Emergency Preparedness Guidance for Outpatient Physical Therapy and Speech Language Pathology Services

Emergency plan

1. Be based on and include a documented, facility-based and community-based risk assessment, utilizing an all-hazards approach.
2. Include strategies for addressing emergency events identified by the risk assessment.
3. Address patient population, including, but not limited to, the type of services the Organizations have the ability to provide in an emergency, and continuity of operations, including delegations of authority and succession plans.
4. Address the location and use of alarm systems and signals, and methods of containing fire.
5. Include a process for cooperation and collaboration with local, tribal, regional, State, and Federal emergency preparedness officials' efforts to maintain an integrated response during a disaster or emergency situation.
6. Be developed and maintained with assistance from fire, safety, and other appropriate experts.

Policies and procedures

1. Safe evacuation from the Organizations, which includes staff responsibilities, and needs of the patients.
2. A means to shelter in place for patients, staff, and volunteers who remain in the facility.
3. A system of medical documentation that preserves patient information, protects confidentiality of patient information, and secures and maintains the availability of records.
4. The use of volunteers in an emergency or other emergency staffing strategies, including the process and role for integration of State and Federally designated health care professionals to address surge needs during an emergency.

Communication plan

1. Names and contact information for the following:
   1. Staff.
   2. Entities providing services under arrangement.
   3. Patients' physicians.
   4. Other Organizations.
   5. Volunteers.
2. Contact information for the following:
   1. Federal, state, tribal, regional and local emergency preparedness staff.
   2. Other sources of assistance.
3. Primary and alternate means for communicating with the following:
   1. Organizations' staff.
   2. Federal, state, tribal, regional, and local emergency management agencies.
4. A method for sharing information and medical documentation for patients under the Organizations' care, as necessary, with other health care providers to maintain the continuity of care.
5. A means of providing information about the Organizations' needs, and their ability to provide assistance, to the authority having jurisdiction or the Incident Command Center, or designee.

Training and testing

1. Training program. The Organizations must do all of the following:
   1. Initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles.
   2. Provide emergency preparedness training at least annually.
   3. Maintain documentation of the training.
   4. Demonstrate staff knowledge of emergency procedures.
2. Testing.The Organizations must conduct exercises to test the emergency plan at least annually. The Organizations must do the following:
   1. Participate in a full-scale exercise that is community-based or when a community-based exercise is not accessible, an individual, facility-based. If the Organizations experience an actual natural or man-made emergency that requires activation of the emergency plan, the organization is exempt from engaging in a community-based or individual, facility-based full-scale exercise for 1 year following the onset of the actual event.
   2. Conduct an additional exercise that may include, but is not limited to the following:
      1. A second full-scale exercise that is community-based or individual, facility-based.
      2. A tabletop exercise that includes a group discussion led by a facilitator, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan.
   3. Analyze the Organization's response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise their emergency plan, as needed.

Integrated healthcare systems

1. Demonstrate that each separately certified facility within the system actively participated in the development of the unified and integrated emergency preparedness program.
2. Be developed and maintained in a manner that takes into account each separately certified facility's unique circumstances, patient populations, and services offered.
3. Demonstrate that each separately certified facility is capable of actively using the unified and integrated emergency preparedness program and is in compliance.
4. Include a unified and integrated emergency plan that meets the requirements of paragraphs (a)(2), (3), and (4) of this section. The unified and integrated emergency plan must also be based on and include all of the following:
   1. A documented community-based risk assessment, utilizing an all-hazards approach.
   2. A documented individual facility-based risk assessment for each separately certified facility within the health system, utilizing an all-hazards approach.
5. Include integrated policies and procedures that meet the requirements set forth in paragraph (b) of this section, a coordinated communication plan and training and testing programs that meet the requirements of paragraphs (c) and (d) of this section, respectively.