The Deadline Passed, This is Getting Serious

CMS is serious about enforcing the emergency preparedness conditions of participation

“the systemic failure…puts all patients and staff at risk in the event of an emergency or disaster.”
For healthcare facilities that have not yet developed compliant emergency plans, your next survey could get ugly.
We helped many healthcare facilities develop an emergency preparedness plan last fall, in advance of the November deadline. Many were unaware of the new requirements, while others put off an unfamiliar new project. Calls to our office peaked in mid-October, but it appears some have not yet heard about the requirements, or have just ignored them. Early results of surveys indicate the Centers for Medicare & Medicaid Services (CMS) are serious about enforcement.
Now, we are getting calls from facilities that have been surveyed and found wanting. The “notice of deficiency” (form CMS-2567) contains strong language:
“The cumulative effect of the [facility’s] systemic failure to develop and maintain an emergency preparedness program … puts all patients and staff of the [facility] at risk in the event of an emergency or disaster.”
At least for nursing homes, CMS identifies four levels of severity for a deficiency:
  • Level 1 – No actual harm with potential for minimal harm
  • Level 2 – No actual harm with a potential for more than minimal harm that is not immediate jeopardy
  • Levell 3 – Actual harm that is not immediate jeopardy
  • Level 4 – Immediate jeopardy to resident health or safety
In addition, CMS defines the scope of a deficiency on this scale:
  • Isolated: When one or a very limited number of residents or employees is/are affected and/or a very limited area or number of locations within the facility are affected;
  • Pattern: When more than a very limited number of residents or employees are affected, and/or the situation has occurred in more than a limited number of locations but the locations are not dispersed throughout the facility;
  • Widespread: When the problems causing the deficiency are pervasive (affect many locations) throughout the facility and/or represent a systemic failure that affected, or has the potential to affect, a large portion or all of the residents or employees.
CMS is considering the lack of a plan to be a Widespread, Level 2 deficiency. Earlier last year there were rumors that CMS would declare an “immediate jeopardy” situation in the absence of a plan. That would set the stage for termination of the Medicare contract, the “death penalty” for most facilities since Medicare is the nation’s largest insurance provider. It appears that CMS is coming as close to this as they can without touching it.
The ramifications could be worse for facilities which actually experience an emergency or disaster without a plan. Indeed, state regulatory agencies, like Florida’s Agency for Health Care Administration, have closed facilities that were grossly unprepared.

What happens if you are found “deficient?”

First, breathe. No one wants you out of business, yet.
You have some time between the actual survey and the receipt of the written deficiency on form CMS-2567. Don’t waste that time. Talk to us. Once you receive it, you have only ten calendar days (including weekends and holidays) in which to respond with a Plan of Correction (PoC) for each cited deficiency (our client had 19 deficiencies related to the emergency plan). You will then have 30 – 60 days (from the notice, not the PoC delivery) to become compliant, which is far less than most clients have taken to develop their plans, gather the data, train their staff, and participate in
two exercises.
We can help you develop your Plan of Correction, and then, of course, we can help you get compliant. You’ll need to dedicate a senior person to lead the project, and we’ll need to move expeditiously.
CMS is serious about enforcing its new emergency preparedness conditions of participation. You need to be too. Spread the word.
Categories: Healthcare
Topics: CMS, Preparedness

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