Facilities should conduct a thorough Hazard Vulnerability Analysis (HVA) to determine what events or incidents may negatively impact operations. While it is impossible to forecast every potential threat, it is important to identify as many potential threats as possible to adequately anticipate and prepare to manage a crisis or disaster situation. The HVA Risk Assessment should be conducted at least annually.
We recommend that facilities use the HVA quantitative tool developed by the American Society of Healthcare Engineering (ASHE) of the American Hospital Association (©2001). The HVA uses a rating system for the probability, risk, and preparedness for various hazards and situations.
If an LTC facility is part of an integrated healthcare system (such as a hospital) the facility must develop a separate HVA based on the unique needs of the resident population and be prepared to carry out the plan, as developed, for the LTC facility. Furthermore, the facility should take part in the development of the integrated healthcare system preparedness plan, including testing and training of the plan in accordance with the needs of LTC facility residents, staff and volunteers.
The following threats may impact facilities:
- Bomb Threat
- Forest Fires
- Ice Storm
- Internal Hazardous Materials Spill/Leak
- Law Enforcement Activity
- Missing Resident (Elopement)
- Pandemic Episode
- Power Failure/Utility Disruption
- Suspicious Mail/Packages
- Tornado/Hurricane/Severe Weather
- Wildland Fires
- Unknown Acts of Terrorism
- Workplace Violence/Security Threat/Active Shooter
Unique Threats: Based on the facility’s geographic location, past history, proximity to other structures and operations, proximity to transportation corridors, as well as other unique factors, it is essential to identify all threats that can potentially impact the facility.
Membership in one of Kentucky’s 10 Regional Health Care Coalitions is essential for conducting a Community-based Risk Assessment. A Community-based Risk Assessment is an assessment developed outside the facility with community partners, not an individual facility’s assessment of their community.
For each potential threat, we’ve developed a template to provide staff clear action steps to take based on the particular disaster or emergency situation. Although some actions may be common among all disaster situations, particular roles and responsibilities evolve as an emergency develops.
Quality, Safety & Oversight Group- Emergency Preparedness Regulation Guidance
Guidance for Surveyors, Providers and Suppliers Regarding the New Emergency Preparedness (EP) Rule
On September 8, 2016 CMS published in the Federal Register the Emergency Preparedness Requirements for Medicare and Medicaid Participating Providers and Suppliers Final Rule. The regulation became effective November 16, 2016. Health care providers and suppliers affected by this rule were to be compliant and implement all regulations one year after the effective date, on November 15, 2017.
On September 30, 2019 CMS published in the Federal Register the Medicare and Medicaid Programs; Regulatory Provisions To Promote Program Efficiency, Transparency, and Burden Reduction; Fire Safety Requirements for Certain Dialysis Facilities; Hospital and Critical Access Hospital (CAH) Changes To Promote Innovation, Flexibility, and Improvement in Patient Care Final Rule which revised some of the emergency preparedness requirements for providers and suppliers.
Purpose: To establish national emergency preparedness requirements to ensure adequate planning for both natural and man-made disasters, and coordination with federal, state, tribal, regional and local emergency preparedness systems. The following information will apply upon publication of the final rule:
- Requirements will apply to all 17 provider and supplier types.
- Each provider and supplier will have its own set of Emergency Preparedness regulations incorporated into its set of conditions or requirements for certification.
- Must be in compliance with Emergency Preparedness regulations to participate in the Medicare or Medicaid program.
Long Term Care Facilities have to be especially vigilante and well prepared when it comes to the current Coronavirus outbreak. It is time to review your Pandemic emergency plans especially for Continuity of Operations Planning.
- In a pandemic, on any given day 20-40%, of staff may not be able to come to work. A big part of pandemic planning is to adjust your staffing plans to be able to provide services with fewer staff. Staff may be sick, quarantined, carrying for someone sick at home. What does your plan say about revising staffing and care plans?
- Identify Isolation or quarantine space
- There may be shortages of supplies if factories or international vendors are unable to make production targets due to inadequate staff. What are vendor arrangements in this current situation, especially since it has been a hard flu season? Have vendors revised their plans?
- Cash is king in a situation where inadequate staffing may force banks to limit hours, pharmacies, local purchases, etc. Look at what sufficient cash on-hand might be if you could not get cash out of banks?
- Communication planning is key. Review your communication plans especially in light of :
- Where to report infections if any staff or residents test positive or need to be tested?
- Communicating with family members and legal representatives
- What is the policy as to whom is authorized to speak to the press?
Important Preparedness Websites
Kentucky Office of the Inspector General
Centers for Medicare and Medicaid Services – Emergency Preparedness
National Weather Service
CDC Infection Control
Kentucky Long-Term Care Ombudsman Program
Kentucky QIO Program
Kentucky Community Crisis Response Board
Kentucky Emergency Management-County Emergency Managers
Kentucky Association of Health Care Facilities
Central U.S. Earthquake Consortium
National Preparedness Month