CMS Regulatory Requirements For Emergency Preparedness Programs and TJC Compliance

From: Oct 26, 2023 - To: Dec 31, 2023

The COVID-19 pandemic and multiple natural and man-made disasters over the past few years have required hospitals to activate their emergency preparedness plan. In anticipation of patient injury because of such disasters, CMS – Centers for Medicare and Medicaid – revised the 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 must have a written program to address the various natural and man-made emergencies that may impact care delivery 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 personnel training. There will also be a brief discussion of references and resources from The Joint Commission.

Learning Objectives:-

After the webinar, attendees will be able to:

  • Recall critical definitions used in the regulations
  • Identify the three critical essentials for emergency preparedness
  • Recall the four core elements of an emergency preparedness program
  • Recall the critical responsibilities of a facility when the emergency preparedness plan is activated.

Outline:-

Definitions and Identification of State Operations Manual 

  • Listing of code references by facility type
  • Key definitions
  • 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
  • Communications Plan
  • Training and Testing
  • Integrated Healthcare Systems

Joint Commission Standards

  • Emergency Management Standards 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
  • Safety/Security Officers

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