assess your plan, Ruppe says. “Earth- quake preparedness is a big threat for us. We had theories about what would be effective responses to an earthquake and developed policies and procedures accordingly. We had a few of our cen- ters conduct tabletop drills to assess our beliefs and made changes from what they learned.”

Avoid Shortcomings While completing an emergency pre- paredness plan might seem straight- forward, Gellenbeck says it is easy to make mistakes that can attract sur- veyor attention and create gaps that reduce plan usefulness. “While there is no harm in working off of a template when beginning to assemble a plan, you cannot get a template and call it your plan. You must customize the template for your center and the spe- cific hazards you are likely to face.” In the same vein, Ruppe says ASCs that receive a plan from a management

and/or hospital partner should update it accordingly. “The plan we provide to our centers is editable. They are expected to complete significant por- tions on their own, including devel- oping a process for evacuation based upon their location.” Henry advises ASCs not to overlook the importance of assigning key staff positions. “Your plan should identify a chain of command during an emer- gency. Individuals should be comfort- able with their assigned responsibili- ties. You also want to account for the possibility that key individuals may be unavailable during a disaster and develop a succession plan.” Gellenbeck cautions ASCs against ignoring requirements. “There is an ele- ment in the CMS regulations essentially stating that if a facility is damaged to the point where operations must cease, you are permitted to move to another location and resume operations.” ASCs might think they do not need to address this

rule as they would typically shut down their central operations if such damage were to happen. Surveyors, however, are still expecting ASCs to acknowledge this section and include information about how they would respond, he says.

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Keep It Alive An emergency preparedness plan should never be considered “final- ized,” Henry says. “Many of your plan’s components will likely undergo changes over time. This includes staff- ing and potential hazards facing your ASC. Regularly evaluate your plan and pursue opportunities to improve it.” Gellenbeck advises ASCs to reeval- uate their plan at least annually. “This should probably occur after every drill. Evaluate and critique your response to the drill, involving all of the staff mem- bers who participated. Did the response go well and as planned? Did your walkie- talkies work? Did everyone know where supplies were and how to find paper doc- umentation? If you experienced hiccups, revising the plan is worthwhile.” Another appropriate time to update a plan is when your community experi- ences a significant change, Gellenbeck says. “For example, there may not be a nuclear power plant in your area now, but if one is added, you will want to consider it a new potential hazard and speak to this in your plan.” Ruppe advises ASCs to always keep

their eyes open for opportunities to strengthen their plans. “Who has already created a plan that can share pieces of it with you to incorporate or emulate? Is there an organization like NWHRN that is willing to review your plan and provide feedback?” An emergency pre- paredness plan has been a requirement for several years, so there are many more resources available now than there were even just a few years ago. “Keep researching, reviewing and

refining. Your plan should be a living tool and not a document that just sits on a shelf, only to be pulled out when sur- veyors come to town,” Ruppe says.

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