And now I would like to introduce our speaker to get us started. Ms. Laura Dixon most recently served as the Director of Risk Management and Patient Safety for the Colorado Region of Kaiser Permanente. Prior to joining Kaiser, she served as the Director of Facility, Patient Safety and Risk Management and Operations for COPEC from 2014 to 2020. In her role, Ms. Dixon provided patient safety and risk management consultation and training to facilities, practitioners and staff in multiple states. Ms. Dixon has more than 20 years of clinical experience in acute care facilities including critical care, coronary care, perioperative services and pain management. Prior to joining COPEC, she served as the Director of Western Region, Patient Safety and Risk Management for the Doctors Company in Napa, California. In this capacity, she provided patient safety and risk management consultation to the physicians and staff for the Western United States. As a registered nurse and attorney, Laura holds a Bachelor of Science from Regis University, a Doctor of Jurisprudence from Drake University College of Law and a registered nurse diploma from St. Luke's School of Professional Nursing. She is licensed to practice law in Colorado and in California. Thank you for being here with us today, Laura, and we invite you to go ahead and get us started. Okay, thank you very much, Lindsay. Well, welcome everyone and those of you who were able to participate in the live presentation right before the holiday. Thank you very much. So, we're going to be talking today about, as Lindsay mentioned, emergency preparedness. Before I start, though, I do want to issue my disclaimer that the information we give today is strictly that, just informational. It is not meant to be legal advice or establish an attorney-client relationship, so please consult with your own in-house counsel, professional legal representative for advice. So, why are we here today? Well, those of you who, you know, over the past several years, we've just seen so many more incidences of events and weather-related events. And what you're looking at right now, as you can see from that introductory, that was a security camera that was in the emergency department waiting room several years ago, but as this hospital was under a tornado warning. And you can start to see some of the areas and the papers there starting to flip around. Now, this place had the opportunity to get people out of there. They moved the patients, the visitors, the staff to a safe location. But as you start to see this flip through, and it's a couple minutes long, so I'll try to get through here as soon as I can. But as you can see, it starts out pretty mild, and you're not thinking, oh, it's not so bad as far as what's going on. But then, as it started to progress, and you'll see it again, how it does become bad, that's where the power went out and the emergency generator kicked in. And then it went very, very fast, how fast and hard it did happen to hit the hospital. And so you can just see the ultimate destruction that occurred with this facility. And so that's why it's so important to have a plan in place. What do you do when this happens? What's the plan? How are you going to prepare for it? What will happen immediately after? How do you take care of your patients, your staff, your visitors in the community, those who may show up to come in and seek care? And so as a result, and I'm just going to go ahead and move through this, the presentation. But as you can see, as that result of that hospital being hit by the tornado, it was very, very horrible what happened. And even the helicopter got flipped. And it doesn't have to be weather-related. As we know, there's other events that are happening within healthcare. Sadly, it also is where people take actions coming into the hospital to cause damage. And it's not just limited to large hospitals, small hospitals. This one happened to be in Marriott, Oklahoma, where the before and after pictures, you can just see it was ripped apart as a result of that tornado. So I'm just going to do a brief introduction on why we are here today. Because we do have standards, conditions of participation that we have to hit. And if you do happen to go through a survey, no one ever wants to get the notice of statement of deficiencies where you have to plan a correction. And of course, no one wants to get the notice of involuntary termination when they haven't done anything or it doesn't meet what was expected, and again, did not meet the conditions of participation. So how does this work? The regulation starts in the federal register. Then CMS has the responsibility to not only send out notice of the new regulation or changes, but they also have to develop interpretive guidelines and survey procedures. And of course, then they have to update the manual. Three types of surveys, validation, certification when you're getting started, and then the complaint, which nobody wants to have done. I'm just going to give you a brief rundown on how to keep up with these changes. I would subscribe to the federal register if you're in compliance. This is where you want to keep an eye on what's coming out. You also want to make sure the most recent manual, there's been multiple updates since it came out in 86. If there is a new manual, there's an easy way to find out what they changed, what they deleted, what they revised, what was new, and that's the transmittal page. And then finally, it's called the survey and certification website. That's where they put out their memos and their notices on what's changed. And I have the links here. This is on slide number 10 that you'll copy paste to your surf engine. The manual we're talking about today, well, first off, CMS has the responsibility for all of these, whether it's hospitals in A, critical access hospitals under W. But the manual I'm talking about today is appendix Z, and that's emergency preparedness for all providers. Now, before 2019, CMS had all of these individual requirements in the individual manuals. And with the 2019 changes, they moved them all into the own appendix. And that made sense because there's so much overlap with what happens, whether it's a critical hospital, a critical hospital, renal disease, whatever it happens to be. There's so many things that overlap. Now, there are some differences. For example, nursing homes, they have a great deal of differences and more requirements than perhaps a hospital would have. And so I mentioned having the most recent manual for acute hospitals. Your last came out in April of this year. And then for criticals, they haven't updated yours for a couple years. I'm surprised they haven't because there have been some changes, but they haven't updated the manual itself. And the transmittals, you'll see that when you pull up that manual and table the contents, you'll see that blue lettering that says transmittals for that particular manual. And that's exactly what it looks like. That'll take you right to that page. Go to the most recent one, and then that's just an example of what you will see. Again, it gives you a brief rundown on what was revised, new, or what was deleted. It's an easier way to see the most recent changes. As to the memos, I have the link there here on slide number 17 for you. You may need to refresh it if you keep it handy in one of your saved favorites because they do change. In fact, the most recent changes, though, happened to be in nursing homes. And the last one that they put out yesterday had to do with the data and compare, Care Compare site. So just keep an eye on which one would apply to you. And that's just an example. Again, this happened to be one of the updates they did for the emergency preparedness. And we're going to cover what was in this manual as we go on. And then deficiency reports. I mentioned no one wants to get that notice of a deficiency report. You have access to all of that information CMS has compiled. It includes acute and critical access. They update it quarterly. And so to get to the site, you'll see here where it says certification and compliance. Now, this is for all hospitals. Scroll to the bottom of the page where you'll see hospital surveys. It will take you to a link that has two Excel documents. Just make sure you get the right years because there's from like 86 to 16 and 17 to current. And this is what will pull up when you do open those particular Excel. If you search by deficiency tag, take note that you will have to add the letter and the four digit number. If you don't add the letter ahead of it, like for hospitals, it's A. For criticals, it's C. You'll get the wrong information. So just keep that in mind. But again, we're talking about Appendix Z and what we have to do. There is another component to this, and that is the life safety code. This is heavily involved in the emergency preparedness because it talks about emergency power, your backup systems, your generators. So you want to keep this one handy too. You're probably your plant manager is very familiar with that life safety code. So as an introduction, again, this applies to all participating hospitals, providers, suppliers, anybody that accepts Medicare or Medicaid payments. And what they're doing, what this plan is to do is to make sure that we adequately prepare for any type of disaster where it's a natural or manmade, and that we coordinate with our other resources, your federal, your state, your regional emergency preparedness systems. And so having this plan in place, then you can meet the needs of everyone that would happen to come in, whether it's patients, residents, whoever it is during and after that emergency. So the requirements have three key essentials. Number one, you want to make sure you safeguard your human resources to maintain your business. You got to keep in business. And then third, protect your physical resources. With the idea, you want to make sure you have a great plan or a better plan that can respond quickly by working with others, and then you can quickly or rapidly recover. Now they do mention in here healthcare coalitions. We know that it's not always feasible, but they do encourage it. You're not required, you are encouraged. And your level of participation, they don't spell that out. But if you are going to use and work with healthcare coalitions in your emergency preparedness plan, make sure that it is documented in writing. Because then you have the ability to show CMS and those, hey, we tried to work with these folks, or we are working with them. And of course, it helps build our relationships. Because you may need these folks when it happens. And you can also leverage your resources. You know, maybe the other hospital wasn't hit as hard as yours was. They can take your patience, and vice versa, that you can help out when it's needed. Could be even staffing. And again, we're going to go through this. The Assistant Secretary for Preparedness Response. Now I'm going to say secretary throughout this. That's to whom they're referring. There are checklists and resources that you can use in developing your plan. And they're also under facility-specific requirement overview. So I have all of that information listed on those. It's really nice to have those checklists handy. So as far as an emergency preparedness survey, when the surveyor comes out, they will cover these during any type of survey. And they, again, I mentioned the life safety code, because they look at compliance in conjunction with that life safety code. And they may also use that in queue, which is immediate jeopardy for emergency preparedness. Because if they find out nothing's been done for years, it hasn't been reviewed, updated, no testing, no training, and you had an incident, it could be considered an immediate jeopardy. Now the surveyors do recognize that how you respond to different events can be very similar. Whether it's a flood, a tornado, or a man-made issue. So you're not required to have a policy and procedure for each and every hazard. That's nice, because, you know, there may be minute differences, but not vast ones. But clearly put into your policy and procedures when you should evacuate, shelter in place, or that there's nothing that needs to be done. You must address each type of hazard within your program. And again, you can consolidate your policy and procedures based on that response. So you don't have to duplicate them. I just mentioned here, you know, fire may be the same as an earthquake, if you happen to be in those type of regions. So just be ready to give CMS that written evidence of your program when they show up for your survey. How you do it, that's up to you. How you document your reviews, how you document your updates, whether it's electronic, paper, just be ready to have that information for them. And the memo I mentioned on emergency preparedness, that did help clarify information, especially on exercise exemptions. And it talked about outpatient requirements, and there were certain definitions. Now the 22 changes, they also add an explanation on a full scale. Again, we're going to go through this, and they really nicely spelled it out, so that we can easily understand, okay, when do I have to do a full scale? When can I do an exercise of choice? All right, let's go ahead and start. This is in, again, Appendix C, we're talking tags E, that's the letter for it, 1-42. And this applies to any size hospital, whether a large university or 25-bed critical access. So overall, what you have to do is make sure that you're complying with all laws, just like normal, and that includes any emergency preparedness laws. You have to develop and maintain a comprehensive plan using an all hazards approach, and the added emerging infectious diseases. And of course, we all know that's in response to the pandemic. Now, how you do it, your comprehensive approach needs to be able to meet the health, safety, and security needs of anyone present, whether it's your staff or your patients. But they also add the community here, and they look at four core elements, the emergency plan, policy and procedures, communication plan, and your testing program. We will go through these individually. Now you also have to make sure it is specific to your facility. Where do you work? Where is your facility located? What type of patient population do you have? What's your facility look like? Is it brand new or is it an older one? And also, what's going on within the community? What assets do you have? Are you in a very small rural area or do you have a large metropolitan? Because you're going to have a lot more resources when you're in that metropolitan area. So what kind of an anticipated hazard could occur? Now you wouldn't think, oh, maybe a little forest fire or a little fire wouldn't be a big deal. But what you're looking at, these are pictures that occurred back in December, I believe it was 2022, when Denver, Boulder, one of our suburbs, had to have a very rabid running fire. This is a wildfire. It started with a spark, they believe, from a downed power line, and the winds whipped up to hurricane force. Well, of course, with the fire, that just enhanced it. And you're looking at pictures as buildings and structures just went up at a rapid rate. It was amazing. The one in the upper right-hand corner happens to be the smog. This was taken from the roof of one of our hospitals. And you can see that the smog is starting to develop it. And it got so bad that it was literally covering up their exhaust and their ventilation system. And they were doing surgeries at the time when this happened, and they ended up evacuating because it was so intense that they couldn't operate, they couldn't work. And that's where their community resources and working with each other came in handy. They were transporting women in active labor in the back of ambulances and cars in order to get them to other locations. It's about a level three trauma, I believe, but nonetheless, it was still a very functioning large hospital. At the end of it, after they had evacuated everyone and gone through, what you're looking at was the soot that ended up in the hospital. They had to close it. It was closed for a good month and a half. They had to go through and clean every vent, every floor, everything had to be flushed, including the water system, in order for it to be deemed safe before they could reopen. They had to activate their emergency preparedness plan. As far as the interpretive guidelines, what they're looking for in your program is that it spells out your approach to these issues so that you can meet the health and safety needs of everyone. How are you going to coordinate with other facilities and the community as a whole during a disaster? It has to be looked at every two years, of course, make appropriate changes, and if you do do, say, a tabletop training or exercise and you find, hey, we got a fault here, then you can do it as more frequently. What is a comprehensive approach? Well, that pretty much takes into effect all hazards that are possible, and it's based on that all hazards definition, again, specific to your location. Are you in a flood zone, a tornado-prone region? What if you have patients with limited mobility? We have a hospital here in Denver who is nothing more, usually, than ventilator-dependent patients. You can imagine how they have to test if, what happens if we have to evacuate this hospital because of a fire or perhaps a tornado? Yes, we do get them here in Denver. How are we going to evacuate them safely given our patient population? What about your behavioral health patients? Perhaps they pose a risk to self and others if they're not carefully taken care of. Now, as far as comprehensive, do not only choose one emergency that could apply. Look at multiple ones, and yeah, it may take a little thinking outside the box, but it could happen. Look and be able to demonstrate how you took those variety of events when you put your plan together, and don't forget our emerging infectious diseases. How will you coordinate if, heaven forbid, COVID rears its ugly head again or the impacts really starts to take hold? The program must be in writing, and I put that in bold just so we're all clear on it. It must be in writing. How you do that, that's up to you. You can make it electronic or paper. If you're going to keep it strictly electronic, you might want to consider having paper backup if you're hit with ransomware. There's no particular system required, but they do recommend, and I put that in bold and italics, they recommend a crosswalk so you can find those documents easily. Two-year retention for inpatients, and as inpatient providers, you are required to have two exercises per year. The surveyors want to see two cycles or four years of documentation. That's what they want to see. Now on your program, CMS doesn't have to give a stamp of approval. It is not required, but you might want to check with your state agency, local emergency planning coordinators. Some do require that they see it in order to have your license, so you might want to check on that. As far as the surveyor for this initial part, they will interview leadership. They want to have them describe the program. They want to see the written policy. They want documentation on your program and that you had an all-hazards approach when you developed your program. How did leadership, how did they describe how the facility used such an approach when they came to developing their program? All right, I'm going to go through the core elements now. I mentioned there were four of them, and the first one, again, is the plan. Lindsay mentioned we have questions. Again, these are totally voluntary, and what I do with these questions is try and spark just some discussion within your facility, and then I address it as we go through. Lindsay, you want to put up question number one, please. Sure, I think I need to read this first part. Put the actual question up for you to choose your response. This says, hospital A activated their emergency plan during fast-moving wildfires in the area, at which time it was discovered the plan had not been updated for at least five years. Will hospital A be cited? Your options here, yes, no, or not sure. And then while you're taking a moment to put in your responses here, if you did join us just a few moments after we began this morning, just note that during the time of these polling questions, we will pause to address any questions that you have for Laura throughout the presentation. So, you should see that Q&A option there at the bottom of your Zoom window, and you can type in your questions there as you think of them, and then we'll address those during the time of these polling questions as well. If for some reason you don't see that Q&A option, you can, of course, utilize the chat to type in your questions as well. And while everybody's waiting to respond, this did happen here in Colorado. What happened, it was a critical access hospital, and they were given a little leeway with when they were supposed to be doing this, and unfortunately, again, they found out the plan hadn't been updated for five years when they had to activate it, and it did not take into account wildfires of this magnitude. So, they did get help from the surrounding community, some of their resources, and were able to evacuate people, get them done safely, and then when they were able to reconvene, they started working on the plan right away because they were worried about being cited by CMS, and this was pretty significant. So, yes, in this situation, they were able to start their plan, get it moving, and then, of course, CMS came out. The state came out shortly thereafter, and they said, well, you got lucky because you recognized this hadn't been done. Under normal circumstances, those who answered yes, you're right on key, they would have been cited because of the time frame that had lapsed in not getting it done. Mar, we just have one question that came in as well that asks, is it required to have some type of statement of authority assigning an emergency prepared and a subject matter expert? I'm going to get to that as far as what to do. In short, you want to have someone who can act and really step up and say, I'm the coordinator for emergency preparedness. That's what you want to have. So, that's a good question. All right, for the plan, you have to develop and keep a plan that is reviewed and updated at least every two years, comply with all federal laws and preparedness requirements, and using that all-hazards approach. It has to be documented. It must include the date you reviewed it and or updated it, and the format, again, at your discretion, electronic or paper. And remember, don't forget this all-hazards approach because it could be anything. And we have started to see some pretty significant weather issues. The Midwest again was hit by another round of tornadoes just last week. What you're looking at here is the derecho that went by in 2020 and hit Illinois, parts of Missouri and Iowa. And the picture at the bottom, fortunately, that happens to be my old nursing college dorm that was wiped out because of the derecho. Even though it was a brick building, it ended up being torn down. So, these things can be pretty devastating. All-hazards approach, well, that's an integrated. You're focusing on what your identified hazards are when you're putting together your plan. And also, what are your capacities? Capabilities, that's a little different. That can address those as well as any wide spectrum of disaster. So, again, and taking a tornado, for example, what are going to be your capacities in the event a tornado hits? And what are you going to be capabilities and maybe writing it out or continuing to function? It can be man-made, active shooter. It could be something, a flood, a loss of water to your facility, and then maybe the surrounding community. So, I'm going to go through some of these definitions pretty quickly. Well, we all know a disaster, that's a hazard impact that causes physical, psychological, economic, and political effects that really challenges your ability to respond rapidly and effectively. And this is despite anything you've done, your capacity, your capability, your changes in order to manage it. And the outcome is lower than what you expected compared to something that's less of a magnitude. An emergency that can affect you internally, it can affect the patient population, your community at large. So, it can be multiple items with any emergency or disaster. The emergency, again, by the secretary's definition, a hazard impact that affects your ability to rapidly respond and effectively respond. As far as your emergency, what it requires, of course, stepped up capability, callback procedures, mutual aid, helping each other out so that you can meet what you want your outcome to be. This usually requires a change from your normal routine, that can be change in management, that you have to use the incident command process to get to where you want to be. As far as the framework, that's what your plan needs to provide. And that includes your assessments, your risk assessments within this framework, because that's going to help you address what your patients are going to need. Also, how are you going to continue business? How are you going to, you know, what support systems do you need in order to continue? And especially those are vital during that actual emergency. What do they need in the plan? The elements? Well, it should support, guide, and make sure you can work with your preparedness officials in your area and hazards most likely to occur, natural or man-made. Continuing with the elements, facility-based disasters, of course, those are care-related. That can be one of those. Maybe you have a complete utility failure. Your powers went down. You may be, there was a system-wide or community-wide power outage. Cyber attacks, those continue to happen. Maybe you've lost part or all of your facility. Interruptions to your supply chain. What are you going to do if you, you know, you have a blizzard and your food can't get there? Your roads are flooded out. And again, the EIDs. Now, this may require certain modification to your protocols. How many patients are you going to allow in? Are you going to allow, I'm sorry, visitors in? So that could be a change in your normal protocols. On EIDs, the type they don't specify, but make sure you add this to your risk assessment because infection prevention, your personnel, your coordinator, they need to be involved in this because they are going to know what's involved, what's going to be required to combat transmission of those infections, such as whether it's bioterrorism, pandemic flu, we all know what COVID did to us, other communicable diseases. And I also want to point out, don't forget the childhood diseases. There has been outbreak of measles within the pediatric population. So be aware that that could be considered one that you'll need to respond, especially if you're a pediatric hospital. Now, continuity, what they're talking about, all of your operation and business, and they split it out. Now, your business continuity, that's planning to make sure that you can continue no matter what. Billing, you've got to still get out billing. You have to admit patients, you have to discharge. So that's business. Continuity, that's more related to patient care. How are you going to continue those operations to make sure that you give care safely and in quality of care, especially during that event? And of course, supply interruptions. What could likely occur during that interruption? With your contractors, your food contractors, your medication contractors, your blood even, make sure that those agreements include and describe a timeframe that they have to initiate services when an emergency has been declared. How are you going to continue to get these supplies and make delivery to your local area? If you're in an area that's a little remote and your road systems are taken out, how are you going to get supplies in? And that's why the contractor needs to continue to supply these through the end of the emergency, and especially those essential supplies. And you may need to add that to the contract. What happens if they can't fulfill their responsibilities and things beyond their control? And what are the backup systems that are going to be in place? Include in your contracts and inventory what your supply needs are. Is it PPE, critical care equipment? How many ventilators are you going to need? What about supply of oxygen and other gases, medical gases? And transportation options. Be ready for surge events. So again, this is all part of the planning. They talk about a risk assessment, and this needs to be based on and include not only your facility, but your community-based risk assessments. And then how are you going to address them? Again, the format's not specified. You just have to document that you included that assessment. Do you live next to a nuclear power plant? You know, when you think about it, or where your hot facility is located, what are you going to do if something horrible happens? What are you going to do if, say, you're next to a petroleum product manufacturing and there's an explosion? That's community-based assessment. All hazards approach. Again, what are your capabilities and your capacities that are critical to that preparedness? And again, taking into account with this assessment, all types of emergencies. Those are likely hazards, unforeseen, like widespread communicable diseases. You need a process so you can assess and document those hazards that's really likely to impact you and your patient population. Then look at the gaps, and what are the challenges you're going to run into in trying to meet those gaps? And the idea is it meant to be comprehensive. Utilize that variety of methods so you can assess and document. It's called the hazard vulnerability assessment or analysis, however you wish to do that. Again, in doing your assessment, take into account your patient population, what their vulnerabilities are. Do they need medical equipment? Do they have to have continuous oxygen? Are they going to, again, be on a ventilator? Where are you located? And you are encouraged to use a national preparedness system from FEMA and the guidance from AHRQ. I have these here for you. And there's many more resources I have in the appendix also in order for developing your preparedness plan. As far as community-based, CMS is going to back away. They're not going to define it. You get to decide what facilities, agencies are considered part of your community. But of course, it should be within your state. Now, if you're close to one of the borders, you may want to also consider other regions, other states in working on your community base. And the idea is they want you to work with other entities within that community. So it is a coordinated, integrated response. It will also help you identify if there's gaps in those capabilities. And you can get those addressed ahead of time. Are you working with an all-volunteer fire department? That's very possible. They're very good. But what happens if they can't get in in order to help respond? So that's why you need to work with these individuals in order to respond. As far as other entities' assessments, you can rely, if you have a community-based assessment that's been developed by those other entities, your public health, your FEMA. Maybe, again, you have that healthcare coalition. You can use and rely on those assessments when you're doing yours. If you are, get a copy of that assessment and work with them because you want to make sure you're in alignment with what your needs are and what the assessment or what you've identified as your risk. So as far as other considerations, what's your business functions you need to have that are critical to your operation? What emergencies can you expect to face and that you've got contingencies planned for? Where are you located? What natural or man-made emergencies could mean you have to shut down or you can only see maybe minor patients? And then what arrangements so that you can have these essential services provided? Other considerations, comprehensive assessment. All risks that could disrupt your operation, categorize them and the likelihood to occur. You know, we've been having some massive heat here in my part of the U.S. and we're not used to that. Some folks are, others aren't, where we have these horrible heat. We've heard about those from overseas where temperatures were hitting 120 and people were dying. Keep those safe temperatures. And again, there is reference to the tracing that they do put into the conditions of participation. Public health emergencies, we've already talked about the pandemics. What's your population? Is it older population? Is it immunocompromised population? And planning so you include those needs based upon the characteristics of that EID. Do you need more personal protective equipment? What about transferring those who are stable or not exposed or have not been infected? What are you going to do with those home health-based care settings? And screening, isolation. So that's all part of your risk assessment that you have to include. And then of course they always mention the man-made emergencies. What you're looking at here is the response that we happen to have in Colorado Springs where an individual walked into a clinic and was killing people. He was shooting up into the parking lot and then he walked into the building and started shooting, killed several individuals including staff members. So it's not just all mother nature. It's also man-made. Things to consider and this came up partly also with that item in Colorado Springs. What if you don't own the structure? What are the emergency preparedness concerns you have? Work with your landlord on that so that if the structure is damaged and you still have to do business, what are you going to do in that situation? Staffing shortages, taking in additional patients, evacuation plans, backup evaluation plan, an evacuation plan. Should they not be able to take patients also? In this situation and I really want you to work with the landlord on this and your council. That particular facility was found and the people who worked in there were found liable for damages because they hadn't prepared. Even though this was never within their focus that that could have happened at least to that degree. So the surveyor wants to see again written documentation of your assessment. They'll talk to your leadership. What hazards did you include? How did you assess them and why did you include them in that assessment? Then they want to see the assessment. Does it describe the process used to assess potential hazards? Something that's likely to impact where you are and then do you rank them? Well that's up to you but they do want to see a ranking of those possible hazards. It's up to you and your expertise. The plan also has to address your patient population. What are the comorbidities? They do specifically mention EIDs. How exposure may put them at higher risk and the type of services that you can provide in an emergency plus continuing your operation. This is where they talk about delegation of authority and secession plan. What happens if your leadership is impacted by this emergency? Who's going to then step up and be in charge and that could also be your emergency preparedness coordinator. What happens if they're injured, unavailable, you can't communicate with them. On your population, of course, inpatient, outpatient, at-risk individuals, they may have additional needs that we have to consider after the fact. Transportation, communication, medical care. If you've got patients who receive dialysis or on chemotherapy, how are we going to continue their therapy? They list out several types of at-risk individuals to consider, and then also what you would have to do for them. You know, whether you have children, pregnant patients, perhaps there's cultures that you have to take into account in taking care of these individuals. Our limited English proficiency folks, we also have to take into account how are we going to be able to communicate with them? Maybe those who have pharmacological dependency, your SUDs, and what do we do to make sure that they're still getting the care that they need? And it also talks mobility and transfer, plan to identify those who maybe we do need to transport to another location, and that the patients, they're aware of what this procedure is when we're going to evacuate them. So your plan has to address needs that can't be provided when you're there, such as just-in-time contracts and those emergency transfers. And of course, what about staffing? Maybe they have to step up and do other roles when another person is absent. So that's where they do talk about secession and delegation. In secession planning, have a process that you can identify and then develop within your staff, those who can fill in key positions if the other individual is not available. So that means you might want to increase your availability of your experienced and capable employees. Start working with them. Because they need to maybe step up right when it happens, when the other individual can't be found. As far as a qualified person, so in response, this is that individual. Have a qualified person who can act in the absence of an administrator or person who's legally responsible for the operation of the facilities. That implies that you already have someone who can do that. So have a general plan that outlines the roles and responsibilities. Don't put a name, just put facility incident commander. That's great. That's all they need to know. Just then you know who that individual would be. Describe in there, what's the role of this person? What's their responsibility during that emergency? What are they supposed to know? How patients also, how they're going to receive care. Are they going to be done in-house or transferred? Because again, we want to continue operations. Now, these are different from continuity plans. Again, this is continuity of operations, taking care of patients. Document your plans, specific individuals. And again, the successors who can activate the plan. Again, to make sure patients are safe and that safe care is provided. So just some general considerations. This is what your continuity of operations should consider. Who's essential? What functions are essential? What critical resources do you have or need? Your records, because you still need to protect health information. Maybe there's an alternative facility and where is it located? And what financial resources? Because you still have to pay staff and buy resources. Include a way for cooperation and collaboration with your emergency preparedness teams and your officials. Maintain an integrated response during a disaster and also enough documentation to support verification of that process. Which means you have to have a process to engage in collaborative planning for an integrated response. Encourage participation in the coalition. That's what they do. Again, it's not required, but you are encouraged because they can help in planning and addressing when you have a broader community needs. Document in enough detail that you can support verification of the process. On communications, of course, we have to have that for collaboration during the environment. Have it pre-planned. Don't do this on the fly. And make sure that facility management knows who are the contacts at your state and federal or local emergency levels. Who do they reach out to? And state licensure accreditation. You may be required to document collaboration when you're talking about state licensure. Next major component, policy and procedures. You know you can't get away with anything with CMS without policy and procedures in place. And so that brings us to the next question. Lindsey. Okay, let's get that one up here on your screen. And I'll read this first part to you. And it says, the city of Benton experienced unprecedented rainfall, three days of heavy sustained rain. The entire community was flooded at varying levels, including Hospital B. As an older facility, Hospital B had sterile processing, laboratory and dietary in the basement, all which was flooded. Hospital B's emergency preparedness policies and procedures did not account for such an event. What should Hospital B do now? And this first option is review the policy and procedures but don't include flooding, such a rare occurrence and then review and update the PMP to include flooding. Happened once and it could. I don't see any pending questions at this time, but if you have any for Laura, go ahead and be typing those into the Q&A or the chat. Looks like we've gotten a resounding response here to this question. I'll go ahead and share that result there. Yeah, number two, excellent. And this did happen. And the one thing that's not listed in here, and I know it sounds a little more worse, but the morgue was also in the basement. So it was not a very pleasant event for them. So policy and procedures, you must develop and put into place these policy and procedures based upon your plan and the risk assessment and the communication plan, which we'll cover later. It must be reviewed and updated at least every two years. Include in there your strategies and succession planning and consider those updates, believe it or not, during a disaster, because you may come across something like we never thought about that. So just kind of keep that in mind if you have the opportunity during the disaster. Make sure your program has policies that you can update or provide additional preparedness procedures to your staff. And how are they going to know what to do, especially when it hits hard and fast like a tornado or some other issue, an explosion, because you have to be able to get your staff information, whether it's directive, recommendations on what they can do or should not be doing. Type of documentation, again, they don't care. Hard copy, electronic, just be able to show compliance when they show up for their survey. Central location is best. How are you going to keep it, where you keep it, again, totally up to you. If you keep it with your emergency preparedness coordinator, fine, again, your decision. The surveyor wants to look at reviews and updates with the policy and procedures, and you can do that through your meeting minutes, and especially when you're doing your testing and your training. Clearly document, when did you review it? Any updates, what did that update entail? We also have to include in our policies food subsistence for our patients and our staff, whether it is food or water or medicine or any other type of supplies. They mentioned in here checking state laws and accrediting organization for specific amounts. CMS won't tell you that. And then of course, we also have to include in their sources of energy. So we keep our patients warm or cool, that we keep our provisions safely stored. How about food and medicines that have to be stored at a certain temperature? Lighting, emergency lighting, our fire detection and alarm systems, sewage and waste disposals, and then continuity of treatment. Now CMS doesn't have any requirement or standard for your provisions, but you have to be able to meet physical environment standards, and that's in tag A702. The emergency power lighting, you want to keep those in your OR, your ICUs, ERs, stairwells for emergency evacuation. Other areas you can use battery lamps and flashlights that you can operate, like perhaps in the hallways, you can have those emergency lights. And then other provisions I already mentioned, food, pharmaceuticals, medical supplies. Now here can be a little challenge for some of the areas. Put them in an area that's least likely to be hit hard by that disaster. As we noted here with the one hospital, flooding in the basement just took out everything. That's why maybe that's not the best place for it. Maybe it is on the first floor. As far as staff and others, have ways that address supplies for them, the patients and the staff. Doesn't matter if you evacuate or you shelter, because you could delay evacuation or could be delayed just for transportation needs. And then others, don't forget that, you may have visitors who come to you because you seem to be the safest place, or they figure, hey, if anything's gonna happen, I'm gonna be hurt. I might as well be at the hospital and there when I can get care. So that could be, you may have a surge of people coming in seeking shelter within your hospital. Now I go into somewhat quite detail on energy sources and temperatures. You determine what's the most appropriate alternative energy source for you. Again, maintain temperature, keep your provisions safe, give your emergency lighting, sewage, waste, continuity of treatment. You are not required to upgrade your source or your electrical systems. You may find it be beneficial after you do your assessment, or so an alternative source must comply with all your local state laws. Of course, manufacturer requirements and life safety code requirements. You are required to have essential electronic systems with a generator that complies with the healthcare facility code. Temperature, you got policy and procedures to determine how you're gonna keep it hot and cool. And especially during the emergency, or if you have a loss, any loss of your primary source. You're not required to heat or cool the entire building evenly, but just make sure you're protecting the patients and your provisions. If you can't, you will need to relocate, which means you have to get your evacuation plan activated and make sure it's done timely. Portable generators, if you're gonna connect it to your electrical grid, there is one recommended by the generators manufacturer, make sure you're using that. Individual extension cords, they should not run from the portable generator outlet to receptacles for appliances. You're not required to have a generator, but you must meet, again, the provisions for your alternative source. So that's why your plant manager is probably the best person to work with. Now, I'm gonna go through some of this pretty quickly because it is pretty specific on alternative resources. Have all wiring in each unit installed according to requirements. That's in chapter three of NFPA. Make sure it's designed to minimize hazards that could be caused by these events. Don't forget vandalism. It's located for adequate ventilation. It's protected so sparks can't reach combustible materials. That it's operated, tested, and maintained according to the manufacturer and other requirements. They talk about extension cords, good, yes, we use them. Again, you can't connect the equipment in the facility to a portable mobile generator. Again, that's using the extension cord. Use power transfer systems, power inlet box mounted outside, and the transfer switch connect to the facility electrical panel. Fuel storage protection. That depends on how much you have and where you're gonna store it. Permanent generator. There are the NFPA codes and standards on them as far as location, testing, storage, and maintenance. It's very extensive in this area. And so in the interest of time, I would urge your plant manager to be very familiar with that or whoever's going to be your emergency coordinator. And sewage and waste. We can't forget about that. You don't have to treat them on site, but you have to have a way to maintain necessary services. Now they don't specify or define necessary services, but you have to make sure that if you have a certain type of facility that you're meeting those requirements for that disposal. And they do expect you to follow EPA practices. For example, how you're gonna access gases, treatment of soiled linen, biohazards materials from infectious disease. You may need additional assistance when you're transporting them. So that's what you want to include within that contract. What are you going to do if there's an issue of getting your trash and biohazard material properly and timely taken care of. The next area you talk about in your policies are tracking staff and patients. So you have to have a way to do that. Who's on duty? What if you, you know, you wrote it out and you have sheltered patients. Those that stayed there during the emergency. What if they relocated? Okay. You have to document where did they go? The facility, maybe other location. Maybe they went home, maybe an outpatient surgery center. Now there's three types of, there's two patients that you don't have to track. Those that left voluntarily on their own. And those of course that were discharged at the time. So if they left on their own or had been discharged, you're not required to track them. You just have to document that, yes, indeed, they left on their own. They were properly discharged. CMS won't tell you what type, but just have information readily available so that it's accurate and you can share among the officials across the emergency response. Where did patient A go? They left and went home. Patient B was properly discharged. They're home. Make sure that if it is recommended, they do recommend electronic with a backup system. Again, you may want a hard copy just to keep that handy. Patient information, who's responsible to make sure we get the records safely and maintained and then transferred. HIPAA doesn't go away in this. What information do you need to track a patient? Tracking staff can also be a challenge and depends on how they sign in and out. Is that even working? Is you're gonna do paper form? If they go to one place to report for duty. You may wanna consider that having one place you report for duty, you check in and you check out. Excuse me, leverage your support and resources from other systems if you can. Again, it's not required, but it can really come in handy. And follow your evacuation procedures. If it is a mandatory evacuation, you must again abide by all laws and mandates. So that's one of the requirements. Community partners say help, like emergency management officials. If you're using full-scale community-based exercises, they can be very helpful in doing this. They can work with you and those that will assist in your emergency. Safe evacuation. You have to have policies that include care and treatment needs of your evacuees. What is the staff going to do? What are their responsibilities in your evacuation? Transportation, identification of location where these people are gonna go. And the primary alternate sources of communication. Now on staff responsibilities, you may have like housekeeping. There can be hugely instrumental in helping transport patients. Transportation, are you going to allow for private cars? Again, to be transferring patients or are you going to require ambulances? If so, how are you going to tap into those ambulances? Your policies must address the needs of those, including staff, maybe families who are on site and those who came in seeking refuge. Staff responsibilities during that evacuation. What are the patient needs in transportation? Do you have a mom who's in active labor? Well, you probably want an RN to go with them as opposed to a non-clinical person. On triage and evacuation, when you are coordinating, tracking potential evacuation, of course, what is the most critical? Start there to the less critical. In other words, those not on life support. What's the acuity? Mobility status. Do they require a wheelchair or a walker? Are they independent in mobility? Where is the unit located? Are you on the top floor or are you in the middle? And availability of that destination where they're gonna be transferred. Show specifically who is tasked with making those decisions, by the way. Okay, next question. Lindsey. Okay, I'm gonna read this first part here. And it says that Hospital S is a critical access hospital in the Midwest. A strong weather system with possible tornadoes is forecasted. Given the age and structure of the hospital and only two patients, both who are stable for discharge, Hospital S elected to evacuate and close the facility. One of the inpatients refuses to leave. Now what? This has never occurred before. Let's get your options up here on the screen. Okay, the first one, demand the patient leaves, nothing more, let them stay alone or possibly something else. And if you have something specific you'd like to recommend here, you can type that into the chat. And Lindsay, I'll let you decide how long you want to keep the polling question up there. Just another couple seconds here. I still see several responses coming in. I see lots of you putting in something else. So I would encourage if you have any other comments, if you would go ahead and type that into the chat, that would be great. Yeah, because sometimes you've already faced this and wouldn't know what to do, which would help your colleagues. Because this one was, you know, they're scratching their heads. What are we supposed to do? And being on the phone with them, it's like, you need to decide like now what you want to do with this individual, as opposed to calling me. That's why your training comes in so handy when you do have these issues. So are there any suggestions on something else, Lindsay, that you could share? And I just posted the results there. And it looks like about 79% said something else. And one comment says, ask for volunteers of the medical staff to remain with the patient. Another comment here, determine why the patient refuses to leave and then possibly find a safe shelter for the stable patient. Great, great. And those are all perfect, perfect examples of what you can do. So I'm going to go through that as we get moving along here. So as far as communication, how are you going to communicate what was done for this patient, what needs to be done when they're at that next facility? So that mean hard copies of their abbreviated condition, history and physical, whatever it is. Color coordination for triage levels. Is red going to be this is the most critical? And green is they're okay. They're more for observation, if anything. Include information on who is their contact, whether it's a representative or a family member. And again, what do you do if the patient says, I'm not leaving, I'm sticking around? It is mentioned, it is not acceptable to leave a patient in an unsafe environment. And so for those of you who suggested perhaps someone can stay with them, that's okay. As long as the person who wants to stay is okay with that. Now be aware, if it's a mandatory evacuation, then you may have to work with your counsel on, okay, what are we going to do if the patient says I'm not leaving and we're under a state law for mandating evacuation? In that case, the patient may not have a choice and you may have to pretty much work with them nicely to transport them out because no one's going to be there. And that's what the state law requires. So that's why I always urge you to work with your counsel and just have that handy in case it does occur. On external sources for communication. Well, it's nice if our phones are working, but sometimes they don't. And that's why you may need to consider as backup satellite phones. The surveyor will look at the plan. They want to make sure it has what's necessary for safe evacuation. And also they're going to ask the staff, they'll ask them this question. What are you going to do if a patient doesn't want to evacuate? And so that's why it's always important to have that part of your emergency plan and training. So if you can shelter in place, because it's just, it's not feasible to evacuate. Okay. Then make sure you've got to have a way to evaluate to see if your building's going to hold up. Again, you saw what happened with that one building with the derecho. Half of it was wiped out, but the other half was still standing. What proactive steps can you take before this happens? Shelter in place, transfer to another setting. That's great if you have the time, but can the building withstand it? So we preserve our information to support continuity of care, again, protect confidentiality and maintain the availability of those records. For volunteers and other staffing, you have to have policies and procedures on the use of them. These volunteers could be other doctors and nurses coming in, laboratory techs, x-ray technicians, whoever it happens to be. Just have a role for integration of those individuals. And don't forget those state and federal designated healthcare professionals. Let's say you have National Guard coming in to help and there's doctors and nurses assigned to them. What type of personnel and the roles are they going to have? Will they be treating patients or will they be transporting patients? And again, surge planning. The idea is we want to preserve the system and yet provide care at all appropriate levels. And that's why your risk assessment is so important to include those EIDs. Planning, focus on your natural disasters. If you're going to evacuate, transfer and how staff is going to help from non-impacted areas. If you've got an infectious disease, of course, we want to reduce morbidity and mortality. We want to minimize transmission and then keep our health, our own staff protected too, but yet keep our hospital running. So on your surge, develop your policies to reduce non-essential visits so we can slow the surge. That may mean we're working with patients, instructing them. How do we use advice lines, telehealth, call options, speak with the staff before coming in, triage protocols for staff. Make sure they know what they're asking and what questions to ask and also what do they do if they get a certain response. That's why your algorithms can help identify the needs. Do they come to ED or can they stay home? Now volunteers, you don't need to accept them from individuals. You don't have to, but you may need to. So you may have everything from a neurosurgeon to an RN to an LPN to whoever. So you may need to help them. So have ways to policies to support and ensure there are credentials. You may know these folks by working in your community is great. Their new regulation is silent on privileging and credentialing, but have a resource somewhere that you can get this going and verify who this individual is because you have to make sure they're working within their scope of practice and training. Off-duty staff include how you're going to contact them. Contingency of staff can't get in because they're injured or they're just physically cannot make it in. And if you decide not to use volunteers, then how are you going to address staffing shortages? And again, your decision if you use volunteers or not. Well, what happens if you have to limit hospital? Because they did separate these. You have to develop arrangements with other facilities and providers to receive patients. So consider your patient population. What's the ability that other facility to give services? Critical access. You have to have arrangements with other facilities or providers to receive the patients to do the same thing. So acute, you have to have both facilities and providers. Critical, it's either or. Consider your population and what that facility or provider can actually do for you. Now waivers, alternative care sites. Again, you have to have policies and procedures that address what is the role of the facility if you do have that waiver. Again, the secretary is the one who issues that. The section 1135 waiver identified by the management officials. Now that's a very long and new section, which we did here. It was actually put up a convention center in case we needed to activate it when the hospitals had such a surge. Unfortunately, we did not have to do that. So it's on your alternative care sites. Anything, any building or structure you can convert for use in health care. The type of emergency and how it's going, what's your capacity level, and how does that relate to other needs or discharges? You may not need one. You may not. But just make sure that your policies and your risk assessment has taken that into consideration. When you're establishing them, these are only used during that emergency. And so CMS has to give its approval. So when you're doing your plan and you have an alternative site, make sure CMS has approved that. And the idea is we want to make sure it's available and that you can get reimbursed if you can't comply with certain requirements. So if it's a single facility, just you, there is no 1134. They can develop the state and local emergencies. They may designate alternative sites. So that's why you need to work with them. And their staff to function within their scope of practice and use best practice. What does their licensure say they can do? If it is, your community has come back, continue operations when that does expire. CMS, and I have the link in there. So third major component is the communication plan. So of course you have to maintain a plan that complies with all laws reviewed and updated every two years in writing. And sure, how are Kate and core care within your facility and across your providers and maybe other health care departments. So what does it coordinate with your management and connect? How are you going to communicate? Is that satellite phones? Is it shortwave radios? Whatever it happens to be. Your contact information for your staff, entities, providing service, physicians, of course, other hospitals, and your volunteers, if you're going to use them. Other facilities, that's your contact information for services of the same type. Now, they all have taken into account those that may not be the same type, but can help out patient transport. It must be readily available to not over a designated coordinator. Electronic, hard copy, same thing, review information you want to have, have the names of your federal emergency preparedness individuals because they're going to be the ones you have to coordinate with. Look at it every two years, make sure it's still current. And of course, any other areas of assistance that you could utilize. May include local officials who support, whether that's fire, police, public health departments, state survey agencies, believe it or not, and of course, FEMA help. And CMS notes, again, you don't need to have the name or specific number to have. John Doe, who's the head of the FEMA, and there's their phone number. Again, you just want to have the director of FEMA and how you would reach that individual. You have to have a primary and alternate means of communication with your staff and your management agencies. It's up to you how you do that. Pager, cell phones, walkie talkies, that would work for you. Procedures on how and when you're going to use those alternate methods and who's going to be able to use them. And make sure it's compatible with those of other facilities or agencies. And again, identify the primary alternate source in your communication plan. Now there's multiple resources here. This is on slide 138 for those of you who are listening. And there's a national communication system. This offers a wide range of preparedness communication services that you can utilize. So I've just listed those out on that slide. And then of course, sharing information on the patients in HIPAA. How are you going to share information and document for the patient as necessary so that other providers know what's going on. Begin with your plan, review it, and update it every two years. If you are evacuated, you can release information under HIPAA and provide information about their general condition, where they are. Again, as permitted under HIPAA. Overall, you have to be able to generate timely information to family and others on where is this patient and how are they doing. You develop your own system. You have to have the system information necessary so that can be done quickly, timely, readily available, and also for those who sheltered in place. As far as the time frame, it's not specified. I don't say 30 minutes, but enough so that patient can continue with care. We don't want to delay transfer just so you can put together the reports and test. You can communicate those once you get the patient moved. Here's the minimum information that you need to have available. And you probably normally have this on their intake form. Age, date, name, date of birth, maybe their allergies. You know, this can be a very quick information that you provide. This is the minimum that you want to send. Again, HIPAA is not suspended during national emergency. You can have certain uses and disclosures, but make sure that you're familiar with that requirement. Usually, who is ever assimilating this information is aware of what can go out. And then there's information on you. That's your facility information. How many patients do you have? What do you need? Can you provide assistance to others? And make sure this information is available to that incident command center or the designee as necessary. If you're in a small community disaster, you need to coordinate through developed processes so they can report directly to those emergency officials. Maybe you need to evacuate, help and transport, shortages of PPE, loss of your facility or staffing shortages. So again, these are the small community disasters. If it's large, widespread, well, that may be altered by the emergency management offices because of the sheer volume of requests that they get. So verify with your incident command structure or state agency who that is and what they need. And that, of course, depends on what happened and how long is expected to last. Emergency management coordinator, they need to know how they monitor and those reporting requirements, such as contact tracing. So again, yes, this happened a lot with COVID. And they do encourage you to actively work with associations and coalitions to reconcile any needs that you may have. And you might be able to get help if you have to do a 1135 waiver. You have to be able to provide assistance, pre-planning collaboration with those officials before really will help determine that. And also, what's the awareness of the operating status of the facility? What available resources and capabilities are there? What do you report? Well, you may need to report to local officials. What can you take care of patients? What requires transfers? What staff? So they can also assist. Electrical, dependent medical advice. Do we have vents going on? And of course, availability of PPE. On your occupancy reporting, how many patients are currently there? What is your percentage of your occupancy? What needs do you have? Food, medical supplies, and include this in your communication plan. How are you going to communicate that required information? Is it going to be you've got five people in the field, they're going to report to the incident command, and this is the information they need to report. So as far as the incident command system, FEMA in 2016, they defined how that works. That really enables effective and efficient domestic incident management by pulling together facilities, equipment, personnel, communications, and procedures so that we can operate within a common goal. And then the fourth and major element is the testing and training. So I'm going to start with training. You have to put together and maintain a training and testing program. You have to provide training every two years after they're initially trained. And of course, this is all based on your plan, your risk assessment, your policy and procedures, and the communication plan. You document and review and update it every two years for training. Now, generally, the program, of course, has to reflect what risk do you have in your area? Is it a flooding risk? Okay. What's going to include in your training and testing on how you communicate closure to those required entities? Multi-campus or multi-locations hospitals, you have to have testing and training that reflects the risk assessment for each site so that they're there because you may rotate staff. On your training, it is your responsibility to provide education to your staff and contractors, don't forget them, and volunteers. They need to be aware of what the program says. And a process within the program that encompasses staff and volunteer training so that it complements the risk assessment. Maintain documentation. In other words, keep a sign-in sheet. Who was there when was their training done? Training is operationalized. In other words, can you evaluate the effectiveness of training by drills? Perhaps that's one way you can do it. Inpatient providers, you are required to conduct two testing exercises annually. That's inpatient. Outpatient, one exercise. At least every two years, one has to be a full scale. That's outpatient. So on your testing process, include all staff and make sure they're all done over a period of time. Look at scheduled exercises with maybe an appropriate department. CMS doesn't require that you have all equipment in a drill or a certain percentage of patients that you're going to utilize, but test according to how you would respond in an actual emergency. The training program for an acute. This is different than a critical. I'll get to a critical in a minute. For an acute, you must do all of the following. Initial training in what are the policy and procedures. All new and existing staff, contractors, and volunteers consistent with their rules. Training every two years. Keep documentation and be able to show staff knows what the procedures are. Of course, if you're updating your policies, then do training on those updated policies. Critical is a little different. Initial training, prompt reporting, and extinguishing of fires. That's not an acute, that's in criticals. Protection where necessary. Of course, evacuation of patients, guests, cooperating with firefighting and disaster authorities. Training every two years, documentation, staff being able to demonstrate knowledge, and again, if you're updating the policy and procedures. Training includes everyone that provides services. It doesn't matter if it's an agency or a full-time. It doesn't matter if it's a laboratory tech, radiology tech, housekeeping, physicians, doesn't matter. Everyone needs to be familiar and trained on what they are to do in response to an emergency. That includes your individual-based response and how the facility is going to manage continuity of care. You have to train staff based on the risk assessment. It should mirror the plan and train on procedures relevant to that hazard. What you're going to do in a flood may be vastly different than what you do, say, in a man-made event. During initial orientation and that the training is program is updated, so what they're going to look at is past two cycles. Keep four years of documentation for training and exercises. Of course, continued training. You determine the focus, when it starts and then two years, but again, it has to align with the plan and your assessment. Modify according as needed. What you learned from your past experiences and demonstrate how training has been updated. For example, you have a new evacuation plan that you documented in your after-action report. If you have an updated plan, then again, you have to make sure there is training on that updated plan. If you have a new risk that's identified, train on the policies and their staff responsibilities. Now, if you do update the plan, you're not required to go back and start and do the entire training on the entire plan. If it's only new or revised, that's the main component that you need to train on. And they talked briefly on volunteers and contracted staff. If you have multiple sites, you don't need to train at each facility. You can bring them into one location, but everyone needs to know what is the program and what's their role. So, it's up to you on delivery of that training, but the surveyor may pull them aside and ask the staff members, okay, what's your role in this type of emergency? And then documentation. Of course, we keep documentation of our training, whether it's initial or subsequent, and you want to include in there what training was provided and how did you do it. Was it lecture? Did you have a quiz afterwards? Did you do a mock drill where it was brought into a room and then you had the emergency? You demonstrate, you have the flexibility to demonstrate how staff know it. Again, test or a Q&A after training. So, then testing. This is a second component, which is our, I believe, our fourth question, Lindsay. Okay, let's get that one up here on your screen. Okay, this question should not be on a screen that says, we have tested our emergency plan annually with input from our leadership and community leaders, yes. And then the second option, yes, but we have challenges with staff or frontline personnel participation. No, or possibly not sure about one or more of the participants' involvement. And then Laura, there was a question that actually goes back to the previous polling question that asks, is there a need to somehow document the patient's refusal in this scenario, either in the medical record or otherwise? Yes, put it in the medical record. That's one way a patient refused to leave the facility. If you have to take further steps, in other words, it's mandated, that individual cannot stay, I would put that in incident report because it may come up later and you wanna keep it as protected as possible. But I would document if the patient refuses. And just again, like an incident report, this is what happened, this is what I did. And then whatever you need for your other documentation. But yes, I would definitely document that in the record. And after a thorough explanation, patient was assisted to a wheelchair and out the door. Perfect, okay, and there are those results. Okay, good, all right. That's good that you're having really good cooperation within your staff. So you must do annual exercises to test the plan. So you can do a full-scale, community-based. If that's not available, then you do a facility-based, functional. If you had an actual or natural man-made emergency that required activation of your plan, you get a pass from the next required full exercise following the onset. And I'll go through this because CMS was really good about spelling it out for us to be compliant. So you must do a full-scale. Now, when they say if it's not accessible, think if you live next to a highly regulated process, whether it's oil and gas, nuclear power, or something that's very regulated and they don't want you anywhere on their facility, then you can do a facility-based test. Number two, after that, you have to do an additional exercise of choice, and that's opposite the year full-scale. Now, this could be a second full-scale if you're so motivated, or you can do a mock disaster, or you can do a tabletop, or you can do a workshop. If you do those, you have to have a facilitator and a group discussion for those. You must analyze how it turned out. How did you respond? Keep documentation of what you learned, whether it's a drill, a tabletop, and then, of course, go back and revise the plan if it is needed. You are expected to test your response. Now, they suggest, please don't use the same scenario year after year, come up with something new, because you want to really identify those gaps in responding to those various emergencies, and make sure staff know what's going on with the program. If you do find gaps, update the program according to the after-action plan. So, as the after-action review, you have to document, of course, compliance and make sure information is available for no less than three years. This is different. They went three years. Document lessons learned, and maybe those actual events. How did you incorporate any of those improvements into the plan? Your AAR, it's a roundtable discussion with those who need to be there. That includes leadership, department heads, critical staff. What'd you learn? What was supposed to happen? What occurred? What went well? What do we need to do differently or change, and then have timelines? It's almost like doing an RCA for this emergency event. Exercise, of course, vary by cycles and frequency. Really what they're trying to do is make sure we have a comprehensive testing and training program. And, of course, based on identified hazards that you know are out there within your community. A full-scale is an operations-based exercise that really is all out. I mean, we're talking multiple agencies, disciplines, and you're performing functional and integration of the elements, operational elements that are involved in the response. This is also known as what they call boots-on-the-ground response activities. No specific number of who gets to play along, the number of entities that are required, but it is recommended to be collaborative, such as your local and state. In my last year of nursing education, the hospital participated, a community-wide one, where we had a mock plane crash out at our airport. Now, this airport is somewhat a distance from where the two hospitals in the city were located. And so it was a great opportunity that we had to find out what's gonna be the response, how do we get the passengers or the survivors out of there safely, how do we transport them, how do we stabilize them in the field? So it was a really good way that brought together fire, police, aviation, the hospital, and other members of the community who could come in and help. Your functional exercise is really there to validate and evaluate what can you do. It's multiple functions, it can be groups of functions. This is really focused on exercising plans, policy, and procedures, and staff members. But don't forget management, because they need to be there, along with your command and control functions. So as far as a mock disaster drill, of course, we know that's coordinated, that's supervised, usually to validate how you're going to respond. Usually it occurs just within your hospital. And it's used also to provide training on maybe new equipment, validate procedures, how you maintain your current skills. Think Code Blue drills. You can do those, you do it during ACLS training. Do you have plans that can be executed as designed? Or do we need much more training? Or do we have to go back and look at our training? You can do tabletop. This is where you have those key people who talk about a simulated scenario. And that's helpful because you can assess your plan, policy, and procedures. Usually this involves senior staff, other key decision-making personnel. It's a group discussion that you have a hypothetical scenario. Have an assessment tool that you can use without deploying your resources. So this is a nice way to do it also. And then finally, our workshop, where you have a planned meeting, you establish your strategy, your structure for that program. Okay, full-scale and community-based. There's a FEMA definition. That's a large exercise, multiple agencies every three to five years. Now, you're not required to do this. But if you are, for this requirement, what you're trying to do is assess your functional capabilities. You simulate a response to an emergency that would impact your operations. The full-scale can include a functional drill. But just remember, you have to do this at least once a year. Community, that's, of course, where you're located and what are the roles and responsibility and the type of providers. You have the flexibility to participate in and conduct, but it will help you identify where you need help or where you can help others. If you're determined to use this as one of your exercises, you have to have the scenario spelled out within your assessment. Participation must be adequate to test your response. In other words, policy, procedures, communication. And the intent is to make sure your program and response capabilities complement everybody else involved. Local and state emergency plan. It supports an integrated response and yet protects health and safety. Other expectations, you're encouraged to actively engage entities that do these. You're expected to contact, excuse me, local agencies to determine, hey, anything going on out there that we can participate in? And you're responsible to resource your own participation. Make sure you have staff and equipment and requisite documentation to show that you are doing. That's why they say healthcare coalition is very helpful in that. But if you're gonna do your own individual-based exercise, the regulation doesn't specify the minimum number of staff or who's involved. You are strongly encouraged that leadership and department heads participate. They need to know what's going on. They need to know how their hospital will respond. If you're going to have it in a specific clinical area, of course, make sure the staff who work there are participating because they have to know their roles and responsibilities. Maybe other members so that they get an insight in what happens. Just use a sign-in sheet so you can show your participation. Okay, exemptions overall. The 2019 Burden Reduction Rule revised all of these requirements. It requires activation of your emergency plan if you're going to get an exemption. It only applies to the next full-scale exercise. So tabletop doesn't apply. And they don't accumulate. So if you don't do one during the year, you lose it. The memo of 22 did clarify that if you're still operating under a current activated emergency plan during your 12-month cycle and you claimed an exemption, then you do have a pass. And I'm going to go through these to really help explain it. So let's just go ahead and do that. So here's the first example. You did your full-scale exercise in January of 19. You did tabletop in November. You did another full-scale in January. You had a workshop for November. In March, you activated your emergency preparedness plan. You resumed normal operation status in December of 21. So here's how this would play out. So you did your full-scale before you activated it. You also did your exercise of choice before you activated it. Then you did another full-scale before you activated it. Then you activated your emergency preparedness. You still have to do your workshop. That's due. But you get an exemption from the next full-scale, but you still have to do your exercise of choice. So here, again, here's number two. You did a tabletop in January, and that was your exercise of choice. You were scheduled for a full in November of that year, but in the previous March, you activated the plan. In 21, you went back to normal operating status. So you get an exemption. Again, January, you did your exercise of choice. Then you activated your plan. You get an exemption for that full-scale when you are due in November. And then you went back to normal operations. After that, you did your exercise of choice as you're required, and then you still had to do your full-scale because you did return to normal operations after that. Number three, you did a tabletop in January. You were exempt from your full-scale because of you activating your plan, and you continued to operate under the plan because you had a surge in the area. So you get a couple passes in this situation where you don't have to do those full-scale, but you must maintain and be still under your emergency preparedness plan in order to not have to do the full-scale. You still have to do your exercise of choice. That's not omitted, but you do get the exemptions. And then finally, you did your tabletop as an exercise of choice. You exempted November because you activated your plan, and then went back to normal operations in March. So again, you activated your plan, you got the exemption for the full-scale, and then it's back to the normal routine. The next required full-scale would be in November of that year. So this is all in that memo. I would urge you to download it and keep those examples so if you have any questions on it, when are we required if we activate our emergency preparedness plan? So as far as determining it, the surveyor will look, what is your annual cycle? They'll make sure you've done two required exercise within your 12 months, and they want you to describe the exemption so that you can show that it was the next required full-scale, not exercise of choice. That's why they wanna see documentation that number one, you activated your plan, and that include, that may be, you sent out alerts and activation to the staff, you have proof of patient transfers, you did additional safety protocols, maybe you mandated your personal protective equipment, and that there was coordination with local emergency officials. Again, they want documentation to support this. They want minutes of your board meetings. If you happen to have a waiver, that they have that proof, and that the incident command system, that there's reports that they were completed in respect to that, because they wanna make sure you are compliant with that clause, and did you reported and required exercises? Now I'm gonna go through emergency systems fairly quickly in the interest of time, but let's go ahead and put this one up because there is some importance that I do wanna stress here. Okay, let's get that question up here on your screen. Okay, this one says that hospital C is an 800-bed university hospital, has three generators, but for emergency services only, ICU, OR, ER, NICU, CCU, food services, pharmacy and radiology, would you recommend additional generators? Yes or no? And as we're getting a little bit closer to the end of the presentation, if you have any questions for Laura, go ahead and be typing those into the Q&A. And if you don't have that as an option, type that into the chat as well, so we can make sure that we address all of your questions with her today. And I always bring up emergency generators because with that video I showed you at the beginning and the hospital that was involved in it, their emergency generator and their incident command center was located both off-site and the tornado took them both out, believe it or not. So their emergency command center was found kind of down the street and the generator was kind of lifted off of its footing. It happened to be in a good secure footing, but it was lifted off a little bit to where they almost couldn't use it. So that's why it's so important that we do discuss our emergency and standby power. So yeah, given the size, and now this is a level one trauma, it's pretty significant. And it's also a level four neonatal intensive care unit, which is the highest level. So they definitely needed another generator as a backup. Okay, so on emergency and standby power, for acutes, you have to implement an emergency and standby power based upon your plan and your policy and procedures. Now for criticals, they didn't go as far as that. They just said you have to have power system based upon your plan. Now why they omitted the policy and procedures, they didn't explain it, but that's what's not included. So as far as where you put your location, of course, what does the healthcare facilities code require, especially with a new build or renovation? Inspection and testing must be done and to make sure that we are maintaining it and that it's secure. The fuel source, that's dependent upon where you're going to locate this generator. So you have to have a plan to keep those essential electrical systems operational. For the duration, of course, unless you evacuate, and that's why your planning should include that we have a limitation in delaying our deliveries. And maybe their source is not limited to other community demands. Don't forget if you're in a large community, the whole area may be wiped out. So NFPA, they do require hospitals to install, maintain, inspect and test those systems in the area of the building where failure could cause some really bad outcomes. And they list ICU, CCU, NICU, surgery, PACU. It is a very long section again. So make sure that you're aware of what's in here. I've just hit the high points. The EES, that is the one that supplies alternative power throughout so that you can have your equipment that works and maintains continuity electricity. These are selected areas and functions. And this is during the interruption of what's normal electrical service. It's usually, of course, again, it's a generator. The emergency power that requirements is emergency lighting, fire detection, extinguishing systems and alarms. They don't specify the power requirements for maintaining supplies, but just remember you do have to maintain food and medications that you have to have and heat and cooling in those areas where needed. They don't require heating in general patient rooms during disruption where the outside temperature is higher than 20 degrees or where you have a selected room that is provided for the needs of all patients that you do have to heat. It should include your design to accommodate electrical additional loads. What do you deem necessary? How are you going to continue subsistence needs? Those that are required by your plan. And of course, unless you decide to evacuate, that's the option. Your generator, of course, you have to inspect it and test it. And if you maintain onsite fuel to power it, how do you keep that power system operational unless you evacuate? Again, that's an offsite. There are requirements that apply to generators that are permanently attached. They don't apply to mobile generators. And this requires the emergency power equipment and generators be designed so we, again, eliminate that damage. Again, from that one tornado, their generator was lifted up off of its footing. So that must be, as far as location, with a structure or building that is consistent with those three requirements, the safety code and the 99 and 110. I just put an example of what one would look like. And of course, routine maintenance, operational testing, maintained and tested according to the requirements based upon manufacturer manuals and minimum requirements. Fuel, the permitted fuel sources, you have liquid petroleum, liquefied gas, or natural synthetics. Generators class X, minimum time rated at a load without refueling, and that they're installed where chance of interruption is very low. Okay, I did want to get to that because we do need to keep things operational and maintain our system. For your integrated healthcare system, if you are part where you have separately certified healthcare facilities, you can have a unified program, and you can also participate in the coordinated preparedness program. If you're going to do that, you must do all of the following. Each facility must show they have actively participated in development of the program. In other words, there's designated personnel to collaborate, there's documentation that shows participation. Who was there and minutes? What was their involvement? The program development maintained for each facility's unique situation. Patient population, who did they, what services are they providing? Anything that would impact operations during an emergency, you have to include those. And that includes location of the facility and what staffing and resources and supplies are available. You have to demonstrate each facility is capable of actively using and complying with the program. And that includes a unified integrated plan that meets the requirements. This is reviewed again every two years. Like anything else, it's based upon an all hazards approach with documentation. You have to have policy and procedures that it is a coordinated communication plan for reporting mechanisms, how you ensure seamless communication to the officials and avoid miscommunication between the system and all of your facilities. Policy and procedures, training and testing develop considering all requirements for each facility and based upon your risk assessment. Each facility has to keep individual training records and all required testing exercises. So this is not something that sounds very easy. They require a lot of documentation because a surveyor is going to verify you did opt for this. They want to see your documentation, who participated and what did you do? They want a copy of the entire unified program and all of its components. And then they're going to sit down and talk to leadership. How did you verify that this program is updated based upon changes within your facility? In short, facilities coming and going. Now, as far as joint commission, they do have some additional information on emergency management. This likewise with CMS, you have an all hazards approach, leadership provides oversight and support of your program and you conduct a hazard vulnerability analysis that you develop an operation plan based upon that approach and that you have a communication plan on how you're going to initiate and maintain communications during an emergency. You have a staffing plan that may include volunteers and that you have a plan for providing care and support during a disaster or emergency. You have a plan for safety and security measures. Now, what are you going to do with those narcotics if your building got hit and maybe how are you going to secure them if you have to evacuate? That you maintain resources and assets during that incident. You plan for managing essential or critical utilities that you continue your operations and plan. You have a disaster recovery plan and that you have an emergency management education and training program. You do these and you conduct those exercises and you evaluate how did it go. I want to go finally to active shooter and you wonder why did we bring this up as a network place violence? Well, yes it is. But if you've gone through any drills because this could be part of your emergency preparedness plan. Now I'm hoping this does work and there is sound according to this, it runs about three minutes. So I do have to thank Baylor Scott and White. They provided this to CMS. It is available on the CMS website. So if you'd like to use it, you can download it and have it available. This can be part of that training exercise that you utilize. And just in the interest of time, I'm just gonna go ahead and move on. Because I wanted to point this out because in the 11 years we've had over 154 shootings and 91 occurred inside the hospital. And so that's why Joint Commission issued their quick safety advisory. And it talks about the rapid increase in these crimes and how we can start to respond. So that's why in part of your planning, consider doing this one. Involve local law enforcement because then they are familiar with what your facility setup is like. And that also helps you have a liaison with law enforcement. So you know who to contact and how to communicate. You wanna make sure that your communication plan includes that primary communication and the emergency hotline. So employees also know how to respond. You see in there, the employees knew what to do, where to go and how to respond. And again, a script for the incident command so that when calls do start to come in, because they will shut down part of your hospital, if not a vast majority of it in investigation. And then of course, what are you going to do on a press release so we can share that information? Prepare the building if it has to be a walk-in. Establish a way and procedures to make sure patients, employees, visitors are safe, that you can account for them. Train and drill, make sure that they have ongoing training on what to look for, how to respond. And that also includes doing maybe tabletop drills. How did we respond in this one? What happened? And by the way, if you are going to do this, plan for those post-event activities. Do a debrief, make sure that you can manage and help with anxiety and fear. This can be patients, staff, leaders. It doesn't have to be the intended victim because these can be very, very impactful on your staff. And so just here's some final suggestions. Again, prepare for the influx of the individuals you might see coming in for shelter. Maybe there's areas you do designate as shelter only. Keep an eye on, say, such locations as your sterile processing. You don't want people just tramping in there. Same with pharmacy. Look for those at-risk patients, whether it's elderly, behavioral health, SUDs, pediatric patients that you want to protect. Prepare your staff on those testing and drills because it can trigger an unwelcome response and again, there's also compassion for even the crisis counselor. SAMHSA has resources for disaster response and how you're going to react to that. And then care for the caregivers. This is an active stress management program and that's why it helps to have that training plan because those who counsel or provide counseling to your staff and others, they're impacted by this too. And that's why it's always helpful to have this as backup so they can continue to do what they need to do. And yes, we have time to go through. This is my final one. We have a hospital. It's a hundred-year-old facility. Recent HVAC updates retrofitted it structurally 25 years prior with additional support added to one wing. That's where the HVAC was located. Of course, we had heavy rains and wind that result in collapse of part of the building that wasn't part of the re-update. Immediately after the collapse, we got a problem. Two staff members, they can't account for them. A review of the emergency plan showed there was no process to account for staff or patients. Now, why that occurred, we never did find out. So what should the hospital do as part of their after action report or review? And Lindsay, I'll leave it to you on how you want them to respond. Yeah, absolutely. If you all would like to just type your comments there in the chat, that would be great. I'll give you a couple of seconds to do that. Laura, if you maybe want to go over some resources. Yes, some of the additional sites. Okay, so again, multiple resources in here. I try to put as many in there. All of these are free. I don't like to add putting things that you have to pay for. They talk about the requirements for the emergency preparedness. I have additional definitions. So when you're putting your policy and procedures into place, just take the definitions that came right out of this memo. Who are they? Who are your staff? What do you need? There is Homeland Security. They do some really good preparedness toolkits that you can have. CDC even has some for them. And they have planning and resources according to what is your setting? Are you a hospital? Are you an outpatient surgery center? The National Institute of Health, they have on talking emergency preparedness for coalitions, your checklist. I did mention that, HWO, excuse me. Getting dry in the mouth here. There's the toolkit that I did mention and the active shooter response and joint commission. FBI has a really good planner, a response planning for active shooter and so does NSO. And I mentioned that readiness tool. That's how you would access that kit. Again, it is on the CMS site. So you can download that video again. Baylor Scott and White put that together for them. Very good tool. Just if you're going to use that for your tabletop or during your drill, that staff is aware. And if you are doing an actual drill, please notify your staff. You might want to do that because they did it at one of our level one traumas here. And they forgot to notify staff that this is a drill and police and fire and SWAT all showed up at the door and some of the staff really panicked. So make sure your staff at least has some comfort knowing yes, it's a drill, but you are expected to respond and act as though it were happening. So again, Lindsay, I'll send it back to you. We've got seven minutes left over. Perfect. Thank you so much. Let's see here. So one comment, let's see. Use your badge access, control system available to determine where staff badged in, add a process for collecting a report on all employees that clocked in on any given day. Payroll may suffice. Use PDSA to develop and add a process. So yeah. So these good comments. Yes, they are. They're very good comments. I don't see any questions, making sure I'm scanning through the list. Okay. And I know it's add an attendance log. Yeah. And I know I went through some of that information pretty quickly, emergency preparedness is, and I'm sure with all of the events that are happening right now, there's going to be some more coming along. I don't know if that most recent hurricane Burl is going to be headed to the Atlantic coast or how that's going to, which direction that's going to head. Absolutely. Good timing for today's session. A comment here saying, not a question, just saying thank you for the updates and resources. The stories will help the information stick a lot longer. I think that is definitely true. Thank you. Okay. I don't see any other pending questions at this time. Yep. I saw, I did go ahead and just post some information for everybody there in the chat. Just as a final reminder that you will receive that email tomorrow morning, but just note that it does come from educationnoreplyatzoom.us. And so because it comes from that Zoom email, it may get caught in your spam quarantine junk folder. And so if you don't see it in your inbox in the morning, I would just encourage you to check those additional folders. And then if it's still not there and you'd like to access the recording, we do record these as on demand, meaning that you can use that same Zoom link to access the recording that you also use to join us for today's live presentation. And then just remember that the recording link is available for 60 days from today's date. And then we do have an additional security measure in place to protect Laura's intellectual property here. So once you click on that Zoom link, it will ask you to enter your information and that will prompt an email to come to us to approve that recording access request. And we do approve those very quickly, but we ask that you give us one business day. And then again, you'll have full access to the recording for 60 days from today's date. And then also included in tomorrow's email will be a link to the slides that Laura presented for us today. But I did go ahead and provide that link there for you in the chat to have as a resource now as well. And then if you are joining us as a member of the Georgia Hospital Association, please pay special attention to that link in tomorrow morning's email that will include the survey. And that is how you will obtain further information on continuing education credits. And if you are joining us as a member of a partner state hospital association, please reach out to your contact with your association to obtain any information regarding CEs for today's webinar that your state is offering as well. And if you do have any additional questions, don't hesitate to reach out to us at education at gha.org. And I know Laura's contact information is included in her slides and you can always reach out to her and she's wonderful about her timely and thorough responses, but you can always just send your questions over to us and we're happy to get them to Laura so that she can respond back as well. Okay, we thank you all so much for joining us during this week and I hope that you all have a wonderful 4th of July and thank you so much, Laura, as always for your time and information that you shared with us. And I hope to have you all back with us for future sessions. I hope you have a wonderful day. Thank you, Laura. Thank you, everyone. Thank you, Lindsay. Bye-bye.

emergency preparedness

healthcare facilities

inclusive planning

risk assessments

continuity of operations

patient populations

staff

alternative energy sources

patient monitoring

collaboration

community partners

essential services

clear communication

evacuation procedures

natural disasters