Citation Trends in Emergency Preparedness New CMS requirements list 22 E-tags on which ASCs can be cited BY KARA NEWBURY

Medicare-certified ASCs have been required to have a disaster preparedness plan since 2009. As noted in State Operations Man-

ual Appendix L—Guidance for Sur- veyors: Ambulatory Surgical Centers, the intent was for an ASC to “have in place a disaster preparedness plan to care for patients, staff and other indi- viduals who are on the ASC’s premises when a major disruptive event occurs.” The governing body of the ASC was responsible for the development of this plan, which is why the requirement fell under §416.41 Condition for Coverage: Governing Body and Management. Although a requirement to have a disaster preparedness plan has been in place for some time, the regulations were recently reworded—it is now referred to as emergency prepared- ness—and greatly expanded. In Sep- tember 2016, the Centers for Medicare & Medicaid Services (CMS) published a final rule that established national emergency preparedness requirements for all 17 Medicare and Medicaid pro- vider and supplier types. The rule cre- ates mandatory elements and planning procedures that facilities must insti- tute to account for facility occupant safety in the event of natural and man- made emergencies. Surveys beginning November 15, 2017, were based off the new requirements in the State Opera- tions Manual Appendix Z—Emergency Preparedness for All Provider and Cer- tified Supplier Types Interpretive Guid- ance. While under the previous require- ments there was one Q-tag, Q-0043, on which ASCs could be cited, there are now 22 E-tags that apply to ASCs.

Citation History for Q-0043 Before the regulation changed, Q-0043, Disaster Preparedness Plan, was consis- tently something for which ASCs were

In September 2016, the Centers for Medicare & Medicaid Services published a final rule that established national emergency preparedness requirements for all 17 Medicare and Medicaid provider and supplier types.”

—Kara Newbury, ASCA

frequently cited. It is difficult to deter- mine exactly what facilities were being cited for, since there was only one Q-tag that applied to any citation involving issues with the facility’s disaster pre- paredness plan. It could have been lack of training or the lack of a plan entirely, but one cannot tell from the data pub- licly available from CMS. There were 282 ASCs—14.9 per- cent of those surveyed that year—that were cited for Q-0043 in 2010. Since 2010, at least 100 ASCs have been cited for Q-0443 every year, with the lowest figure being 105 in 2017, which repre- sents only 6.8 percent of all facilities surveyed. The number of citations were steadily decreasing between 2010 and 2017. ASCA is tracking E-tag citations to see if there is a spike in citations due to the new, more robust requirements.

E-Tag Citations for ASCs CMS began surveying based on Appendix Z as of November 15,


2017. ASCs were cited on five dif- ferent E-tags, and by December, our facilities were cited on 21 of the 22 E-tags that apply to ASCs. The one E-tag for which an ASC has never received a citation as this article goes to print is E-0042, Integrated Healthcare Systems.

This E-tag

applies only to ASCs that are “part of a healthcare system consisting of multiple separately certified health- care facilities that elect to have a unified and integrated emergency preparedness program.”

Of the other 21 E-tags, those for

which ASCs have been cited, E-0037, Emergency Prep Training Program, and E-0039, Emergency Prep Testing Requirements, are the two tags that have been cited most frequently. Since implementation of Appendix Z, each of these tags has been cited 18 times in ASCs—almost double the citations as any other E-tag.

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