Posted On: September 25, 2017 by NARA in: Compliance Fall Conference Regulatory Issues Rehab Agency
By Nancy J Beckley, MS, MBA, CHC
Disasters have captured national attention with hurricanes in Florida, Texas, and Puerto Rico, top that off with an earthquake in Mexico City and wild fires in Idaho, Oregon and Montana. The heartbreaking deaths in a rehabilitation facility in Florida during Hurricane Irma (for lack of air conditioning) brings home the urgency of being prepared for any and all disasters coming into the path of your facility. The Emergency Preparedness Rule was final last November 15th, and the final implementation (compliance) date is November 15, 2017. Are you ready?
At the NARA Fall Conference in Las Vegas I’ll review the four key requirements of the emergency preparedness rule, identify the required components of the emergency plan specific to rehab agencies, provide tips on doing a hazard vulnerability assessment and running a table top exercise, and identifying what will be required to show surveyors are evidence of compliance.
Rehab agencies, comprehensive outpatient rehabilitation facilities (CORFs), and home health agencies are among the 17 providers required to be in complicate with the new emergency preparedness (EP) Condition of Participation (CoP) no later than November 15th. CMS released the Interpretive Guidelines (IG) earlier this summer as Appendix Z to the State Operations Manual. The interpretive guidance and regulatory citations for all 17 providers types are comingled leaving rehab agencies, for example, to sort through 72 pages of “comingled” guidance. The good news is that the new CoP for emergency preparedness replaces the existing Disaster CoP on November 15th. The unfortunate news is that the compliance elements are substantially more detailed, complicated, and time intensive than previously required.
The emergency preparedness CoP for rehab agencies specifically indicates compliance with the 2014 CMS updated fire safety regulations for rehab agencies. For providers that haven’t had a survey in several years, what will come as a surprise is the CMS mandate that those not in compliance will be cited per the normal survey and certification process. CMS has mandated 17 hours of surveyor training, and given concerns over recent disasters, surveyors are likely to pay attention to every required detail. Do you think a rehab agency that is cited on this condition can be in compliance within the 10 days allowed for a plan of correction? (Answer: likely not!).
What happens in Vegas, stays in Vegas….except all the take home value getting ready for compliance with the Emergency Preparedness Condition of Participation.
Nancy J. Beckley, MS, MBA, CHC
Nancy Beckley & Associates
https://nancybeckley.com
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