By now you are well into developing your Emergency Preparedness Plan for your Rural Health Clinic (RHC) or Federally Qualified Health Center (FQHC).  You conducted an all-hazards approach to your risk assessment.  That is, you identified all probable hazards and developed response procedures for each type of hazard which include natural, man-made, and/or facility emergencies.  Additionally, as you conducted your risk assessment, you took a facility-based approach.  You concentrated on risks specific to your facility and your region; for instance, you developed plans for a blizzard in Colorado or a tidal wave in Hawaii.  You may have also decided to use a community-based risk assessment where you use plans developed by other entities such as public health and emergency management agencies, or regional health care coalitions.  All the while, you reviewed your current HIPAA policies to look for overlaps or areas of commonality so you can use what you have already developed and have in place. Your next step for your Emergency Preparedness is to implement your plan in policies and procedures.

Centers for Medicare and Medicaid Services (CMS) requires you to develop policies and procedures and review and update them if needed at least annually.  The policies and procedures must align with the risk assessment and hazards identified during the risk assessment.  You can choose to make them part of your facility’s Standard Operating Procedures or Operating Manual, however, CMS recommends you have a central place to house your emergency preparedness program documents.  This will make it easy for CMS to review them should they conduct a survey.

There are four key issues CMS asks you address in your policy and procedures:

1.     Safe evacuation

2.     Shelter in place

3.     Preserve Medical Documentation

4.     Using Volunteers

1.     Safe Evacuation:  CMS wants you to develop an evacuation plan which considers the care and treatment needs of evacuees.  The plan should also spell out staff responsibilities, transportation needs, and identify locations that will be used for evacuation.  The evacuation protocols should address where the evacuees will go but also where the staff members go as many times the evacuation location for the two are different.  What will your transportation needs look like?  How many vehicles do you have?  Will you use vehicles of opportunity to evacuate your patients and staff?  If you are an RHC or FQHC, you must also place exit signs to guide patients and staff in the event of an evacuation from your facility.

2.     Shelter in Place:  CMS wants you to develop a plan to shelter in place for your patients, staff, and volunteers.  Not every emergency allows you to evacuate your facility.  The most common threat that requires a shelter in place decision is probably a tornado.  Your policy and procedures should identify the criteria for determining which staff and patients will shelter in place before an evacuation.  When developing your plan, don’t forget to consider the ability of your building to survive a disaster as well as what proactive steps you can take prior to a situation that requires you to shelter in place.  These are critical decisions that need to be well thought out before an actual emergency occurs.

3.     Preserve Medical Documentation:  CMS requires that you establish a system of medical documentation that preserves patient information, ensure patient records are secure and kept confidential, and readily available to support continuity of care during and after an emergency.  Your policy and procedures should explain how you will accomplish this as well as stay in compliance with the HIPAA privacy and security rule.  That is to say, your procedures must show how you will protect the privacy and security of individual’s personal health records whether you have electronic or paper medical records.

4.     Using Volunteers:  CMS wants you to develop policy and procedures to use volunteers in an emergency and other staffing strategies.  Your procedures should explain how you will use volunteers with different skill levels. For instance, you may have healthcare professionals who volunteer during an emergency.  How will you provide privileging and credentialing process in an emergency that ensures the volunteers can perform services within their scope of practice and training?  You will have to look at your state laws and regulations for guidance.  You also have federal teams that may volunteer in an emergency and are federally designated health care professionals such as the Public Health Service (PHS) staff, National Disaster Medical System (NDMS) medical teams, Department of Defense (DOD) Nurse Corps, or the Medical Reserve Corps (MRC).  Your policy and procedures should also spell out how you will use non-medical volunteers.  These individuals will perform non-medical tasks during your emergency.

CMS requires you to develop policies and procedures and review them annually.  This allows you to update them if needed.  The policies and procedures must align with the risk assessment and hazards identified during your risk assessment and address safe evacuation of your patients and staff, sheltering in place, preserving medical documentation, and how you will use both medical professional and non-professional volunteers. CMS recommends you have a central place to house your emergency preparedness program documents.  And remember to review your current HIPAA policies for areas where there is commonality or where you have already addressed some of the requirements of the Emergency Preparedness Plan.