CMS Regulatory Requirements For Emergency Preparedness Programs and TJC Compliance

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By - Laura A. Dixon, BS, JD, RN, CPHRM

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The COVID-19 pandemic and multiple natural and man-made disasters over the past few years has required hospitals to activate their emergency preparedness plan. In anticipation of patient injury because of such disasters, CMS – Centers for Medicare and Medicaid Services – revised the Emergency Preparedness Conditions of Participation for hospitals in 2020.

This webinar will cover CMS regulations for a facility regarding emergency preparedness with the recent updates to include emerging infectious diseases. All covered facilities are required to have a written program to address the various natural and man-made emergencies that may impact delivery of care and patient safety. Training of staff and testing of the program must be done. This program will cover the required elements for compliance with CMS regulations, including mandatory testing and training of all personnel. There will also be a brief discussion of reference and resources from The Joint Commission.

Objectives

At the conclusion of the webinar, attendees will be able to:

Identify the 3 key essentials for emergency preparedness
Recall the 4 core elements of an emergency preparedness program
Recall key responsibilities of a facility when the emergency preparedness plan is activated.
Describe when and the extent of an exemption to mandatory testing could occur.

Detailed Program Outline

Identification of State Operations Manual

Introduction
Overview of Appendix Z
Abbreviations used by CMS

Core Elements

Emergency plan – basics and requirements
Risk Assessments
Policies and procedures needed
Items for plan development
Patient populations
Continuity of operations
Cooperation and collaboration with local, tribal, regional, State and Federal officials
Power sources
Evacuations or Shelter in Place
Alternate care sites
Communications Plan
Training and Testing
When an exemption to testing may apply
Emergency and standby power systems
Integrated Healthcare Systems

Joint Commission standards

Emergency management Standard and elements of performance
Active shooter

Resources and Links

WHO SHOULD ATTEND

CEO
Compliance Officer
Chief Medical Officer
Chief Nursing Officer
Nurse Education
Nurse Directors/Supervisors
Risk Managers
Compliance officer
Patient Safety Officers
Quality Improvement staff
Hospital Legal Counsel
QAPI Director
Emergency/Disaster Preparedness Officer
Safety/Security Officers

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Webinar Type

Clear

Speaker Detail

Laura A. Dixon recently served as the Regional Director of Risk Management and Patient Safety for Kaiser Permanente Colorado where she provided consultation and resources to clinical staff. Prior to joining Kaiser, she served as the Director, Facility Patient Safety and Risk Management and Operations for COPIC from 2014 to 2020. In her role, Ms. Dixon provided patient safety and risk management consultation and training to facilities, practitioners, and staff in multiple states. Such services included creation of and presentations on risk management topics, assessment of healthcare facilities; and development of programs and compilation of reference materials that complement physician-oriented products. Ms. Dixon has more than twenty years of clinical experience in acute care facilities, including critical care, coronary care, peri-operative services, and pain management. Prior to joining COPIC, she served as the Director, Western Region, Patient Safety and Risk Management for The Doctors Company, Napa, California. In this capacity, she provided patient safety and risk management consultation to the physicians and staff for the western United States. Ms. Dixon’s legal experience includes medical malpractice insurance defense and representation of nurses before the Colorado Board of Nursing. As a registered nurse and attorney, Laura holds a Bachelor of Science degree from Regis University, RECEP of Denver, a Doctor of Jurisprudence degree from Drake University College of Law, Des Moines, Iowa, and a Registered Nurse Diploma from Saint Luke’s School Professional Nursing, Cedar Rapids, Iowa. She is licensed to practice law in Colorado and California.