Brian Williams
Brian Williams

In 2016, the Centers for Medicare & Medicaid Services set forth new regulations related to life safety and emergency preparedness.

Designed to protect Medicare and Medicaid beneficiaries — namely those in long-term care facilities — the updates cover a wide range of safety and fire prevention requirements related to adoption of the 2000 edition of the National Fire Protection Association’s Life Safety Code. CMS also published the Emergency Preparedness Final Rules, requiring facilities to have emergency preparedness plans in place, which should be reviewed and updated annually.

In early 2018, the Office of the Inspector General conducted a series of unannounced compliance audits within 20 nursing homes across the state of New York. What the OIG found was quite alarming: There were severe deficiencies at all 20 facilities, including 205 areas of noncompliance related to life safety and 219 areas related to emergency preparedness. The OIG determined that residents at these nursing homes were all at increased risk of injury or death in the event of an emergency.

These discoveries prompted the department to declare this August that, “New York should improve its oversight of selected nursing homes’ compliance with federal requirements for life safety and emergency preparedness.” In its report, the OIG cited inadequate management and lack of standardized training as causes for these deficiencies. 

What happened in New York should inspire some introspection. It’s an opportunity for other long-term care facilities to examine their own life safety measures and emergency plans as required by CMS. It’s a matter not only of compliance, but also resident safety.

If you are looking at reevaluating or updating your facility’s life safety and emergency preparedness plan, keep these five tips in mind:

1. Look at all possible risks

To develop an effective emergency preparedness plan that meets CMS requirements, it’s important to conduct an all-risk hazardous assessment. This helps ensure there are specific plans in place for any and all types of emergencies or disasters that may occur — and this can differ greatly from site to site, region to region. For instance, a facility in a flood zone in Florida or Texas will need a plan in place to evacuate residents and get them to higher ground. Similarly, a facility in Southern California will need an evacuation plan in case of wildfires.

Beyond natural risks, there are also nearby ones, such as local power plants or prisons that can pose dangers. An all-risk hazardous assessment helps weigh the probability of these incidents occurring and determine if your facility is well equipped and capable of recognizing and responding to an event.

2. Digitize policies and procedures

After conducting an all-risk hazardous assessment, it’s then possible to define appropriate policies and procedures based on identified risks. Better yet, consider digitizing these policies and procedures rather than storing them in paper binders. A compliance management solution can help, providing modules to compile the information.

Staff members thereby have access to all policies and procedures at the click of a mouse. They can easily search for what to do in case of an emergency, such as the provision of subsistence needs (e.g. food, water and medical supplies) for staff and residents, or whether they evacuate or shelter in place. Managers can assign certain policies to all staff, specific departments or employees with certain positions — plus require them to digitally sign and acknowledge that they have read the policy. This helps to keep everyone accountable and informed.

3. Establish a comprehensive communication plan

Part of the CMS requirements for emergency preparedness is a communication plan. There are several types of communication that need to occur if there is an emergency or disaster, including notice to first responders, resident families and employee families. Beyond these individuals, facilities should think broadly about their available resources and identify who they can contact to minimize the health and safety risks for their residents. For instance, some can look to local hospitals for support.

The plan should integrate county disaster preparedness capabilities and identify state and federal resources, as well as other affiliated long-term care facilities to relocate residents. It’s important to note that all communication and release of patient information must be consistent with the HIPAA Privacy Rule and federal, state and local laws.

4. Move training online

Training on proper protocol in the event of an emergency, as well as how to use life safety equipment, is vital to proactively prepare your staff. As the issue in New York showed, adequate training can make a big difference in terms of compliance. One way to deliver better education to staff members is opting for online training, rather than traditional slideshow-driven seminars and lectures.

By moving training online, staff can complete necessary courses on their own time, instead of taking time away from resident care. Courses are delivered in a consistent, standardized way. Further, managers can conveniently see who has and hasn’t completed the required training. Look for a learning management solution that comes with common important courses — such as the proper handling of fire extinguishers — and custom course options. 

5. Invest in equipment lifecycle management

Life safety compliance is heavily reliant on the ongoing and documented maintenance of equipment and building maintenance systems. It is difficult to maintain compliance with manual processes so it’s a good idea to utilize a compliance management solution that includes an equipment lifecycle management module. Namely, CMS requires that all long-term care facilities have an emergency power generator on site. An equipment lifecycle management module should include the ability to upload digital policies that align with a generator manufacturer’s specifications, as well as the user manual to support staff training.

Managers should also be able to log and track what maintenance work has been done from outside contractors. This helps ensure generators and all other life safety equipment are in working order when they are needed most.

Life safety and emergency preparedness are essential to running a long-term care facility. By following these outlined tips, you can readily meet CMS requirements with a proper emergency plan, policies and procedures, communication and training. Perhaps most importantly, you can protect your residents in case of any unforeseen crisis or disaster. 

Brian Williams is director of compliance and regulatory affairs for MedTrainer.