Annual Review of Emergency Preparedness Plan


Current CMS Emergency Preparedness Conditions of Participation require an annual review of your emergency preparedness plan. Under the proposed rule, the plan “must be evaluated and updated at least every 2 years.” Not in the rule, but in the explanation, CMS says,
“We expect that facilities would routinely revise and update their policies and operational procedures to ensure that they are operating based on best practices. In addition, facilities should update their emergency preparedness program more frequently than every 2 years as needed (for example, if staff changes occur or lessons-learned are acquired from a real-life event or exercise).
“As noted in the Emergency Preparedness final rule (81 FR 63860), “…there are various infections and diseases, such as the Ebola outbreak in October 2014, that required updates in facility assessments, policies and procedures and training of staff beyond the directly affected hospitals. The final rule requires that if a facility experiences an emergency, an analysis of the response and any revisions to the emergency plan will be made, and gaps and areas for improvement should be addressed in their plans to improve the response to similar challenges for any future emergencies.”
We agree with this proposed rule, but would like to see two changes:
  1. We would like to see an annual requirement for a risk assessment. A serious risk assessment is the best way to determine what changes need to be made in your emergency plans, and risks do change more often than biennially. Ebola is one example, but changes in the facility, in occupancy, in utilities, all change the threat matrix that we face. If the changes in the risk assessment are minor, then perhaps no changes in plans, policies, and procedures are needed.
  2. We would like to see more honesty and objectivity in risk assessments. The Kaiser-Permanente model is easy to complete, but that is its major asset. We need more objective data, and we need to be serious about how prepared we are NOT.
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