On September 8th CMS published Survey and Certification memo 16-38 notifying us of the publication of its final rule for emergency preparedness. The details of this rule were published in the Federal Register on September 16th and the new regulation goes into effect November 16, 2016. Accredited hospitals should have a relatively easy time with this, but the scope of this regulation goes far beyond hospitals. This rule will also affect community mental health centers, residential treatment centers, ambulatory surgery centers, hospice, PACE programs, long term care facilities, intermediate care facilities, home health agencies, comprehensive outpatient rehabilitation facilities, end stage renal dialysis centers, rural health clinics and even your organ procurement organization.
CMS identifies 4 essential elements that must be put into place which include risk assessment, policies and procedures, communication plan, training and testing. The risk assessment should prioritize the types of hazards likely to occur in your area. In a Joint Commission survey, this is referred to as the hazard vulnerability analysis. In this instance CMS specifically suggests that the potential hazard of a cyber attack be analyzed. The policies and procedures would be the action steps your team needs to implement in the event of an emergency to manage the situation. Communication should detail how you will reach staff, providers, vendors, suppliers and others to ensure that patient care responsibilities can be carried out. Training and testing will require on-boarding training and annual training for staff as well as testing through drills.
While this may be old news for Joint Commission accredited programs, your health system may own other components that have not been accredited and will need technical advice on how to meet these new CMS requirements.
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