Common deficiencies cited by AAAASF and how to fix them — emergency preparedness

In our ongoing series, Becker's ASC Review spoke with American Association for Accreditation of Ambulatory Surgery Facilities’ Director of Accreditation Jeanne Henry about the organization's commonly cited deficiency related to emergency preparedness.

Jeanne Henry: AAAASF launched the CMS Emergency Preparedness standards in November 2017. ASCs surveyed after Nov. 15, 2017 must comply with the emergency preparedness requirements listed under CMS Condition for Coverage 416.54. Recent surveys have shown that many ASCs have not created and implemented sufficient emergency preparedness plans. Essential elements of an appropriate emergency preparedness plan include a documented, facility and community-based risk assessment, evacuation and shelter plan, communication plan and a procedure for the proper management of medical documentation. The ASC must develop and maintain an emergency preparedness communication plan that complies with federal, state and local laws. The ASC is required to review and update the emergency preparedness plan annually. The review should include full-scale drills and training. Initial training must consist of emergency preparedness policies and procedures for all new and existing staff, individuals providing on-site services under arrangement and volunteers consistent with their expected roles.

All potential risks must be assessed including natural and man-made disasters. The plan should include strategies for addressing emergency events identified by the risk assessment. Be sure to address patient population, including the type of services that the ASC has the ability to provide in an emergency and continuity of operations. CMS requires the ASC to collaborate with local, state and federal officials in an effort to maintain an integrated response during a disaster or emergency situation, including documentation of the ASC’s efforts to contact such officials.

Plans must address a system to track the location of on-duty staff and sheltered patients in the ASC care during an emergency. If on-duty staff or sheltered patients are relocated during the emergency, the ASC must document the specific name and location of the receiving facility or other location.

An adequate plan addresses the safe evacuation and signage from the ASC and takes into consideration the care and treatment needs of evacuees. It should specify staff responsibilities, transportation and identification of evacuation locations. A primary and alternate means of communication with external sources should be considered. Safe shelter for patients, staff and volunteers who remain in the ASC must be identified. A systematic way of medical documentation is also required and must preserve patient information and protect confidentiality. The system must ensure the availability of records.

If an ASC is part of a larger healthcare system consisting of multiple separately certified healthcare facilities, they may choose to participate in the healthcare system's coordinated emergency preparedness program. If they opt to participate in the integrated healthcare system’s coordinated emergency preparedness plan, the plan must include all required elements set forth by CMS.

Although the task of creating an emergency preparedness plan may feel overwhelming, there are resources available to help an ASC get started. Many state agencies offer free emergency preparedness templates online. Additionally, CMS has compiled a list of useful national emergency preparedness resources to assist state survey agencies, their state, tribal, regional, local emergency management partners and health care providers to develop effective and robust emergency plans. CMS has set up a mailbox for questions regarding the Emergency Preparedness Rule at SCGEmergencyPrep@cms.hhs.gov. AAAASF encourages ASCs to visit the CMS website directly for further information.

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