Should we stay or should we go? Hurricane preparedness in long-term care

Vivid memories of desperate nursing home residents in wheelchairs submerged waist-high in flood waters will forever be etched in our minds, especially during hurricane season. The shocking photos and tragic heat-related deaths of numerous skilled nursing and assisted living residents caught in the throes of and aftermath of hurricanes such as Harvey and Irma underscore the need for each long-term care facility to have an effective emergency preparedness plan and evacuation strategy.

As we deal with the aftermath of Hurricane Florence and prepare for the potential of additional storms still to come this hurricane season, we are again reminded of the importance of comprehensive planning to ensure the safety of residents.

Plan your work

According to the last tally by the Centers for Disease Control and Prevention, there were 1.4 million residents in nursing homes in 2014. In the wake of prior natural disasters, such as Hurricane Katrina, it was recognized that process improvements were needed to protect the safety and well-being of residents in long-term care and other healthcare facilities. Obviously, hurricanes, fires and other natural or even man-made disasters are nothing new, and facilities have had emergency preparedness policies and procedures in place for many years. However, change was necessitated when an alarming rate of non-compliance was uncovered. The Centers for Medicare and Medicaid Services found more than 1,850 incidents of nursing homes that failed to have written emergency evacuation plans between 2011 and 2018. In addition, they found 3,770 nursing home violations of the requirements to inspect power generators weekly and test them monthly, according to a review of CMS’ Nursing Home Compare Safety Deficiency data.

In September of 2016, the Federal Register posted the Emergency Preparedness Requirements for Medicare and Medicaid Participating Providers and Suppliers. The purpose of the updated September 2016 rule was to establish national emergency preparedness requirements to ensure adequate planning for natural and man-made disasters, as well as coordinate with local, state, tribal, regional and federal emergency preparedness systems.

The new rule consists of four core components:

  1. Risk assessment and creation of an emergency plan based on disaster risks and likelihood of occurrence
  2. Creation of policies and procedures with an all-hazards approach to emergency preparedness
  3. The development of a plan to maintain communication with state and federal authorities
  4. The creation and execution of training and testing exercises to verify understanding of changes and/or policies within the new rule

Additionally, the new rule applies to 17 facility and provider types including:

  1. Hospitals
  2. Ambulatory surgical centers
  3. Hospice and hospice agencies
  4. Psychiatric facilities, including inpatient and outpatient facilities
  5. Long-term care facilities
  6. Critical access hospitals
  7. Intermediate care facilities for those with intellectual or developmental disabilities
  8. Home health agencies
  9. Outpatient rehabilitation facilities
  10. Mental health centers, serving communities or religious-affiliated groups
  11. Rural health clinics
  12. End-stage renal disease facilities
  13. Organ procurement organizations
  14. All-inclusive care for the elderly, including skilled nursing facilities
  15. Outpatient rehabilitation facilities
  16. Clinics, rehabilitation agencies and public health agencies acting as outpatient providers of therapy
  17. Religious non-medical home care institutions

These provider and service types must be in compliance with the Emergency Preparedness regulations in order to participate in the Medicare and/or Medicaid programs. Of note, however, any state or local regulations that supersede compliance with the minimum requirement contained in the new rule will remain in effect in the respective jurisdiction.

The current compliance deadline is November 16, 2018. CMS has the capability to track compliance with the new rule. A facility’s failure to update its emergency preparedness plan by the deadline could result in penalties by CMS. Non-compliance penalties may extend beyond fines levied by CMS to include revocation of participation in Medicare and Medicaid programs, immediate suspension of the ability to offer services to residents with existing coverage under the programs, revocation and demand for repayment of financial incentives through CMS. Other “soft” damages could flow from non-compliance, such as harm to a facility’s reputation. CMS also offers a six-page checklist as a way to ensure an organization is able to comply and meet all the requirements under the new rule.

Work your plan

The speed at which emergent situations occur can be sudden or develop over time. Key considerations that drive the decision to evacuate or shelter-in-place must be part of a facility’s emergency management plan. There are several internal and external factors that impact this kind of decision. Internal considerations involve resident acuity, transportation, destination, staffing, physical structure and supplies. External factors include the nature of the event, the location of the facility (urban, rural, etc.) and the risk of storm impact or flooding based upon the location of the facility. Each nursing home’s emergency management plan must include a primary and alternate individual who has the authority to call for an evacuation. Decision-makers could be the nursing home administrator or designees, facility owner, local or state emergency operations center representative or even the governor of the state.

The decision to evacuate nursing home residents is a serious undertaking that is fraught with inherent risks to the very residents it seeks to protect. These individuals are often very frail, immobile, cognitively impaired or even ventilator-dependent, which makes moving them en masse quite complex. And the evacuation of these residents is only one part of the equation: other items must also be moved, such as medical records, medication, medical equipment, disposable products, food and water. In addition, there must be sufficient staff and transportation available to effectively move residents from one location to another. Laws and regulations require comprehensive planning to ensure the protection of nursing home residents in all phases of an evacuation or shelter-in-place situation. Special care is required to maintain proper hydration and nutrition; adequate staffing through all phases of the event, and essential communication with residents’ families as well as government officials is critical.

In light of the possibility of another natural or manmade disaster, it is vital to keep the points below in mind:

  • Maintain an emergency preparedness plan that aligns with the new Federal Register rule
  • The decision-maker during the time of emergency must understand all internal and external considerations when determining the correct steps the facility should take
  • Understand all parts of the equation when making decisions, such as items necessary for residents during their stay
  • Communication is essential in maintaining consistent understanding of the steps that will be performed

The evacuation process overall is time-consuming, complex and expensive and must be thoughtfully addressed in the facility’s emergency preparedness plan. Considering the value of life at stake, as well as compliance and reputational concerns, it is necessary to have a strong understanding of the facility’s plan in order to have the capacity to react quickly and confidently in the case of another natural or man-made disaster. Although it is impossible to prepare for every scenario, proper planning and response can certainly lessen the chances that the history behind those haunting post-hurricane photos will repeat itself.



Resources

CMS Online Emergency Preparedness Checklist: https://www.cms.gov/Medicare/Provider-Enrollment-and-Certification/SurveyCertEmergPrep/Emergency-Prep-Rule.html

Nursing Homes Cautiously Wade Into Hurricane Season: https://www.bna.com/nursing-homes-cautiously-n73014477779/ 

Facility Transfer Agreements: https://www.cms.gov/Medicare/Provider-Enrollment-and-Certification/SurveyCertEmergPrep/Downloads/Facility-Transfer-Agreement-Example.pdf

Are You Ready to Weather the Storm: Aftermath of Hurricanes Harvey and Irma: https://www.hcca-info.org/Portals/0/PDFs/Resources/Conference_Handouts/Compliance_Institute/2018/611_2.pdf

National Criteria for Evacuation Decision-Making in Nursing Homes: https://www.in.gov/isdh/files/NationalCriteriaEvacuationDecisionMaking.pdf

How to Get Ready for the New CMS Rule for Emergency Preparedness: https://nhcps.com/get-ready-new-cms-rule-emergency-preparedness/


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