modified every year, incorporating lessons learned from recent exercises and any real-life emergencies that occurred in the past year. For example, annual training could include training staff on new evacuation procedures that were identified as a best practice and documented in the facility “After Action Report” (AAR) during the last emergency drill and were incorporated into the emergency plan during the program’s annual review. Under this E-tag, surveyors will:

  • Ask for copies of the facility’s initial emergency preparedness training and annual emergency preparedness training offerings.
  • Interview various staff and ask questions regarding the facility’s initial and annual training course, to verify staff knowledge of emergency procedures.
  • Review a sample of staff training files to verify staff have received initial and annual emergency preparedness training.

The Centers for Disease Control and Prevention (CDC) provide several training and educational resources for specific emergencies such as bioterrorism and chemical emergencies, as well as trainings targeted to specific audiences such as public health professionals and clinicians. Additional resources are available through CDC’s Clinician Outreach and Communication Activity (COCA) program.

The Federal Emergency Management Agency (FEMA) also supplies many training courses through its Emergency Management Institute. There are web-based training courses that come out roughly every week, as well as a comprehensive course catalog that combines all FEMA emergency preparedness resources in one place.

E-0039: Testing Requirements

Facilities must conduct exercises to test the emergency plan on an annual basis and document that these tests occurred. Whereas under previous requirements one test per year sufficed, as of November 15, 2017, ASCs must conduct at least two tests. The first exercise should be a community-based drill, if available, but regardless it must be a full-scale exercise. For the purposes of this requirement, a “full scale exercise is defined and accepted as any operations-based exercise (drill, functional, or full-scale exercise) that assesses a facility’s functional capabilities by simulating a response to an emergency that would impact the facility’s operations and their given community.”

If a community drill is not available, CMS will require an ASC to conduct an individual facility-based drill. For the second exercise, an ASC would be required to conduct either a facility-based drill or a tabletop exercise. If the facility had an actual emergency during the year, that can count toward this testing requirement. Under this E-tag, surveyors will:

  • Ask to see documentation of the annual tabletop and full-scale exercises (which may include, but is not limited to, the exercise plan, the AAR, and any additional documentation used by the facility to support the exercise.
  • Ask to see the documentation of the facility’s efforts to identify a full-scale community-based exercise if it did not participate in one (i.e., date and personnel and agencies contacted and the reasons for the inability to participate in a community-based exercise).
  • Request documentation of the facility’s analysis and response and how the facility updated its emergency program based on this analysis.

For additional information and tools, visit the CMS Survey & Certification Emergency Preparedness website or ASPR TRACIE.

ASCA also has customized a CMS-developed spreadsheet that identifies all parts of the rule and interpretive guidelines applicable to ASCs. That document is available to our members.

Kara Newbury is ASCA’s regulatory counsel. Write her at