Thank you to Cheryl DuBois, RN, RAC-CT, HHI Specialist for writing this article. Edited by Kris Mastrangelo, OTR/L, LNHA, MBA.
Hurricane Ida’s August 29th, 2021 assault on Louisiana served as a grim reminder that disasters, emergencies, and crises have no manners nor do they not their turn. In the midst of a global pandemic with the pressure of a looming vaccine mandate that could wreak havoc on the nursing home industry’s already depleted and exhausted workforce, Louisiana nursing homes were put to yet another test i.e., activating their Emergency Preparedness Plan and, in some cases, evacuating staff and residents.
Last week saw the news that the licenses of multiple nursing homes were revoked after the death of several residents who were evacuated to a warehouse facility due to Hurricane Ida. Power outages and unsanitary conditions were noted as the coroner determined that five of seven deaths were directly storm related.
The loss of license for the facilities may be the headline, but this tragic loss of life is the real story. Each person represents a life that may have been spared. Now, many staff who are still processing the losses related to seventeen months of COVID outbreaks will be dealing with more feelings of helplessness as they ask themselves,
“What could have been done differently with the cruel wisdom of hindsight?”
“What can we learn from this tragedy?”
As an HHI Specialist, RN, MDS Certified, Infection Control Certified and Patient Care Advocate, here are the Top 5 Things to know about emergency preparedness:
- First, review the requirements for Emergency Preparedness.
Appendix Z of the State Operations Manual provides the interpretive guidance for facilities and surveyors.
- 483.73(d) requires two exercises that will test the facility’s preparedness for emergencies, crises, and disasters.
The first is an annual participation in a community-based drill
a facility based functional exercise if a community-based drill is not accessible.
An additional annual exercise that could be either a second full-scale exercise or a tabletop exercise or workshop where a facilitator leads the team through an event scenario.
Analysis of the drill, actual activation, or tabletop workshop to evaluate the plan’s efficacy and identify potential areas of improvement is also required.
The State Operations Manual goes on to say that if a facility activates their Emergency Plan due to a natural or manmade emergency, the facility is exempt from the next required full-scale functional exercise.
You can read more about the interpretive guidelines in the State Operations Manual here:
- Second, take time to review company policies for Emergency Preparedness.
Is your policy more stringent than the regulation requires?
Remember, if your policy is more stringent, that is the standard to which the facility will be held.
Facilities must follow their own policies, and state surveyors will cite facilities whose processes meet the regulatory standard, but do not follow their company policies.
Do your policies include strategies for managing processes under waivers?
The ever-changing guidance for preservation of Personal Protective Equipment at the onset of the COVID-19 Public Health Emergency showed us that deviations from known best practice and what is the “norm” creates a substantial risk for system failure, even when the deviation is necessary to preserve supply.
Continually refine policies to fit the needs of the facility.
Include the policies in the analysis during drills and practice exercises. When a potential problem is identified, determine whether it is:
- a policy problem,
- a plan problem, or
- an execution problem.
Be sure this is part of the root cause analysis.
- Third, carefully process any 1135 waivers and exemptions due to Emergency Plan activations.
A minor fire may require a facility to activate their Emergency Plan for fires, but does it really test the facility’s plans for a major event? Consider including a tabletop exercise with a major fire scenario in the analysis of the facility response to the minor fire.
Embrace the process as the necessary steps the facility must take to make sure they are prepared to save lives in a disaster rather than a regulatory obligation that is just one more thing on the never-ending to-do list.
- Fourth, continue to review the facility’s risk analysis and learn from other incidents outside of your region.
Prior to COVID-19, a “global pandemic” was most likely not on anyone’s radar. When events are observed elsewhere, assess if there is something that you may not have been considered in the most recent facility risk assessment.
- Do your event-specific plans include continencies such as power outages?
- In the recent tragedy in Louisiana, we read that staff were scrambling to obtain oxygen cannisters when the power failed because oxygen concentrators need electricity to function.
- Does your facility plan include maintaining a back-up supply of oxygen cannisters?
- Does the facility have an agreement with a supplier who will commit to maintaining sufficient inventory to enable them to provide several days’ supply in the event of a power outage?
- Does the facility have portable generators and a fuel supply?
- Fifth and final, staffing shortages have always been a potential collateral effect of a crisis or disaster event. Savvy leaders are recognizing that staffing is a potential crisis in itself.
- What is your facility plan for dealing with staffing shortages? The long-term care industry as a whole has been experiencing great difficulties filling caregiving positions for so long that it has become the expected “norm.” It is important to remember that what is already challenging is often exacerbated by a crisis or disaster, and what is already bad can definitely get worse.
- Do your plans include a hierarchy for taking care of residents based upon the number of caregivers available? Are you actively trying to recruit volunteers who can be trained as feeding or hospitality aides?
- Have you brought staffing difficulties to the QAPI process? Using our evidence based, proven method for problem solving is the first step.
- Are you looking at your personnel policies and procedures to see whether they are having a positive or negative effect on staff development and retention? We could talk about how things “should be,” and “work ethic,” and generational differences in the work force all day long and never come closer to developing solutions for the staffing struggles in long-term care.
- Possibly the most important, yet often missed opportunity for recruitment is asking your direct care staff for their input. What could a facility do to attract quality caregivers?
- We all know that the first response is usually pay centered, and that should not be taken lightly. When SNFs are competing for applicants with department stores who offer merchandise discounts and comparable if not higher wages, the outcome is predictable. Avoid disregarding this aspect with direct care staff. If the leadership team excludes compensation from the root cause analysis, then the opportunity to innovate potential solutions is If the sole focus is compensation, then the opportunity to examine potential solutions that do not have associated costs is lost.
- Push beyond compensation to the other reasons why people stay and why people leave jobs. Where can staff be given more autonomy? Facility leaders show the value they put on their direct care staff every day, whether or not it is done intentionally. What can leaders do to show staff that they are a valued member of the team?
The Roman philosopher Seneca said that:
“luck is what happens when preparation meets opportunity.”
Optimal outcomes are not the result of luck. When reviewing and analyzing your facility’s response to an actual crisis or disaster, you may identify pivotal events that, had they gone one way or another, the outcomes would have been vastly different. It is important to differentiate between events that are uncontrollable and unpredictable and those that are not.
“The tornado flattened buildings across the street, but our facility was spared” is an uncontrollable and unpredictable event. We can’t determine the path of a tornado.
“If we had not lost power, we would have been able to manage tube feedings, ventilators, and supplemental oxygen delivery” is a predictable event. While you cannot control whether the power supply is maintained, you can predict the likelihood of power interruptions in certain emergency situations and plan for that contingency.
“We should have purchased portable generators” is both predictable and controllable. Has your facility acknowledged the potential for loss of power, identified and prioritized its potential impact, constructed a plan to address it, and taken the steps to make sure the facility has the needed supplies to enact the plan?
Maybe 3-time Indianapolis 500 winner Bobby Unser said it better than Seneca.
“Success is what happens when preparations meet opportunity.”
The SNF business is a people business. Operations encompass providing for the care and well-being of the residents. The Emergency Plan should define success as the optimal outcome for continuity of operations in the crisis or disaster event as the circumstances unfold. From this, one must plan for success.
Harmony Healthcare International (HHI) is hosting our 9th Annual Post-Acute and Long Term Care (PALTC) Interdisciplinary Symposium on Thursday, October 21st, 2021, and Friday, October 22nd, 2021 at the Encore Boston Harbor resort and casino.