A few weeks ago, the CMS Quality, Safety, and Oversight Group (QSO) issued a Memo to State Survey Agencies titled “Emergency Preparedness Programs – Updates to Appendix Z of the State Operations Manual (SOM)”. Appendix Z is the interpretive guideline for surveyors of all healthcare types in implementing the emergency preparedness Conditions of Participation (COP) that took effect in 2017. This memo describes how CMS has changed its guidance to surveyors on how to survey / enforce specific parts of the Emergency Preparedness Programs at various facilities. Specifically noted were the issues surrounding adding and addressing of Emerging Infectious Diseases to the definition of “All Hazards” and clarifications regarding the use and testing of portable electrical generators.

The guidance now specifically calls out that a facility’s “all hazards” planning should include emerging infectious disease (EID) threats. Examples of EIDs include Influenza, Ebola, Zika Virus and others. These and other EIDs may require modifications to facility protocols to protect the health and safety of providers and patients, such as isolation and personal protective equipment (PPE) measures. In the Appendix Z revisions, under Tag E-0004, concerning the requirement for healthcare organizations to use an all-hazards approach, CMS adds emerging infectious diseases (EIDs) to examples of hazards it expects facilities to consider, and notes “these EIDs may require modifications to facility protocols to protect the health and safety of patients, such as isolation and personal protective equipment (PPE) measures.”

On the use and testing of portable electrical generators, the memo outlines that their use in certain circumstances will be considered acceptable if the appropriate code and provisions are met. “If a facility risk assessment determines that the use of a portable and mobile generator would be the best way to accommodate for additional electrical loads necessary to meet subsistence needs required by emergency preparedness plans, policies and procedures, then the LSC provisions such as generator testing, maintenance, etc. outlined under the NFPA guidelines requirements would not be applicable, except for NFPA 70 National Electrical Code.” Regardless of the alternate sources of energy a facility chooses to employ, it must be in accordance with local and state laws, manufacturer requirements, as well as applicable Life Safety Code and electrical code requirements. The revisions go on to state that the detailed requirements in the National Electrical Code (NFPA 70), regarding portable and mobile generators should be followed (e.g., location, ventilation, distance from combustibles, operated, tested and maintained in accordance with manufacturer, local and/or State requirements, no extension cords).

Since there is now a clear expectation that facilities include emerging infectious diseases (EIDs), consider a specific response or mitigation plan to address this hazard. If your Hazard Vulnerability Analysis and mitigation plans include portable generators to maintain temperatures, emergency lighting, fire detection and extinguishing systems, or sewage and waste disposal, pay attention to the detailed requirements of this guidance. We encourage you to further read the entirety of the memo for all applicable changes and interpretations regarding your plan and facility, as addressed under Appendix Z and this memo.

Resource

• QSO19-06-ALL, “Emergency Preparedness—Updates to Appendix Z of the State Operations Manual (SOM): Click here to download