42 CFR 484.102 — Condition of Participation: Emergency Preparedness

What this rule requires your agency to do

• 1If part of an integrated healthcare system electing a unified program, the HHA's unified and integrated emergency preparedness program must demonstrate active participation and capability of each separately certified facility, take into account each facility's unique circumstances, and include a unified emergency plan, integrated policies and procedures, a coordinated communication plan, and training and testing programs meeting this section (subd. e).(42 CFR 484.102 — Condition of Participation: Emergency Preparedness)
• 2The HHA must conduct exercises to test the emergency plan at least annually, including a full-scale community-based exercise (or facility-based functional exercise when community-based is not accessible), plus an additional exercise in the opposite year, and must analyze its response, maintain documentation of all drills and events, and revise the emergency plan as needed (subd. d(2)).(42 CFR 484.102 — Condition of Participation: Emergency Preparedness)
• 3The HHA must develop and maintain an emergency preparedness communication plan complying with federal/state/local law, reviewed and updated at least every 2 years, containing names and contact information for staff, entities under arrangement, patients' physicians, and volunteers, and contact information for emergency officials and other sources of assistance (subd. c).(42 CFR 484.102 — Condition of Participation: Emergency Preparedness)
• 4The HHA must develop and maintain a training and testing program, reviewed and updated at least every 2 years, providing initial training to new and existing staff/contractors/volunteers, training at least every 2 years, documentation of training, demonstration of staff knowledge, and retraining on significantly updated policies (subd. d(1)).(42 CFR 484.102 — Condition of Participation: Emergency Preparedness)
• 5The HHA must develop and maintain an emergency preparedness plan, reviewed and updated at least every 2 years, that is based on a documented facility-based and community-based all-hazards risk assessment, includes strategies for identified emergency events, addresses patient population and continuity of operations (including delegations of authority and succession plans), and includes a process for cooperation with local, tribal, regional, state, and federal emergency officials (subd. a).(42 CFR 484.102 — Condition of Participation: Emergency Preparedness)
• 6The HHA must comply with all applicable federal, state, and local emergency preparedness requirements and establish and maintain an emergency preparedness program meeting this section (introductory paragraph).(42 CFR 484.102 — Condition of Participation: Emergency Preparedness)
• 7The communication plan must include primary and alternate means for communicating with staff and emergency management agencies, a method for sharing information and medical documentation with other providers, a means of providing patient condition/location information as permitted under 45 CFR 164.510(b)(4), and a means of providing information on the HHA's needs and ability to assist to the authority having jurisdiction (subd. c(3)–(6)).(42 CFR 484.102 — Condition of Participation: Emergency Preparedness)
• 8The HHA must develop and implement emergency preparedness policies and procedures based on the plan, risk assessment, and communication plan, reviewed and updated at least every 2 years, addressing patient plans during disasters, informing officials of patients needing evacuation, follow-up with staff/patients during service interruptions, medical documentation that preserves and secures patient information, and use of volunteers/surge staffing (subd. b).(42 CFR 484.102 — Condition of Participation: Emergency Preparedness)