CMS COMPLIANCE: Emergency PreparednessWhat We Do For Healthcare Providers
Your Crisis Team provides expert guidance in emergency preparedness to help you successfully navigate complex CMS Emergency Preparedness Conditions of Participation.
Members of Your Crisis Team have responded to events where loss of life and property were clearly the result of a lack of emergency preparedness planning. Your Crisis Team was founded to meet this need and foster resilience.
We know how bad it can be – so you don’t have to find out the hard way. Our team of specialists
CMS Healthcare Compliance can be intimidating. Your Crisis Team has demystified the process and will help you identify where you are and then walk you through the steps towards compliance.
Healthcare Providers We Support
Home Health Agencies
Long-Term Care / Nursing Homes
Clinics, Rehabilitation Agencies, Public Health Agencies
Ambulatory Surgical Centers
Community Mental Health Centers
Comprehensive Outpatient Rehabilitation Facilities
Federally Qualified Health Centers
Intermediate Care Facilities for Individuals with Intellectual Disabilities
Organ Procurement Organizations
Programs of All-Inclusive Care for the Elderly
Psychiatric Residential Treatment Facilities
Religious Nonmedical Healthcare Institutions
Rural Health Clinics
End-Stage Renal Disease Facilities
CMS Compliance Services for Healthcare Providers
Online Training: How to conduct an effective Risk Assessment for your healthcare facility
The first step in emergency preparedness is to assess the risks that your community and your facility face. This process involves several people from your facility discussing the specific threats you face, including natural disasters, technological emergencies, and malicious attacks. Not only do you need to know what can happen, but also what problems they can cause: structural damage, power outage, access problems, supply shortages, etc.
This, in turn, determines the capabilities you must develop and strengthen as part of your emergency plan (i.e., the ability to continue serving patients even without commercial power; the ability to evacuate to a safer location; the ability to shelter in place for an extended period, etc.)
Your Crisis Team provides an online tutorial and booklet to guide you through the process. We also connect you with local resources who may have already identified the risks in your community.
Emergency Operations Plans Review
We will review your emergency preparedness plans against the CMS Conditions of Participation, identify any gaps, make recommendations and provide guidance for you to bring your plans into compliance.
You will receive a custom report, showing the CMS Emergency Preparedness Conditions of Participation line by line, along with relevant content from your current plan, whether your plan meets or fails to meet the rules, and recommendations for compliance and improving your plan.
Since part of CMS planning requires you to develop relationships with, and gather information from, resources in your community, we will identify and help introduce you to these resources.
Another key part of compliance includes training your staff on how to carry out the emergency procedures in your plan. You must keep good records. In addition to training new employees, all staff need training annually. We will review your current records and help you document the time you invest in training moving forward.
Your facility is required to participate in two exercises each year.
One of these required exercises can be a tabletop exercise. A tabletop exercise is a low-stress exercise, designed to test plans, policies, and procedures. We can conduct a tabletop exercise for you, in person or online. During a tabletop exercise, we will present to you a scenario. You will get a chance to talk about your plans, review them, and see how your plans would allow you to manage the situation we describe. Our role is to design the exercise (including all HSEEP documentation), facilitate the discussion, and then evaluate your ability to meet the emergency preparedness capabilities that CMS requires.
You will receive an “After-Action Report/Improvement Plan” which will summarize the exercise, your actions, and identify strengths as well as areas
This exercise is designed and monitored by a US Department of Homeland Security certified “Master Exercise Practitioner.” This is the highest possible certification for anyone conducting readiness exercises in the U.S.
On-Site Training Series: Elopement Prevention & Response for LTC/ICF
- Understanding different types of missing person incidents at healthcare facilities and reasons why residents/clients wander
- Assessing your facility’s likelihood, impact, and preparedness regarding missing residents/clients, as required by the Centers for Medicare and Medicaid Services (CMS) under §483.73(a)(1) and §483.475(a)(1)
- Discussing available prevention and mitigation strategies, including electronic tools such as Project Lifesaver; staff training; and alarm/alert systems
- Developing key elements of policies and procedures for missing resident/client incidents
- Training in initial search operations and incident management for missing resident/client incidents
- Live operations-based exercise to allow students to demonstrate knowledge. This can count as your “full-scale exercise” for CMS compliance
Specifically designed for Long-term care and Intermediate Care facilities
Helps meet CMS training and exercise requirements
Follow-up review of elopement plans is conducted two weeks after training
Select the CMS compliance service that’s right for your healthcare facility
What does a project engagement with Your Crisis Team look like?
Our proven process and methodologies ensure a smooth and productive project.
Just like any incident, it’s important to first determine the initial facts and objectives. What’s the current situation with your emergency plans, training, and/or exercises? What are your mission objectives?
We will ask you the hard questions that help you draw a clear picture of where you are or need to be, and what obstacles exist between here and there.
We will work with you to develop a step-by-step plan to help you achieve your objective. We will define operational periods – often two-week or monthly periods – which each contain clear steps to be taken. We will update you each period with an Incident Action Plan that reflects what has happened so far, and what is expected of each of us in the coming period. (If this sounds a lot like the NIMS you’re used to, that’s a good thing!)
We will work with your staff and/or independently, as dictated by the Action Plan, to achieve the tangible deliverables promised – plans, training guides, exercise elements – that reflect your organization’s culture and our professionalism.
You will have the opportunity to review and revise each, so the final version exceeds your expectations.
No significant project is complete until you and we have had the chance to weigh in on how well we did, and how this project has improved your preparedness.
We thrive on feedback. We can’t get better unless we get honest feedback from you.
Clients & Testimonials
Thank you for your assessment of our Emergency Preparedness Plan! Working with you has helped us understand how to prepare in an emergency and increase communication between our staff and patients.Marian
Healthcare Leadership Team
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Blog Posts Related to Healthcare
by Rick Christ 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...read more
by Rick Christ Currently, almost every provider type is required to participate in two exercises per year. One “should be” a “community full-scale exercise” while the other can be a tabletop. The original version of the current exercise standards was...read more
by Rick Christ Currently, the typical CMS regulation says this about the training requirement: The training and testing program must be reviewed and updated at least annually. (1) Training program. The hospital must do all of the following:(i) Initial...read more