Applicable to All Provider types except OPO’s and Transplant Centers
(42 CFR 482.15) EP Program Patient Population: Address patient/client population, including, but not limited to, persons at-risk; the type of services the [facility] has the ability to provide in an emergency; and continuity of operations, including delegations of authority and succession plans.
Example: CMS Statement of Deficiencies – “Findings Include: A review on 11/08/20 of the facility document titled “Emergency Operations Plan” (2/18) did not contain a plan which addressed: the patient population within the facility, the ability to provide care on any given level of emergency, the ability or continuity of operations during any given level of emergency or delegate authority on who could make decisions affecting the facility and patients being served if senior staff were incapacitated or unavailable to make determinations which effect the facility.
Who are Persons at Risk?
Many facilities over the years have done very well with their all hazard approach in a Hazard Vulnerability Analysis. However, they leave out one very important factor in their Emergency Operations Plan (EOP) – that is persons at risk. The EOP should include a population assessment and services assessment of the populations being served; specifically identifying persons at risk. Evacuation plans must be specific to the different populations being served (i.e: surgical patients, recovering patient, pediatric patients, non-ambulatory patient, behavioral health patients, geriatric patients, limited English speaking patients, visual or hearing-impaired patients, etc.). The goal of the EOP is to identify, plan and be able to respond to ALL patient populations / persons at risk within a given facility type at any given time. Different provider types will have different patient population/persons at risk – Home Health, Long Term Care, Hospice, etc., please review your EOP today to ensure the persons at risk within your organization have been assessed and included in the emergency operations plan.