In our last blog, we wrote about the policies and procedures you needed to develop for your Rural Health Clinic (RHC) or Federally Qualified Health Center (FQHC). The policies and procedures are developed after you have conducted your all-hazards risk assessment. CMS wants you to have at minimum, policies for:
- Safe Evacuation
- Shelter in Place
- Preservation of Medical Documentation
- Using Volunteers
Your next step is to develop your communications plan. This is critical as “communication” is often severely hampered during an emergency. This can be a personnel problem caused by lack of training and preparation, or it can be a structural problem where communication systems are degraded or destroyed by the emergency or disaster. Preparing a plan and ensuring all understand it will lead to success should you have to implement it for an emergency.
In developing your communications plan, CMS wants you to have the names and contact information for:
- Individuals providing services under arrangement
- Patient’s physicians
- Other RHCs or hospitals
- State or local emergency agencies
You must also develop a system to correctly provide the general condition and location of patients under your care while still meeting the HIPAA privacy rules. Your plan should include the ability to notify the Incident Command Center about your needs and status during the emergency. You should have a recall roster so you can notify off duty personnel to report to duty as needed or to stay away. Your plan should also include a listing of communication avenues that have been tested and are compatible with other agencies you may need to contact. Remember, during an emergency, regular land lines or cell phones may not be operational, so you must plan ahead and consider other communication options such as HAM radios, Walkie-Talkies, or Radio Amateur Civil Emergency Services (RACES) to name a few.
CMS understands how critical it is for an RHC/FQHC to have a well thought out communications plan where staff have been trained and the plan has been tested. Don’t wait until the emergency is upon you. Develop your plan now and test it so you will be ready when a disaster strikes. Oh yes, don’t forget, someone must be in charge of activating your emergency communications plan. This is usually the clinic administrator or someone else you have designated in writing.
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 Communications Plan. We at HIPAAtrek are developing an RHC/FQHC Emergency Preparedness Plan Package that includes a HIPAA/Emergency Preparedness Crosswalk, Emergency Plan Checklist, Risk Assessment Form, Policies and much more, so stayed tuned to HIPAAtrek for future updates. In the meantime, start working on that Communications Plan!
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.
We know many of you are currently rushing to meet the November 16, 2017 deadline for developing your Emergency Preparedness Plan for your Rural Health Clinic (RHC) or Federally Qualified Health Center (FQHC). As you do so, the Centers for Medicare & Medicaid Services (CMS) wants you to keep in mind these three key essentials for maintaining access to healthcare during disasters and emergencies;
- Safeguarding human resources
- Maintaining business continuity
- Protecting physical resources
In addition, your emergency preparedness plan will be made up of these four sections;
- Emergency Plan (including risk assessment)
- Policies and Procedures
- Communication Plan
- Training and Testing Program
In developing your emergency plan, you must first conduct a facility based risk assessment. You may already have some or most of this accomplished because you conducted the HIPAA security rule’s risk analysis and implemented a risk management plan. Nevertheless, CMS wants your risk assessment to take an all-hazards approach. An all-hazards approach looks at all possible emergencies and disasters and spells out the response procedures for each. You can’t depend on procedures for responding to one type of emergency to provide sufficient response for a different type of emergency. For instance, your procedures for an active shooter in your facility will not help you respond to a ransomware attack of your electronic health records. Makes sense, right? Your risk assessment and subsequent plan should identify and include procedures for natural, man-made, and/or facility emergencies. It should;
- Identify all business functions essential to the facility’s operations that should be continued during an emergency
- Identify all risks or emergencies that the facility may reasonably expect to confront
- Identify all contingencies for which the facility should plan
- Consider the facility’s geographic location
- Assessment of the extent to which natural or man-made emergencies may cause the facility to cease or limit operations
- Determination of what arrangements may be necessary with other health care facilities, or other entities that might be needed to ensure that essential services could be provided during an emergency
CMS uses the term “facility-based” to mean the risk assessment and emergency preparedness program is specific to your facility. This is important as this approach will more clearly identify as well as eliminate, natural disasters for your facility and area. For instance, an RHC in Florida should consider preparedness actions in the face of an approaching hurricane as opposed to an RHC in South Dakota which should consider capabilities after a three-day winter blizzard, which is more reasonable to expect. On the other hand, both RHCs should assess and develop plans to respond to a power outage which was not caused by a natural disaster, yet does require immediate response to continue operations. For instance, do you have backup generators and fuel to run the generators, thereby providing the power needed to run essential operations?
CMS allows you as an RHC to use a community-based risk assessment developed by other entities, such as public health agencies, emergency management agencies, and regional health care coalitions or you can use theirs while conducting your own facility-based assessment. If you use a community- based risk assessment and plan, you need to have a copy of it and you need to work with the organization that developed it to ensure it meets the needs of your facility’s emergency plan.
Again, you may have already addressed these emergencies and hazards while implementing your HIPAA plan and policies, so a review of your plan may only require additional considerations. We at HIPAAtrek believe that many of the CMS requirements are already addressed by the HIPAA security rule. We are currently putting together an Emergency Preparedness Plan and HIPAA security rule cross-walk so you don’t have to reinvent the wheel; so be on the lookout for it. Until then, review your current HIPAA security plan for similarities that meet the CMS Emergency Preparedness Plan requirements and/or begin to document your all-hazards risk assessment.