Appendix Z

---

Emergency Preparedness for All Provider and Certified Supplier Types - Interpretive Guidance 

Appendix Z was new in June 2017 and there have been three updates since that time.  The latest update was April 2021.  

In 2021 the updates to Appendix Z were substantial and included a lot of information about PPE, COVID-19, Health Departments, and Training & Testing.  Cooperation and collaboration, alternate care sites, surge capacity, reporting a facility’s needs, and ability to provide assistance were also updated.  Many of the updates look to be a direct response to the pandemic.

There are forty-four (44) total E-tags reviewed in Appendix Z.  However, eighteen (18) of the tags do not apply to LTCFs.  If the provider type citation for LTCFs appears under the tag it applies.  The provider type citation for LTCFs is 483.73.  

I have summarized and highlighted the important points for each tag below.  Notice that the majority of the E-tags can be grouped into four categories.  1. Emergency Preparedness Program/Plan  2. Policies and Procedures  3. Communication Plan  4. Training and Testing

E-0001 – Emergency Preparedness Program 

An LTCF must establish and maintain a comprehensive emergency preparedness program. The emergency preparedness program must describe an LTCFs comprehensive approach to meeting the health, safety, and security needs of their staff and patient population during an emergency or disaster situation. The program must also address how the facility would coordinate with other healthcare facilities, as well as the whole community during an emergency or disaster. The emergency preparedness program and its elements must be reviewed annually for LTCFs, and the program must be in writing.

 E-0002 (Does not Apply to LTCFs)

 E-0003 (Does not Apply to LTCFs) 

E-0004 – Emergency Preparedness Plan 

An LTCF must develop and maintain an emergency preparedness plan that must be reviewed and updated at least annually.  The plan shall take into consideration Natural Disasters, Man-made Disasters, Facility-based Disasters, and Emerging infectious diseases (EIDs).  The emergency plan should consider contingency planning, such as evacuation triggers. 

E-0005 (Does not Apply to LTCFs) 

E-0006 – Emergency Plan (Facility and Community-based Risk Assessments) 

The emergency preparedness plan at an LTCF is to be based on the documented facility-based and community-based risk assessments.  The Facility-based risk assessment should be done using the “all-hazards” approach and includes missing residents. The comprehensive risk assessment should include all risks that could disrupt an LTCFs operations and necessitate emergency response planning to address the risk mitigation requirements and ensure continuity of care. However, the Community-based assessment is not specifically defined. The facility could use an assessment completed by local emergency management officials, regional healthcare coalitions, or other healthcare entities.  Ultimately, these assessments should take into consideration staffing strategies, surge capacity, and evacuation procedures. 

E-0007 – Emergency Plan (Resident Population & Continuity of Operations) 

The facility emergency preparedness plan must address specific resident populations, types of services the facility can provide during an emergency, continuity of operations, delegations of authority, and succession planning. It should be clear who is in charge and specific roles for staff during the emergency event. At the very least there needs to be one qualified person authorized in writing to act in the absence of the administrator. 

E-0008 (Does not Apply to LTCFs)

E-0009 – Emergency Plan (Integrated Response, Cooperation & Collaboration) The emergency preparedness plan at an LTCF needs to include a process for cooperation and collaboration with local, tribal, regional, State, and Federal emergency preparedness officials.  The facility must include this integrated response process in its emergency plan and will need to provide documentation of efforts to contact emergency officials.  However, every detail of the process is not required to be documented in writing.  

E-0010 (Does not Apply to LTCFs) 

E-0011 (Does not Apply to LTCFs) 

E-0012 (Does not Apply to LTCFs) 

E-0013 – Policies and Procedures  

Emergency Preparedness policies and procedures must be developed and implemented by an LTCF.  These policies and procedures must be based on the emergency preparedness plan, the risk assessment, and the facility communications plan.  All policies and procedures must be reviewed and updated annually.  CMS does not specify where an LTCF must keep the emergency preparedness policies and procedures.  A facility may choose whether to incorporate the emergency policies and procedures within their emergency plan or to be part of the facility’s Standard Operating Procedures or Operating Manual.   

E-0014 (Does not Apply to LTCFs)

E-0015 – Policies and Procedures (Subsistence Needs) 

The emergency preparedness policies and procedures must include the subsistence needs of staff and residents.  This requirement applies to the facility when the decision has been made to evacuate.  However, it also applies when the decision is made to shelter in place.  The subsistence needs for staff and residents includes food, water, medical/pharmaceutical supplies, and alternate sources of energy.  These alternate sources of energy must maintain the following: temperatures for protection of patient health/safety, emergency lighting, fire detection, extinguishing, alarm systems, sewage/waste disposal, and the safe storage of provisions. If a facility is using portable generators the Life Safety Code and NFPA guidelines for generator testing would not apply.  However, for permanently installed generators the facility would still be required to comply with the existing Life Safety Code and NFPA guidance.  An LTCF is not required to provide on-site treatment of sewage or waste during an emergency.  However, the facility would need to follow requirements under the Conditions of Participation for food receiving and storage.   

E-0016 (Does not Apply to LTCFs) 

E-0017 (Does not Apply to LTCFs) 

E-0018 – Policies and Procedures (Tracking of Staff and Residents) 

The emergency preparedness policies and procedures must include a system to track on-duty staff and sheltered residents during an emergency.  If either is relocated; the facility must document the specific name and location of the receiving facility or other location. CMS does not specify which type of tracking system should be used; rather, a facility has the flexibility to determine how best to track patients and staff, whether it uses an electronic database, hard copy documentation, or some other method. However, it is important that the information be readily available, accurate, and shareable among officials within and across the emergency response systems as needed in the interest of the patient.  If a resident has voluntarily discharged as a result of the emergency that resident does not need to be tracked by the facility, assuming the resident has been appropriately discharged.   

E-0019 (Does not Apply to LTCFs)

E-0020 – Policy and Procedure (Evacuations) 

The emergency preparedness policies and procedures must address the safe evacuation from the facility.  This evacuation must take into consideration the care and treatment needs of evacuees, staff responsibilities, transportation, and a primary and alternate means of communication at the facility.  The facility should have the capability to contact external sources for assistance. 

E-0021 (Does not Apply to LTCFs)

E-0022 – Policies and Procedures (Sheltering-in-Place) 

The emergency preparedness policies and procedures must address sheltering in place at the facility for residents, staff, and volunteers. Therefore, LTCFs are required to have policies and procedures for sheltering in place which align with the facility’s risk assessment.  Ultimately, based on its emergency plan, a facility could decide to have various approaches to sheltering some or all of its residents and staff. 

E-0023 – Policies and Procedures (Medical Documentation) 

The emergency preparedness policies and procedures include a system for medical documentation that preserves and protects the confidentiality of resident information.  The facility shall secure and maintain the availability of the records. These policies and procedures must also be in compliance with the Health Insurance Portability and Accountability Act (HIPAA). 

E-0024 – Policies and Procedures (Use of Volunteers) 

The emergency preparedness policies and procedures must address the use of volunteers in an emergency or other emergency staffing strategy.  This process must include the integration of State and Federally designated health care professionals to address surge needs during an emergency.  During an emergency, a facility may also need to accept volunteer support from individuals with varying levels of skills and training. The facility must have policies and procedures in place to facilitate this support. In order for volunteering healthcare professionals to be able to perform services within their scope of practice and training, facilities must include any necessary privileging and credentialing processes in its emergency preparedness plan policies and procedures. Non-medical volunteers would perform non-medical tasks. Facilities have flexibility in determining how best to utilize volunteers during an emergency. CMS recommends that facilities include policies and procedures on the use of volunteers including if a facility chooses not to use volunteers, however at a minimum, the facility must have policies and procedures which address emergency staffing strategies.  

E-0025 – Policies and Procedures (Transfer Agreements) 

The emergency preparedness policies and procedures must demonstrate the facility has made arrangements with other facilities to receive patients if the sending facility cannot maintain operations.  The receiving facility should be able to provide for the continuity of services to sending facility residents.  If a facility has a transfer arrangement with another facility and this facility could not accommodate all patients, then the facility should plan accordingly to provide continuity of services with another facility who could receive the remaining residents. LTCFs should consider reviewing their developed transfer agreements annually to ensure the contract/agreement/MOU is still applicable. 

E-0026 – Policies and Procedures (Section 1135 Emergency Waiver)

The facility’s emergency preparedness program must include policies and procedures which outline the facility’s role in the provision of care and treatment under section 1135 waivers during a declared public health emergency in alternate care sites. Facilities should also be aware of what flexibilities are exercised with or without an 1135 waiver.  In addition, LTCFs should have in place policies and procedures which address emergency situations in which a declaration was not made and where an 1135 waiver may not be applicable, such as during a disaster affecting a single facility. In this case, policies and procedures should address potential transfers of residents; timelines of residents at alternate facilities, etc. Section 1135 waivers by nature are time-limited.

E-0027 (Does not Apply to LTCFs)

 E-0028 (Does not Apply to LTCFs) 

E-0029 - Emergency Preparedness Communication Plan 

The facility must develop and maintain an emergency preparedness communication plan and the plan must be reviewed annually for LTCFs.  The plan should contain information on how the facility will coordinate patient care.  In addition, the plan should demonstrate how the facility plans to coordinate with emergency management agencies, public health departments, and other healthcare providers.  CMS does not require a standard format for the plan; however, it should include alternate communication means.  For example, hand-held radios, amateur/ham radio, pagers, or satellite phones. 

E-0030 - Emergency Communication Plan (Internal) 

An LTCF is required to have contact information for staff, service providers, physicians, other facilities, and volunteers.  The LTCF has discretion on the formatting of this information.  The information must be available for leadership and/or the emergency preparedness coordinator if the facility has one.  The contact information must be accurate and reviewed annually for LTCFs.  Contact information contained in the communication plan must be accurate and current.  Facilities must update contact information for incoming new staff and departing staff throughout the year and any other changes to information for those individuals and entities on the contact list.

E-0031 – Emergency Communication Plan (External) 

The contact information in the communication plan must include external federal, state, and local emergency preparedness staff.  Emergency management officials include public health departments.  In addition, for LTCFs it must also include the state long-term care ombudsman and the state licensing and certification agency. There are no formatting requirements for the contacts.  However, leadership must be able to access the information and the contacts must be reviewed annually for an LTCF.  When individual contact information is not available it is acceptable to utilize a general phone number for emergency management agencies. 

E-0032 - Primary & Alternate Means of Communication 

An LTCF must have a primary and alternate means to communicate with staff, federal, state, and local emergency management agencies.  There is not a specific requirement for meeting this standard and the LTCF has discretion on what alternate communication system to utilize.  However, examples of acceptable alternatives include mobile phones, pagers, and amateur/ham radios.  In the communications plan, the LTCF should identify and list both their primary and secondary means of communication. 

E-0033 – Communication Plan (Methods of Sharing Medical Information) 

The facility must have a method for sharing resident medical documentation with other health providers.  For example, if the facility were to order an evacuation a procedure for releasing resident information would be needed.  However, CMS does not specify how this information must be shared with other facilities. 

E-0034 – Communication Plan (Sharing Information on Occupancy/Needs) 

The facility must have a way to report the occupancy and needs of the facility to the authority having jurisdiction. CMS does not require a format to report any of these needs. Examples, of needs, might include PPE, transportation assistance, or staff shortage.   In addition, the facility would need to report its own ability to provide assistance to the same authority of jurisdiction as part of the surge planning at the facility. 

E-0035 – Communication Plan (Informing Residents and Families)

The communication plan also needs a method for sharing the emergency preparedness plan with residents, families, and/or representatives.  CMS does not require this information to be shared in a standard format.  However, providing the families with a fact sheet or letter during the admission process should allow the facility to be compliant with this requirement.  In addition, the facility can provide the information to residents at a neighborhood meeting for example. Other options include providing instructions on how to contact the facility in the event of an emergency on the public website or to include the information as part of the check-in procedures.  Also, CMS also does not dictate what emergency preparedness information the facility must share with the residents and/or families; so, there is some flexibility in meeting this requirement.  

E-0036 – Emergency Preparedness Training and Testing  

An LTCF must develop and maintain an emergency preparedness training and testing program.  The program must be based on the emergency plan, policies, and on the facility risk assessment.  The program also must be reviewed and updated at least annually.  The facility is responsible for training staff, service providers, and volunteers.  Although, each of these might not receive the exact same type of training.  To prove that the facility has completed the required training on emergency preparedness the facility should keep sign-in sheets of the individuals that have completed the training.  In addition, LTCFs are required to conduct two testing exercises annually.  However, there is not a CMS requirement on the percentage of the residents or staff that need to be included in the testing of the program. 

E-0037 - Emergency Preparedness Training Program  

An LTCF must provide initial training on the emergency preparedness policies and procedures to staff, service providers, and volunteers.  This initial training is typically completed as part of the orientation process and should not be delayed.  However, subsequent training on emergency preparedness is also required annually.  It is up to the facility what level of training various staff and departments might receive.  So, the training can be developed for specific areas if the facility decides this would be the best method for training completion and delivery.  The facility is required to keep documentation of the emergency preparedness training and staff knowledge of the material. 

E-0038 (Does not Apply to LTCFs)

E-0039 – Emergency Preparedness Testing Requirements 

The facility must test its emergency plan twice a year, by conducting training exercises.  One of the exercises needs to be a full-scale exercise that is community-based.  If a full-scale exercise is not available, the facility can conduct a facility-based exercise.  However, if the facility has had an actual emergency during the year the facility is exempt from the required full-scale exercise.  The facility must have activated its emergency plan for it to count towards a full-scale exercise. A functional exercise may also be utilized in the place of a full-scale exercise.  A functional exercise is like a full-scale exercise, but it involves less participation from various community partners.  The second training exercise that the facility must conduct can be one of their choice.  The exercise choices include full-scale, facility-based, mock disaster drill, or table-top exercise.  The facility is required to keep documentation of all the required training exercises for the year.  The testing exercise and scenarios a facility decides to use should be based on the risk assessment of the facility.  However, these testing scenarios should not be the same every year.   

E-0040 (Does not Apply to LTCFs)

E-0041 - LTCF Emergency and Standby Power Systems 

CMS requires LTCFs to comply with the 2012 edition of the National Fire Protection Association (NFPA) codes.  This includes NFPA 101-Life Safety Code and NFPA 99-Health Care Facilities.  If the facility is using a permanent generator for emergency and standby power NFPA 110-Standard for Emergency and Standby Power Systems also applies.  Proper temperatures do not need to be maintained in every resident room or the entire facility.  An LTCF might decide to relocate residents to an area of the facility that is being maintained by the generator.  If a facility has recently had a major renovation or building a new structure the facility must meet the location requirements for NFPA when installing a permanent generator.  This is to reduce the possibility of such events as flooding for example.  All NFPA routine maintenance and testing requirements apply for permanent generators.  The facility must also meet the NFPA requirements for emergency generator fuel and storage.  If the LTCF has agreements in place for fuel delivery the facility must take into consideration the possibility of delays in the delivery of the fuel. 

E-0042 - Integrated Healthcare Systems 

If the facility is part of an integrated healthcare system, it is acceptable to have an integrated emergency preparedness program.  However, it is not mandatory that a facility utilize the integrated approach and each facility still has the option of developing its own program.  If the facility decides to utilize the integrated program, it must be able to demonstrate that it participated in the development of the program and demonstrate they are capable of using the program for its specific location, circumstance, and population.  To prove each facility was involved in the program the facility should record the names of those involved and any meeting minutes available.  Also, an annual review of the program is still required for LTCFs, and each facility must be able to demonstrate they were part of this annual review of the integrated program.  In addition, each facility must have a separate facility-based risk assessment completed utilizing an all-hazards approach.  A documented community-based risk assessment is also still required when utilizing the integrated program.  Lastly, each facility must have a communications plan with information specific to the individual facility.   

E-0043 (Does not Apply to LTCFs)

E-0044 (Does not Apply to LTCFs)

https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/downloads/som107ap_z_emergprep.pdf