Since the COVID pandemic, regulatory officials have escalated the review, via various audits, of SNF emergency preparedness. COVID highlighted the sporadic and often, non-existent preparations for disasters (natural and other) and disease outbreaks (pandemic or other) that existed with the SNF industry.
In reality, the issues have been present for years but only regionally, highlighted by floods, fires, hurricanes, and other natural disasters. COVID was the first national, wholesale disaster requiring full scale response across all states. While some facilities fared fine in terms of response, others fared miserably and the result, as oft reported in the media, significant loss of life, especially during the first wave.
CMS via various regulatory actions during and post the pandemic, has increased regulatory focus on infection control. CMS has yet to alter, the emergency preparedness requirements in the Code of Federal Regulations for SNFs substantively, since original issue in 2016.
On September 8, 2016 CMS published in the Federal Register the Emergency Preparedness Requirements for Medicare and Medicaid Participating Providers and Suppliers Final Rule. The regulation became effective No tvember 16, 2016. Health care providers and suppliers affected by this rule were to be compliant and implement all regulations one year after the effective date, on November 15, 2017.
In March of 2021, CMS released update guidance to surveyors on emergency planning with specific focused changes on Emerging Infectious Diseases (EID). Per CMS: Additionally, since CMS had revised Appendix Z in February 2019 to add “emerging infectious diseases” (EIDs) to the definition of all-hazards approach, we are taking the opportunity to
further expand upon the interpretive guidelines where applicable to include best practices and planning considerations for preventing and managing EIDs in light of lessons learned during the onset of the COVID-19 public health emergency (PHE). The CMS Fact Sheet on this guidance change in 2021 is available here: CMS Releases Updated Emergency Preparedness Guidance
In early-September, the Office of the Inspector General for Health and Human Services issued a report on disaster preparedness and planning in SNFs. The report found that more than three-quarters of US nursing homes in areas at high risk for natural disasters face significant challenges in preparing for them. The primary challenges highlighted were finding enough staff to enact a plan, securing transportation for residents, and accessing resources needed to make their planning efforts significant and realistic. Staff challenges in terms of amount have been a significant compliance concern for facilities, beyond emergency situations. Another highlighted area is a lack of cooperation at the state and local level involving SNFs in disaster preparations. Facilities complain about inadequate training resources and communication about local/regional level disaster plans/programs. The OIG report is available here: OIG Report on SNF emergency preparation 9 23
In a recent report on the same subject, the OIG focused on a survey of 20 Pennsylvania SNFs. In its survey activities, OIG identified deficiencies related to life safety, emergency preparedness, or infection control at all 20 nursing homes that were audited, totaling 586 deficiencies. OIG found 220 deficiencies related to life safety, 288 deficiencies related to emergency preparedness, and 78 deficiencies related to infection control. Deficiencies in this survey process mean conditions that are not consistent and compliant with federal regulatory requirements.
OIG noted that the deficiencies occurred because of frequent management and staff turnover, contributing to a lack of awareness of, and/or failure to address, Federal requirements. In addition, poor record keeping, combined with an inconsistent application of policies, also contributed to deficiencies. Inadequate survey/enforcement activity is also cited as a cause for concern. The full report is available here: OIG Pennsylvania Emergency Preparedness Audit 11 23
The most interesting elements of the report for me were the recommendations OIG made to Pennsylvania’s Department of Health. In classic government health policy as applied primarily with provider but even more so within the SNF industry, the recommendations all involve additional governmental involvement and/or regulations. From the report, the recommendations are as follows.
- Provide annual written reminders to nursing homes with K-tag, F-tag, and E-tag requirements.
- Work with CMS to develop standardized life safety training for nursing home management
teams and staff. - Work with CMS to improve standardized emergency plan testing and training for nursing
home management teams and staff. - Develop additional infection control training resources for nursing home management teams
and staff. - Implement verification standards to confirm completion of written training and training drills.
- Work with CMS to refine the current risk-based approach to identify nursing homes at which
surveys should be conducted more frequently than once every 15 months, such as those with
frequent management turnover. - Develop a plan in conjunction with CMS to address the foundational issues preventing more
frequent surveys at nursing homes with a history of multiple high-risk deficiencies.
The above, if implemented, will do little to change the disaster preparations for most facilities as inadequate staff numbers and skills plus management turnover cannot be solved via regulation. The challenges facilities face with regard to all regulatory compliance issues today can be boiled down to one major obstacle – insufficient resources, particularly, adequate reimbursement to fund the demands for more training, more staff, better management, etc. Continuing to layer on more regulations to fix problems somewhat driven by too much existing regulation, is a primary reason for staff turnover, particularly management.