There’s no more excuses for getting ready to meet the new emergency preparedness Conditions of Participation (CoP). The final version of the rules came out in late June, and surveyors with CMS and The Joint Commission will begin assessing compliance with the new emergency management (EM) CoPs on November 15, regardless of the revision timetable.

CMS first announced the new CoPs in September 2016, which compel hospitals to communicate and coordinate their emergency plans with other hospitals and government agencies. They also require regular emergency preparedness training with staff and disaster contingency planning. CMS published the final version of the new Appendix Z of Medicare’s State Operations Manual online, and state surveyors will use newly created E-tags to score deficiencies and expectations set in it.

While many providers had been waiting for the final guidelines to come out before working to meet the new emergency preparedness requirements, note that the new 72-page appendix might not be as helpful as hoped. The guidelines are not separated out by provider type but rather by the CoP, Condition for Coverage, or Condition for Certification (CfC) that was set out in the final rule issued September 2016.

You should also remember that the version online could “vary slightly” from the advance guidelines published June 2. However, the online version is the final policy, so you will need to check it to reconcile policies and procedures if necessary.
 
E-tags separated by provider
The final rule is divided by provider type, and each E-tag has different expectations outlined depending on provider. That means you’ll have to select which part of the E-tag applies to your facility, notes Frank Ruelas, facility compliance professional at St. Joseph’s Hospital and Medical Center/Dignity Health in Phoenix. And that gets a little busy to read, he says, but when in doubt one should still turn to the final rule for guidance.

“Sometimes one can find very useful information to help clarify questions that come up when reviewing these requirements,” he says.

Look to the provider-specific sections of the final rule for explanations. “Using this approach can take a lot of the mystery out of what needs to be done,” Ruelas observes.

The Joint Commission is working on revisions to its EM standards chapter in light of the new CoPs.

Long time coming
Work on the new EM Interpretive Guidelines has been ongoing since 2014, and CMS has been warning healthcare organizations (HCO) since 2016 not to hold off on preparing for them—especially those HCOs required to meet the annual emergency preparedness exercises set forth in the September 2016 final rule establishing the CoPs or CfCs.

Most organizations are required to conduct two exercises per year, including at least one full-scale drill involving the local community or, if that is not possible, the entire facility.

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