Are you ready?
After a bit of a reprieve due to the pandemic, surveyors are once again out doing the important job of ensuring compliance and quality of care for patients. Do not be surprised when the surveyor comes to your organization unannounced.
Whether it is a triennial survey or a focused survey, it is important to know one of the major focuses in the age of COVID-19 is our response to the pandemic. Focused surveys are assessing the care delivered to patients and our staff during this time and ensuring systems are in place for infection control and quality care delivery.
In 2017, the Centers for Medicare and Medicaid Services (CMS) and the Centers for Disease Control (CDC) emphasized that each healthcare organization must have a robust disaster/emergency preparedness plan in place. Part of that plan included a response to a pandemic because it was not if a pandemic happened, but when.
We are now living in that forecasted reality. Not only are we all trying to adjust to a “new normal,” but also a continuously changing environment that demands quick reaction and appropriate implementation of interventions as new information becomes available or circumstances change.
The Hazard Vulnerability Analysis
When creating a disaster/emergency management plan, a hazard vulnerability analysis (HVA) should be completed to assess the potential impact of disasters on staffing, equipment (PPE), finances, back-up plans, and more.
Recently, in reviewing a client’s HVA, the category of pandemic was listed as unlikely to occur. This definitely needs to be updated! The HVA needs to be reviewed no less than annually and as changes occur.
Assess your organization just as a surveyor would do. At minimum, ask the following questions to evaluate the implementation of your emergency plan:
- Was the response effective?
- Were policies and processes changed as needed?
- Were staff and patients educated in a timely manner with pertinent information such as mitigating risk, symptoms, modes of transmission, screening, work exclusions, and reporting to the appropriate authorities?
- Was there adequate staff? How did the organization address staffing shortages? Was the back-up plan effective?
- Was there adequate personal protection equipment (PPE)?
- Have staff been fit tested annually with the N95 mask? This is an OSHA requirement and not new!
- What methods are used to conserve supplies?
- How are staff and patients screened?
- How are symptoms tested and reported?
- Did the agency follow CDC guidelines such as reporting COVID-19 cases and returning to work?
- How does the organization determine essential and non-essential services?
- Does the organization now have a pandemic infection control policy based on current federal and state guidelines and lessons learned?
Create a binder or other file to document everything that has been done for the pandemic response to COVID-19. As we know in healthcare, “if it is not documented, it is not done.” Be ready to show this to the surveyor.
Information could include a timeline of events, emergency plan implementation, responses to new COVID-19 guidelines and information, education to staff and patients, actions to obtain PPE, and alternate forms of addressing patients’ needs, such as telehealth.
Do not be surprised when staff and patients are interviewed to verify the emergency plan implementation and to determine if adequate information and protection was provided to them. Consider knowing this information before the surveyor does with your own survey to assess the organization’s response.
Some state regulations mandate an organization must be prepared to deliver the same amount and kind of care in an emergency that a patient would normally receive. Even under duress or extreme conditions such as a disaster, an organization must be prepared to respond well and ensure the highest level of care for our patients and our staff. In this way, we will be prepared not only for the challenges of the age of COVID-19, but for the surveyor as well.