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In 2016, the Centers for Medicare & Medicaid Services (CMS) updated its life safety and emergency preparedness regulations related to health care facilities to improve protections for all individuals enrolled in Medicare and Medicaid, including those residing in long-term care facilities. The updates expanded requirements related to sprinkler systems, smoke detector coverage, and emergency preparedness plans (EPPs). Additionally, facilities were required to implement an infection control program.

As part of its oversight activities, the Office of Inspector General (OIG) is performing audits in nursing homes across the country as many residents of nursing homes have limited or no mobility and are particularly vulnerable in the event of a fire or other emergency. Nursing homes are also communal living environments; therefore, residents are susceptible to infectious disease.

In the state of Colorado, the OIG surveyed 20 nursing homes September through November of 2022. There were a total of 210 deficiencies with Emergency Preparedness, (EP). The EP requirements were related to the emergency preparedness plan, which included emergency supplies, power, plans for evacuation, sheltering and tracking residents and staff members during an emergency and having an EPP that training and testing was in place. Access the Colorado OIG Audit.

The Colorado report was shared with nursing home partners in a recent BOOST call to highlight the recommendations made by the OIG and the corrective actions made regarding the life safety, emergency preparedness, and infection control deficiencies identified.

Stephanie Meduna“Our team develops tools and resources for nursing home staff to utilize while reviewing or updating your emergency preparedness plan. We encourage nursing home team members to review and utilize these tools and resources, including the Colorado OIG audit report, to better understand recommendations and regulations to ensure compliance and enhance quality of care for our residents. If we can assist in any way, please connect with us; we would love to help,” shared Stephanie Meduna, RN, BSN; Quality Improvement Advisor.

One of the elements is the emergency preparedness plan needs to be reviewed on an annual basis. Great Plains QIN has developed the Long-Term Care (LTC) Emergency Preparedness Plan (EPP) Resource Document, which includes a comprehensive list of resources to utilize while updating your Emergency Preparedness plan. The Great Plains QIN team has also created a Nursing Home Emergency Preparedness Plan Review, which outlines each of the Appendix Z regulations to help ensure an Emergency Preparedness plan is up-to-date and has the foundation to be effective in the case of an emergency. 

For more information, visit the Great Plains QIN Nursing Home Quality Webpage.

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Emergency Preparedness – Are You Ready?: Emergency preparedness is knowing what to do if there is a disaster or emergency in your community that may affect you or your family. Join the conversation and learn how you can best be prepared for any type of disaster or emergency situation.