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Preparation Key to Effectively Handling Emergencies

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August 1, 2023

A disaster or crisis can happen any time. These natural or man-made events often occur suddenly, creating dangerous, unexpected emergency situations that require an immediate response.

Emergencies are more common than some may think. For example, many states have already experienced catastrophic weather events this year. Tornadoes, heavy rain, and flooding caused damage that disrupted lives and restricted access to healthcare and public services — even in areas not historically affected by such events.

Emergency Preparedness Plan

Accreditation Commission for Health Care (ACHC) recognizes the importance of preparing properly for a potential disaster or crisis. ACHC Accreditation Standards require organizations to develop an emergency preparedness plan to address the needs and safety of clients/patients and personnel during disaster or crisis situations.

ACHC Standards require behavioral health organizations to develop an emergency preparedness plan to meet service recipient and personnel needs.

The plan must also ensure personnel are trained and prepared to respond rapidly during a disaster or crisis and communicate with community emergency management agencies, seeking assistance when necessary.

Standard Requirements

The following ACHC Behavioral Health Standards focus on emergency preparedness requirements. Topics covered are emergency planning, policies and procedures, personnel training, and plan testing.

  • Standard BH4-4A: Written policies and procedures are established and implemented that describe the orientation process. Documentation reflects that all personnel have received an orientation.
  • Standard BH4-4D: A written education plan is developed and implemented which defines the content, frequency of evaluations and amount of in-service training for each job classification of personnel.
  • Standard BH7-3A: Written policies and procedures are established and implemented that outline the process for meeting service recipient needs in a disaster or crisis situation.
  • Standard BH7-3B: The organization provides education to the service recipient/ responsible person regarding emergency preparedness.

Tips for Compliance

  • Policies and procedures (P&P) for your emergency preparedness plan should identify potential threats and required actions, including but not limited to development, training, testing, activation, implementation, and resolution of an emergency response process.
  • Processes should be clearly defined on requirements for staff training and testing/conducting drills to evaluate effectiveness or identify areas of improvement. For service recipients, processes should be clearly defined and include orienting service recipients on what to do, where to go, and whom to contact in the event of an emergency.
    • Emergency preparedness staff training and testing should reference situations identified in the organization’s risk assessments. Evidence of staff training, testing, and service recipient education must be documented. Drills and staff training must be conducted annually.

Learn More

Get additional information on preparing for emergency situations:

ACHC Standards require home care agencies to develop an emergency preparedness plan to meet client/patient and personnel needs.

The plan must also ensure personnel are trained and prepared to respond rapidly during a disaster or crisis and communicate with community emergency management agencies, seeking assistance when necessary.

Standard Requirements

The following ACHC Home Care Standards focus on emergency preparedness requirements. Topics covered are emergency planning, policies and procedures, personnel training, and plan testing.

  • Standard HC4-5A: Written policies and procedures are established and implemented that describe the orientation process. Documentation reflects that all personnel have received an orientation.
  • Standard HC4-7A: A written education plan is developed and implemented which defines the content, frequency of evaluations and amount of on-going in-service training for each classification of personnel.
  • Standard HC7-3A: Written policies and procedures are established and implemented that outline the process for meeting client/patient needs in a disaster or crisis situation.
  • Standard HC7-3C: The Agency provides education to the client/patient regarding emergency preparedness.

Tips for Compliance

  • Policies and procedures (P&P) for your emergency preparedness plan should identify potential threats and required actions, including but not limited to development, training, testing, activation, implementation, and resolution of an emergency response process.
  • Processes should be clearly defined on requirements for staff training and testing/conducting drills to evaluate effectiveness or identify areas of improvement. For clients/patients, processes should be clearly defined and include orienting clients/patients on what to do, where to go, and whom to contact in the event of an emergency.
    • Emergency preparedness staff training and testing should reference situations identified in the agency’s risk assessments. Evidence of staff training, testing, and client/patient education must be documented. Drills and staff training must be conducted annually.

Learn More

Get additional information on preparing for emergency situations:

ACHC Standards and Medicare Conditions of Participation (CoPs) require home health agencies to develop an emergency preparedness plan to meet patient and personnel needs.

The plan must also ensure personnel are trained and prepared to respond rapidly during a disaster or crisis and communicate with community emergency management agencies, seeking assistance when necessary.

Standard Requirements

The following ACHC Home Health Standards focus on emergency preparedness requirements and compliance with guidance from the Centers for Medicare & Medicaid Services (CMS):

  • Emergency Planning and Risk Assessment
    • Standard HH7-3A: An Emergency Preparedness Plan outlines the process for meeting patient and personnel needs in a disaster or crisis situation. Part of this process includes conducting a community based risk assessment and the development of strategies and collaboration with other health organization in the same geographic area. 484.102 (E-0001), 484.102(a), 484.102(a)(1-4) (E-0004), (E-0006), (E-0007), (E-0009)
  • Policies and Procedures
    • Standard HH7-3B: Written policies and procedures and an Emergency Preparedness Plan outline the process for meeting patient and personnel needs in a disaster or crisis situation. Part of this process is the development of specific policies and procedures and the review of them every two years. 484.102(b)(1-5) (E-0013) (E-0017) (E-0019) (E-0021) (E-0023) (E-0024)
  • Communication Plan
    • Standard HH7-3C: An Emergency Preparedness Plan includes the development of a communication plan that includes personnel, patients and other emergency and health care organization in same geographic area. 484.102(c)(1-6) (E-0029) (E-0030) (E-0031) (E-0032) (E-0033) (E-0034)
  • Training and Testing
    • Standard HH7-3D: An Emergency Preparedness Plan includes the process of training and testing the emergency preparedness plan. 484.102(d)(1-2) (E-0036) (E-0037) (E-0039)
  • Integrated Healthcare Systems
    • Standard HH7-3E: The Emergency Preparedness Plan identifies each separately certified facility and how each facility participated in the development of the unified and integrated program. 484.102(e)(1-5) (E-0042)

Tips for Compliance

  • Your agency’s emergency preparedness plan must be based on risk assessments that anticipate and address potential hazards likely to impact your region, community, agency, and patient population. The emergency preparedness plan must be evaluated and updated at least every two years.
  • Policies and procedures (P&P) for your emergency preparedness plan should identify potential threats and required actions, including but not limited to development, training, testing, activation, implementation, and resolution of an emergency response process. The P&Ps for your emergency preparedness plan must be reviewed at least every two years.
  • Processes should be clearly defined on requirements for staff training and testing to evaluate effectiveness or identify areas for improvement. For patients, processes should be clearly defined and include orienting patients on what to do, where to go, and whom to contact in the event of an emergency.
    • Emergency preparedness staff training and testing should reference situations identified in the organization’s risk assessments. Evidence of staff training, testing and patient orientation must be documented.
      • Emergency preparedness training for staff must be conducted at least every two years.
      • Testing of the emergency preparedness plan must be conducted annually.
  • If your organization is part of a healthcare system consisting of multiple, separately certified healthcare facilities, you may elect to participate in a unified and integrated emergency preparedness program. However, each separately certified organization still must meet all requirements of ACHC Home Health Standards HH7-3A, HH7-3B, HH7-3-C, HH7-3D, and HH7-3E.

Learn More

Get additional information on preparing for emergency situations:

ACHC Standards require home infusion therapy organizations to develop an emergency preparedness plan to meet client/patient and personnel needs.

The plan must also ensure personnel are trained and prepared to respond rapidly during a disaster or crisis and communicate with community emergency management agencies, seeking assistance when necessary.

Standard Requirements

The following ACHC Home Infusion Therapy Standards focus on emergency preparedness requirements. Topics covered are emergency planning, policies and procedures, personnel training, and plan testing.

  • Standard HIT4-3A: Written policies and procedures are established and implemented that describe the orientation process. Documentation reflects that all personnel have received an orientation.
  • Standard HIT4-6A: A written education plan is developed and implemented which defines the content, frequency of evaluations and amount of ongoing in-service training for each classification of personnel.
  • Standard HIT7-3A: Written policies and procedures are established and implemented that outline the process for meeting client/patient needs in a disaster or crisis situation.
  • Standard HIT7-3B: The organization provides education to the client/patient regarding emergency preparedness.

Tips for Compliance

  • Policies and procedures (P&P) for your emergency preparedness plan should identify potential threats and required actions, including but not limited to development, training, testing, activation, implementation, and resolution of an emergency response process.
  • Processes should be clearly defined on requirements for staff training and testing/conducting drills to evaluate effectiveness or identify areas of improvement. For clients/patients, processes should be clearly defined and include orienting clients/patients on what to do, where to go, and whom to contact in the event of an emergency.
    • Emergency preparedness staff training and testing should reference situations identified in the organization’s risk assessments. Evidence of staff training, testing. and client/patient education must be documented. Drills and staff training must be conducted annually.

Learn More

Get additional information on preparing for emergency situations:

ACHC Standards and Medicare Conditions of Participation (CoPs) require hospices to develop an emergency preparedness plan to meet patient and personnel needs.

The plan must also ensure personnel are trained and prepared to respond rapidly during a disaster or crisis and communicate with community emergency management agencies, seeking assistance when necessary.

Standard Requirements

The following ACHC Hospice Standards focus on emergency preparedness requirements and compliance with guidance from the Centers for Medicare & Medicaid Services (CMS):

  • Emergency Planning and Risk Assessment
    • Standard HSP7-4B: An Emergency Preparedness Plan outlines the process for meeting patient and personnel needs in a disaster or crisis situation. Part of this process includes conducting a community based risk assessment and the development of strategies and collaboration with other health organizations in the same geographic area. (418.113) E-0001, (418.113(a)(1-4)) E-0004, E-0006, E-0007, E-0009
  • Policies and Procedures
    • Standard HSP7-4C: Written policies and procedures and an Emergency Preparedness Plan outline the process for meeting patient and personnel needs in a disaster or crisis situation. Part of this process is the development of specific policies and procedures and the review of them every two years. (418.113(b)(1-6)) E-0013, E-0016, E-0019, E-0023, E-0024, E-0025, (418.113(b)(1-6)(i-v)), E-0015, E-0016, E-0018, E-0020, E0022, E-0026
  • Communication Plan
    • Standard HSP7-4D: An Emergency Preparedness Plan includes the development of a communication plan that includes personnel, patients and other emergency and health care organization in same geographic area. (418.113(c)(1-7)), E-0029, E-0030, E-0031, E-0032, E-0033, E-0034
  • Training and Testing
    • Standard HSP7-4E: An Emergency Preparedness Plan includes the process of training and testing the emergency preparedness plan. (418.113(d)(1-2)) E-0036, E-0037, E-0039
  • Integrated Healthcare Systems
    • Standard HSP7-4F: The Emergency Preparedness Plan identifies each separately certified facility and how each facility participated in the development of the unified and integrated program. ((418.113(e)(1-5)) E-0042

Tips for Compliance

  • Your agency’s emergency preparedness plan must be based on risk assessments that anticipate and address potential hazards likely to impact your region, community, agency, and patient population. The emergency preparedness plan must be evaluated and updated at least every two years.
  • Policies and procedures (P&P) for your emergency preparedness plan should identify potential threats and required actions, including but not limited to development, training, testing, activation, implementation, and resolution of an emergency response process. The P&Ps for your emergency preparedness plan must be reviewed at least every two years.
  • Processes should be clearly defined on requirements for staff training and testing to evaluate effectiveness or identify areas for improvement. For patients, processes should be clearly defined and include orienting patients on what to do, where to go, and whom to contact in the event of an emergency.
    • Emergency preparedness staff training and testing should reference situations identified in the organization’s risk assessments. Evidence of staff training, testing, and patient orientation must be documented.
      • Emergency preparedness staff training must be conducted at least every two years.
      • Testing of the emergency preparedness plan must be conducted annually.
  • If your organization is part of a healthcare system consisting of multiple, separately certified healthcare facilities, you may elect to participate in a unified and integrated emergency preparedness program. However, each separately certified organization still must meet all requirements of ACHC Hospice Standards HSP7-4B, HSP7-4C, HSP7-4D, HSP7-4E, and HSP7-4F.

Learn More

Get additional information on preparing for emergency situations:

ACHC Standards require palliative care organizations to develop an emergency preparedness plan to meet patient and personnel needs.

The plan must also ensure personnel are trained and prepared to respond rapidly during a disaster or crisis and communicate with community emergency management agencies, seeking assistance when necessary.

Standard Requirements

The following ACHC Palliative Care Standards focus on emergency preparedness requirements. Topics covered are emergency planning, policies and procedures, personnel training, and plan testing.

  • Standard CBPC4-3A: Written policies and procedures are established and implemented that describe the orientation process. Documentation reflects that all personnel have received an orientation. (Guideline(s) 2.1, 3.1, 5.1, 6.1, 7.1)
  • Standard CBPC4-5A: A written education plan is developed and implemented which defines the content, frequency of evaluations and amount of on-going in-service training for each classification of personnel.
  • Standard CBPC7-3A: Written policies and procedures are established and implemented that outline the process for meeting patient needs in a disaster or crisis situation.
  • Standard CBPC7-3C: The palliative care program provides education to the patient regarding emergency preparedness.

Tips for Compliance

  • Policies and procedures (P&P) for your emergency preparedness plan should identify potential threats and required actions, including but not limited to development, training, testing, activation, implementation, and resolution of an emergency response process.
  • Processes should be clearly defined on requirements for staff training and testing/conducting drills to evaluate effectiveness or identify areas of improvement. For patients, processes should be clearly defined and include orienting patients on what to do, where to go, and whom to contact in the event of an emergency.
    • Emergency preparedness testing and staff training should reference situations identified in the organization’s risk assessments. Evidence of staff training, testing, and patient education must be documented. Drills and staff training must be conducted annually.

Learn More

Get additional information on preparing for emergency situations:

ACHC Standards and Medicare Conditions for Coverage (CfCs) require renal dialysis organizations to develop an emergency preparedness plan to meet patient and personnel needs.

The plan must also ensure personnel are trained and prepared to respond rapidly during a disaster or crisis and communicate with community emergency management agencies, seeking assistance when necessary.

Standard Requirements

The following ACHC Renal Dialysis Standards focus on emergency preparedness requirements and compliance with guidance from the Centers for Medicare & Medicaid Services (CMS):

  • Emergency Planning and Risk Assessment
    • Standard RD7-Q: An Emergency Preparedness Plan outlines the process for meeting patient and personnel needs in a disaster or crisis situation. Part of this process includes conducting a community-based risk assessment and the development of strategies and collaboration with other health organizations in the same geographic area. (494.62) E-0003, (494.62(a)) E-0004, (494.62(a)(1-2)) E-0006, (494.62(a)(3)) E-0007, (494.62(a)(4)) E-0009
  • Policies and Procedures
    • Standard RD7-R: Written policies and procedures and an Emergency Preparedness Plan outline the process for meeting patient and personnel needs in a disaster or crisis situation. Part of this process is the development of specific policies and procedures and the review of them every two years. (494.62(b)) E-0013, (494.62(b)(1)) E-0018, (494.62(b)(2)) E-0020, (494.62(b)(3)) E-0022, (494.62(b)(4)) E-0023, (494.62(b)(5)) E-0024, (494.62(b)(6)) E-0025, (494.62(b)(7)) E-0026, (494.62(b)(8), (494.62(b)(9) E-0028
  • Communication Plan
    • Standard RD7-S: An Emergency Preparedness Plan includes the development of a communication plan that includes personnel, patients, and other emergency and health care organizations in the same geographic area. (494.62(c)) E-0029, (494.62(c)(1)) E-0030, (494.62(c)(2)) E-0031, (494.62(c)(3)) E-0032, (494.62(c)(4-6)) E-0033, (494.62(c)(7)) E-0034
  • Training and Testing
    • Standard RD7-T: An Emergency Preparedness Plan includes the process of training and testing the emergency preparedness plan. (494.62(d)) E-0036, (494.62(d)(1)) E-0038, (494.62(d)(2)) E-0039, (494.62(d)(3)) E-0040
  • Integrated Healthcare Systems
    • Standard RD7-U: The Emergency Preparedness Plan identifies each separately certified facility and how each facility participated in the development of the unified and integrated program. (494.62(e)(1-5)) E-0042

Tips for Compliance

  • Your facility’s emergency preparedness plan must be based on risk assessments that anticipate and address potential hazards likely to impact your region, community, facility, and patient population. The emergency preparedness plan must be evaluated and updated at least every two years.
  • Policies and procedures (P&P) for your emergency preparedness plan should identify potential threats and required actions, including but not limited to development, training, testing, activation, implementation, and resolution of an emergency response process. The P&Ps for your emergency preparedness plan must be reviewed at least every two years.
  • Processes should be clearly defined on requirements for staff training and testing to evaluate effectiveness or identify areas for improvement. For patients, processes should be clearly defined and include orienting patients on what to do, where to go, whom to contact, and, if they’re capable, how to disconnect from dialysis treatment in the event of an emergency.
    • Emergency preparedness staff training and testing should reference situations identified in the organization’s risk assessments. Evidence of staff training, testing, and patient orientation must be documented.
      • Emergency preparedness training for staff must be conducted at least every two years.
      • Testing of the emergency preparedness plan must be conducted annually.
  • If your organization is part of a healthcare system consisting of multiple, separately certified healthcare facilities, you may elect to participate in a unified and integrated emergency preparedness program. However, each separately certified organization still must meet all requirements of ACHC Renal Dialysis Standards RD7-Q, RD7-R, RD7-S, RD7-T, and RD7-U.

Learn More

Get additional information on preparing for emergency situations:

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