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CLIMB THE LADDER OF SUCCESS WITH CoPs: Key Factors for Emergency Preparedness

Part 4 of 6

This is the fourth installment of six in a Simione series on the NEW Centers for Medicare and Medicaid (CMS) Conditions of Participation (CoPs) for Home Health.  Home health agencies must take steps now to ensure compliance with these important requirements by the implementation date of July 13, 2017.

The final rule, Emergency Preparedness Requirements for Medicare and Medicaid Participating Providers and Suppliers (CMS-3178-F), establishes national emergency preparedness requirements for Medicare- and Medicaid-participating providers and suppliers to ensure adequate emergency plans are developed and in place to address natural and manmade disasters.  These plans must coordinate with federal, state, tribal, regional and local emergency preparedness systems.

Historically, these regulations were developed based on prior disasters such as Hurricane Katrina.  Multiple gaps were identified following this and other major disasters having a negative impact on health care recipients.  Shortfalls were identified related to communication and coordination with other systems of care for local jurisdictions, contingency planning, and training of personnel.

The components of this final rule have been incorporated into the Home Health CoPs and will be found at CFR 484.102.  Home health agencies must prepare for these new requirements by developing an Emergency Preparedness program and plan to ensure their patients, caregivers and staff needs are met in the safest manner possible in the event of a disaster. 

An emergency plan, in the most basic sense, is a guiding document that outlines in detail the systems and protocols that an organization has in place to:

  • ensure the safety of staff and patients
  • operate within the larger emergency management system, and
  • maintain continuity of services to patients during and after an emergency

Goals of the new regulations are as follows:

  • establish/maintain an emergency preparedness program to addresses medical and non-medical needs
  • ensure predictable staff behavior
  • enable government agencies and health care providers to respond in a manner that is timely, collaborative, organized and effective

Compelling reasons beyond compliance with these regulations include:

  • ensuring the safety and well-being of staff
  • maintaining continuity of care to patients
  • ensuring agency financial viability and continuity of business operations
  • providing agency legal protection
  • ensuring appropriate utilization of resources
  • supporting community and partners during a disaster

Agencies will need to complete five steps to comply with this new regulation:

  • Conduct a risk assessment
  • Develop policies and procedures
  • Develop communication plans
  • Train staff and patients
  • Evaluate effectiveness of the plan

Conducting a Risk Assessment

Risk assessment and planning needs must include an “all hazard approach”, and should be updated annually.  The first step to the risk assessment is to consider all types of potential natural and manmade disasters.  Recommendations for risk assessment include the following:


  • Every effort should be made to include all potential hazards that could affect the agency’s patient population and community, and interrupt necessary utilities, supplies or staffing. Examples include: pandemics, hurricanes, tornados, fires, earthquakes, tsunamis, power outages, chemical spills, terrorist attacks, floods, bridge collapses, cyber-attacks and nuclear accidents. 
  • Once potential hazards are identified, the assessment must include determination of the actions necessary for hazard mitigation.  This includes necessary steps to eliminate or reduce the probability of an event, or reduce its severity or consequences either prior to or following an event.
  • Agencies need to establish a procedure to connect with local and state emergency preparedness organizations to coordinate the plan in conjunction those authorities and facilities.
  • Agencies should review all tate regulations pertaining to emergency preparedness, because some states require them to follow additional state-specific procedures and regulations for operating and responding in an emergency.  

Plan Development

Home care agencies must be prepared to rapidly identify patients at risk within the affected area.  They also must be able to contact staff, have available information related to the specific incident or disaster, and work collaboratively with their local emergency management partners and health department. Preparation plans need to include the following elements:

  • Agency identification of a 24/7 emergency contact telephone number and e-mail address of the emergency contact person and alternate
  • Telephone call tree of agency staff and procedure for keeping the telephone call tree current
  • Contact list of community partners/agencies, including local emergency management and health department, regional healthcare coalition or organization, emergency medical services, law enforcement, DME providers, medical gas vendors; and a policy for keeping this information current
  • Collaboration with the local emergency manager, local health department, regional healthcare coalition, and other community partners in planning efforts, including a clear understanding of the agency’s role and responsibilities in the county’s emergency management plan
  • Current patient roster that identifies and locates patients at risk to include: identifying information, contact information, patient classification as to risk level, and technology dependence to sustain life

Patient Classification Risk Levels

Emergency planning is essential to provide quality care while maximizing available resources. A patient classification system will identify patients at risk and assist in the triage of staff based on patient acuity.  Classification examples include:

  • Level one or highest priority:
    • patients requiring uninterrupted services
    • patients with unstable condition, who may deteriorate or require inpatient admission if not seen
    • patients requiring a home visit within 24 hours
  • Level two or medium priority:
    • patients requiring home visit within 48-72 hours
    • caregiver available to provide basic care
    • may postpone visit if telephone contact made
    • condition somewhat unstable, but could postpone visit without harm to patient
  • Level three or lowest priority:
    • home visit can be deferred longer than 72 hours
    • condition stable with access to informal resources for help
    • can safely miss a scheduled visit with basic care provided by family or informal support

Developing Policies and Procedures

Agencies will need to consider the following topics when developing policies and procedures related to emergency preparedness:

  • protocols established to coordinate agency readiness with National Alert Levels
  • procedures in place to identify and review patient priority
  • measures in place to respond to different categories of emergencies: weather-related, power outage, chemical, nuclear, or radiological emergency, mass trauma incident, etc.
  • isolation or quarantine of patients
  • evacuation coordination with community
  • infection control plan
  • PPE and equipment policy and procedure

Community Partnerships and Communication Plans

Areas to consider in agency communication and partnership plans include:

  • annual contact with local emergency management (LEM)
  • partnership with Emergency Medical Services (EMS), local public health and care delivery network in immediate/surrounding community
  • partnership established with Regional Healthcare Coalition (HCC)
  • evacuation coordination established
  • designation of an emergency communications center
  • establishment of a communication network with contingency plan if primary system fails (cell or satellite phones, pagers, Radio Amateur Civil Emergency Service, wireless priority service, land phones)
  • internet access established with HCC and Office of Public Health Preparedness (OPHP)
  • plan for maintaining patient and staff communications

Training Staff and Patients

Once home health agencies have established a risk assessment, preparedness plan, policies and procedures, and communication and partnership plans, they must provide education to staff and patients defining roles and responsibilities during an emergency. 

  • Orientation for new employees needs to include emergency preparedness expectations.
  • A plan needs to be in place for education of all staff annually. Patient education should include agency emergency procedures and plans for sheltering in place or evacuation. 
  • The patient’s personal emergency plan should be documented in the patient record.

Plan Evaluation

Emergency drills and exercises will enable agencies to test and evaluate their emergency preparedness plan. The purpose of these exercises includes methods to:

  • test and evaluate the plan, policies and procedures
  • reveal any weaknesses that may become evident
  • identify resource gaps that may be present
  • improve individual performance, organizational communication, and coordination
  • train personnel to clarify roles and responsibilities
  • satisfy regulatory requirements

Involvement with your local responders in community drills related to “mock” emergencies is a valuable tool to evaluate your agency’s plan and effectiveness.

Simione Healthcare Consultants understands that home health agencies want specific strategies will help them achieve compliance with the new CoPs, while demonstrating efficiency and effectiveness. Our expert consultants will work with your agency to evaluate the impact of these new requirements, conduct a CoPs Readiness Assessment for clinical operations, and provide staff training to support improvements in quality and efficiency for key performance measures. 

Contact us at 844-215-8820 or

About Simione Healthcare Consultants

Founded in 1966, Simione Healthcare Consultants provides accessible, cost-effective business solutions for home health and hospice organizations across the U.S. Key areas of expertise include operations, compliance and risk, finance, sales and marketing, cost reporting, information technology, and mergers and acquisitions.  Simione supports progress across the healthcare continuum, engaging agencies, hospitals and health networks for more effective delivery of home health and hospice care. More than 1,500 organizations use Simione’s experts and tools to improve quality, reduce cost, and minimize risk to drive business performance. 

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