Emergency Preparedness in Home Health

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Introduction   

A home health agency’s emergency preparedness response plan can assure that in the event of a disaster, there is a plan in place to meet the needs of their most vulnerable clients. It also acts to identify the realistic actions an agency can take and be accountable for, communicate those to staff, clients, referral sources, county and state agencies and have available for state and federal survey and certification agencies.  

Home health agencies are the foundation that can support the traditional health care system of hospitals during a time of disaster. Agencies’ infrastructure must be strengthened to utilize the skills of their healthcare providers for the response efforts. 

Definition of an Emergency Preparedness Plan for Home Care 

Emergency preparedness in home care refers to having a clear, actionable plan that enables caregivers to continue providing essential care during unpredictable situations. The emergency plan is a guiding document that outlines in detail the systems and protocols that an organization has in place for: 

1. Ensuring the safety of staff and clients 
2. Operating within the larger emergency management system 
3. Maintaining continuity of services to clients during and after the emergency 

The types of emergencies could include natural events like flooding, hurricanes, winter weather conditions, infectious disease outbreaks, man-made disasters or accidents causing widespread exposure or dangerous conditions, cyber-attacks, and an all-hazards approach. In 2019, CMS added “emerging infectious diseases” to the definition of the all-hazards approach as CMS determined that it was critical for facilities to include planning for infectious diseases within their emergency preparedness program. Emerging infectious diseases (EID) include Influenza, Ebola, Zika Virus, SARS, COVID-19 and others that require modifications to agency protocols to protect the health and safety of clients, such as isolation and personal protective equipment. (1) 

For home care providers, preparedness is a critical part of the operations for ensuring client care and safety, staff security, continuity of business operations, and the agency’s reputation.  

The critical components of the plan should be based on a Risk Assessment and designed to include: 

• Emergency policies and procedures 
• Communication and coordination of response activities 
• Education and training 
• Testing and evaluation of exercises 
• Clear evacuation plans that consider each client’s unique requirements 
• Accessible transportation 
• Essential medical supplies 
• Arrangement with local shelters that can accommodate medical equipment 
• Resources needed to continue to provide care 
• Interruptions in communication and power, water, gas failures. 

(2) 

The plan needs to be comprehensive to ensure that agencies do not only choose one potential emergency that may occur in their area but rather consider any number of events and be able to demonstrate that they have considered this during the development of their plan. For example, as infectious disease outbreaks occur, they may affect any agency in any location across the country, so a comprehensive emergency preparedness program should include emerging infection diseases and pandemics during a public health emergency. 

One of the requirements for an emergency preparedness plan is that it must be in writing. It is up to each agency to be able to demonstrate in writing their emergency plan along with identifying where these documents are located. If their plan is located in a binder, specify this for surveyors, or if there are policies/ procedures to specific requirements, identify where these are located. (3) 

Breaking Down the Elements of an Emergency Preparedness Plan 

The Centers for Medicare and Medicaid Services (CMS) issues the Emergency Preparedness Requirements for Medicare and Medicaid Participating Providers to establish consistent emergency preparedness requirements for healthcare providers participating in Medicare and Medicaid, increase client safety during emergencies, and establish a more coordinated response to natural and human-caused disasters.  

The plan must be reviewed and updated at least every 2 years. (4) 

The location of the home care agency can dictate important elements that the agency needs to address in its plan. If an agency is in a large flood zone or a tornado-prone region, these risks need to be addressed, and employees need to be educated in their role and the steps to be taken in the event of one of these disasters. Additionally, if clients within the agency’s population have limited mobility, agencies need to be able to identify who those clients are and how their needs will be addressed, especially for the on-call / after-hours personnel.  

Risk Assessment 

One of the unique challenges in home care is the fact that each setting is different from the next, so agencies need to prepare for everything and know how to react.  

A risk assessment using an “all hazards” approach must be done to identify the potential hazards and incorporated into the plan and documentation as to how the risk assessment was conducted. In addition, potential emergencies that would affect employees and clients with vulnerabilities and the types of hazards most likely to occur in their location and then create plans to address them. The “all hazards” planning does not specifically address every possible threat or risk but ensures the agency will have the capacity to address a broad range of related emergencies. (4) 

An agency may rely on a community-based risk assessment developed by other entities, such as public health agencies, emergency management systems and regional health coalitions, they are expected to have a copy of the community-based risk assessment and to work with the entity that developed it to ensure that the agency’s plan is in alignment.  

Agencies should categorize and rank the various probable risks and hazards identified by the likelihood of occurrence and further create supplemental risk assessments based on the disaster or public health emergency.  

• Potential Hazard 
• Probability  
• Human Impact  
• Service Impact 
• Business Impact 
• Community Impact 
• Relative Impact Magnitude  

(5)  

For Public Health emergencies such as Emerging Infectious Disease (EID) or pandemics, agencies need to include in the risk assessment the needs of the client population they serve and include: 

• Influx in need of Personal Protective Equipment (PPE) 
• Influx in need of medical equipment, medical supplies, cleaning and disinfection supplies, and other supplies as needed 
• Considerations for screening and/or testing staff or clients for infectious disease 
• Physical environment, including changes needed for distancing, isolation, or capacity/surge: i.e. how the agency would handle the influx of clients if requested 
• Education and training of staff 
• Emergency staffing contingency plans, i.e., developing a staffing strategy if staff shortages are identified. 
• Communication processes following current guidance and requirements 

(5) 

Emergencies 

Many potential hazards could be faced because of the home care setting, but the emergencies that would require the emergency preparedness plan to be activated include: 

• Mass casualty 
• Hazards waste spill or exposure 
• Power or communications failure 
• Disease outbreak or pandemic 
• Natural disasters including: 
  • Earthquakes 
  • Tornados  
  • Hurricanes 
  • Typhoons 
  • Tsunamis 
  • Avalanche 
  • Volcano 
  • Mud and rockslides  
  • Wildfires 
• Any type of severe weather, such as thunderstorms, high winds, hail, winter storms, and extreme heat, drought or cold 
  • Blizzard 
  • Cold 
  • Flooding 
  • Heat 
  • Ice storms  
• Man-Made 
  • Airplane Crash (Consider the epicenter of the crash and an extended debris field. Is the agency along the take-off or landing flight path of a regional airport?)  
• Biological Disease Outbreak-Pandemic Flu 
  • Pandemic or Infectious Disease (EID  
• Civil Demonstration 
• Communications Disruption  
  • Computer Failure  
• Explosives Attack-Improvised Explosion  
• Fuel Shortage  
• Hazmat Release/Explosion  
  • Nuclear Facility Incident   
• Power Outage  
• Supply Distribution  
  • Water System Failure  
  • Municipal Water Contamination 

(5) 

The Plan 

Once the relative risk for each hazard is determined, the team can develop and prioritize a work plan. The Emergency Preparedness Plan and the Assessment should be integrated into the Quality Assurance and Performance Improvement process. As part of the agency’s QAPI process, the use of an action plan to assign and to manage work tasks associated with the plan is essential.  

The agency should put together a team consisting of nursing, professional medical staff, allied healthcare providers, infection control, as well as key administrative staff and maintain up to date contact lists of these individuals. A system to rapidly notify them, such as a telephone tree, needs to be in place.  

(8) 

Continuity of operations must be part of the emergency plan, including delegations of authority and succession plans. The delegation needs to outline staff roles and responsibilities and delineate qualified individuals who are authorized in writing to act in the absence of the administrator. The plan should also address how the agency will protect vital records and IT data. (7) 

Developing a staffing strategy if staff shortages were identified in the Risk Assessment is important, along with the response to a surge capacity if the agency will likely be requested to accept additional clients during an emergency. Staff need to be identified as essential or non-essential and what roles they can assume. (9) 

Continuity of operations of the plan should include: 

• Facility and community-based risk assessment findings 
• Identification of key personnel 
• Essential functions and critical resources to maintain operations internally and externally 
• Protection of vital medical, client and agency data 
• Identification of alternate agencies for transfer of clients 
• Contractual agreements 
• Financial resources 
• Staff and employee resources 
• Communication plan 

(5) 

In case of a disaster, home care agencies need to be able to rapidly identify clients at risk within the affected area. To respond effectively, the plan needs to have the following information: 

1. Identification of a 24/7 emergency contact telephone number and email address of the emergency contact person and alternate 
2. A call down list of agency staff and a procedure which addresses how the information will be kept current 
3. A contact list of community partners, including the local emergency management, local health department, regional healthcare coalition, emergency medical services, law enforcement, utilities, durable medical equipment (DME) provider, and medical gas vendors. Including a policy that addresses how this information will be kept current 
4. Collaboration with the local emergency manager, local health department, regional healthcare coalition and other community partnership planning efforts, including a clear understanding of the agency’s role and responsibilities in the county’s emergency plan 
5. A current client roster that is capable of facilitating rapid identification and location of patients at risk. It should contain at a minimum: 
6. Client Name, address and telephone number 
7. Client Classification Risk Level 
   1. Level 1 
      1. Home visit within 24 hours 
      2. High priority 
      3. Require uninterrupted services 
      4. Condition unstable, may deteriorate or require inpatient admission if not seen 
      5. Examples: No caregiver support or cannot be left alone. Bedbound, ventilator dependent, daily insulin dependent unable to self-administer, fresh wound or extensive wound care, infusion therapy requiring daily visits, apnea monitoring 
   2. Level 2 
      1. Home visit within 48-72 hours 
      2. Moderate priority  
      3. Caregiver available to provide basic care 
      4. May postpone visit if telephone contact made 
      5. Condition somewhat unstable, but could be postponed without harm to the client 
      6. Examples: uses assistive device, (wheelchair, etc.) able to manage alone for period of time up to 24-48 hours, uses equipment such as oxygen, suctioning, nebulization on PRN basis, Diabetic but self-administers insulin, requires skilled monitoring of blood glucose less than every 24 hours, extensive would care but has support / backup assistance, cardiac or respiratory with multiple medication changes in the past 1-2 weeks 
   3. Level 3 
      1. Home visit can be deferred longer than 72 hours  
      2. Low priority 
      3. Condition stable with access to informal resources for help 
8. Can safely miss a scheduled visit with basic care provided by family or informal support  
9. Examples: able to manage alone for more than 72 hours, significant other or support systems in place, mobile, independent functioning, uncomplicated wound care, self-manages medications/ diet 
10. Pediatric Patients 
11. Can be significantly at risk if they have serious or chronic health conditions 
12. Due to acuity and caregiver support needs, it is recommended that they be assigned a risk level of 1 or 2.  
13. Home health agencies should encourage caregivers to contact their local emergency medical services to let them know of their special needs. 
14. Procedures to respond to requests for information by the local health department and other emergency responders in emergencies 
15. Policies addressing the annual review and update of the emergency plan and the orientation of staff to the plan 
16. Records of participation in agency-specific or community-wide disaster drills and exercises 

(6) 

Demobilizing the Response 

Demobilizing or deactivating the plan and returning to normal requires a transition plan. If clients are evacuated to shelter, what would the process be for returning clients home and resuming services?  

The deactivation process may include the following: 

• Abbreviated paper assessments being converted to full electronic format 
• Notify staff 
• Updated employee worked hours in the computer system 
• Billing 
• Return to office if it was abandoned due to disaster, i.e., flooding, fire, etc. 
• Reassessment of client needs and possible return to original services 

Education 

Client Education 

Client preparedness is a vital part of a safe emergency response. Agencies should have policies related to client and family or caregiver education, as well as policies outlining client communication before, during, and after an emergency. 

Clients must be aware that they need to have several days’ supply of medications and a medication list. They should also be aware of the need to contact the agency if they decide to relocate if there is a pre-warned emergency.  

Review the client’s emergency plan at Start of Care and regularly thereafter and then in advance of an event with pre-warning, such as flooding or snowstorm. Prepare a standard brochure that outlines these procedures, agency contact numbers, and client responsibilities and expectations. It is also a good idea to develop scripts for staff to use when communicating with clients before, during, and after the event to ensure that clients uniformly receive the correct information.  

Staff Education 

Include emergency preparedness in staff orientation programs, as it establishes it as part of their job responsibilities with the understanding that they will not be asked to put themselves at risk as part of agency response. Define what their role in evaluation situations would be and what procedures to take if the client refuses to evacuate.  

Hold regular briefings on seasonal threats, such as flooding, heat, or snowstorms. Inform them of points of communication for them via radio stations, website, and text message. Test the staff’s responses at least once a year (6). 

Training must be specific to the individual’s duties and responsibilities. For direct care staff, evidence of PPE training per CDC guidelines. The training program is reviewed and updated at least every two years or whenever a new policy or guideline is implemented. (10) 

Conclusion

The efforts a home health agency puts into the development and maintenance of an Emergency Response Plan can help to ensure a safe, swift, and effective response to most emergencies and assure the safety of employees and clients. 

While the agency can educate and encourage, they cannot force clients or their families to follow a specific emergency plan. Clients have the ultimate responsibility for planning appropriately. For children, the parent or guardian has that responsibility. The agency’s communication of the importance of preparing for the unexpected can help both employees and clients cope with these events safely.  

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