Home Health Emergency Preparedness Plan Requirements: The Four Required Pieces, the Two-Year Review, and What Surveyors Ask For

An administrator who has a survey date, or a storm on the forecast, usually asks the same thing. What does the rule actually make us have on paper? The answer is in one regulation, 42 CFR 484.102, the home health condition of participation for emergency preparedness. It has four required pieces, a review cycle, and a few items written only for home health.

This page walks through the text, then through what surveyors are told to check. Every quotation is from 42 CFR 484.102 as published on Cornell LII, from the CMS State Operations Manual Appendix Z (Rev. 204, issued 04-16-21), or from the 2019 final rule, unless another source is named. Your state and county may add requirements on top. The regulation says so itself: the agency "must comply with all applicable Federal, State, and local emergency preparedness requirements."

The Four Pieces at a Glance

The surveyor's tags in Appendix Z follow the same paragraphs.

Paragraph (e) applies only to an agency in a system of separately certified facilities that elects a unified program.

The Review Cycle

Each of the four pieces carries its own review sentence. The plan "must be reviewed, and updated at least every 2 years." The policies and procedures "must be reviewed and updated at least every 2 years." The communication plan "must be reviewed and updated at least every 2 years." The training and testing program "must be reviewed and updated at least every 2 years."

That is a change. The 2019 burden reduction final rule (84 FR 51732, published September 30, 2019) says: "We proposed to change the requirement for facilities to review their emergency preparedness program at least every 2 years. This would increase the facility's flexibility to review their programs as they determine best fits their needs." The same rule describes the old requirement this way: providers "are required to review their emergency preparedness program annually." The 2019 rule kept the annual review only for long-term care facilities. Home health agencies got the two-year interval (amendment at 84 FR 51825).

Older checklists and templates may still say "annual review." That was true before the 2019 rule. Exercises have their own clock, covered below.

Piece One: The Emergency Plan

Paragraph (a) lists what the plan "must do." In the regulation's words, it must:

"Be based on and include a documented, facility-based and community-based risk assessment, utilizing an all-hazards approach."

It must "include strategies for addressing emergency events identified by the risk assessment," and "address patient population, including, but not limited to, the type of services the HHA has the ability to provide in an emergency; and continuity of operations, including delegations of authority and succession plans." The last item is "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."

The policies, the communication plan and the testing program are each required to be "based on" the risk assessment. It is where the agency says which hazards are its own.

Piece Two: Policies and Procedures

Paragraph (b) names five topics the policies must address "at a minimum." Three are written around home health patients.

Each patient has a plan. Section 484.102(b)(1): "Individual plans for each patient must be included as part of the comprehensive patient assessment, which must be conducted according to the provisions at § 484.55." Appendix Z says "The individualized emergency plan should be in writing and could be as simple as a detailed emergency card to be kept with the patient," with a copy kept "in the patient's file" and given to the patient or caregiver. The survey procedure is direct: "Through record review, verify that each patient has an individualized emergency plan documented as part of the patient's comprehensive assessment."

Evacuation reporting. Section 484.102(b)(2) requires "the procedures to inform State and local emergency preparedness officials about HHA patients in need of evacuation from their residences at any time due to an emergency situation based on the patient's medical and psychiatric condition and home environment." Appendix Z lists what officials may need to be told, including "whether or not the patient is mobile," what life-saving equipment the patient requires, and whether it "is able to be transported."

Follow-up on staff and patients. Section 484.102(b)(3) requires "the procedures to follow up with on-duty staff and patients to determine services that are needed, in the event that there is an interruption in services during or due to an emergency. The HHA must inform State and local officials of any on-duty staff or patients that they are unable to contact." The surveyor is told to "ask the HHA to describe the mechanism to inform State and local officials of any on-duty staff or patients that they are unable to contact."

The other two topics are (b)(4), "a system of medical documentation that preserves patient information," and (b)(5), "the use of volunteers in an emergency or other emergency staffing strategies."

The (b)(1) check is a record review, so a plan that lives only in a binder at the office does not satisfy it. If an emergency interrupts care and the patient comes back from a hospital stay, the next assessment is covered in resumption of care.

Piece Three: The Communication Plan

Paragraph (c) is a list of contents. The plan must include names and contact information for staff, "entities providing services under arrangement," "patients' physicians," and volunteers. It must include contact information for "Federal, State, tribal, regional, or local emergency preparedness staff" and "other sources of assistance." Then four more items, quoted in full:

• "Primary and alternate means for communicating with the HHA's staff, Federal, State, tribal, regional, and local emergency management agencies."
• "A method for sharing information and medical documentation for patients under the HHA's care, as necessary, with other health care providers to maintain the continuity of care."
• "A means of providing information about the general condition and location of patients under the facility's care as permitted under 45 CFR 164.510(b)(4)."
• "A means of providing information about the HHA's needs, and its ability to provide assistance, to the authority having jurisdiction, the Incident Command Center, or designee."

Appendix Z adds for home health: "contact information should also include patient's physicians or allowed practitioners." The HIPAA reference in (c)(5) is the same disclosure rule covered in HIPAA compliance for home health agencies.

Piece Four: Training and Testing

Training, under (d)(1), means "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"; training "at least every 2 years"; documentation of the training; a way to "demonstrate staff knowledge of emergency procedures"; and new training if the policies "are significantly updated."

Testing, under (d)(2), starts with one sentence: "The HHA must conduct exercises to test the emergency plan at least annually." Then it says what counts. The first exercise: "Participate in a full-scale exercise that is community-based." When that is not possible, the regulation allows a substitute, and it is worded awkwardly in the published text: "When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise every 2 years." The second exercise: "Conduct an additional exercise every 2 years, opposite the year the full-scale or functional exercise under paragraph (d)(2)(i) of this section is conducted." That one may be a second full-scale or functional exercise, "a mock disaster drill," or "a tabletop exercise or workshop that is led by a facilitator and includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan."

Appendix Z explains how CMS reads this for home health. For outpatient providers including HHAs, "Facilities are required to only conduct one testing exercise on an annual basis, which may be either one community-based full-scale exercise, if available, or an individual facility-based functional exercise. The opposite years (every other year opposite of the full-scale exercises), these providers may choose the testing exercise of their choice."

An actual emergency counts for something: "If the HHA experiences an actual natural or man-made emergency that requires activation of the emergency plan, the HHA is exempt from engaging in its next required full-scale community-based or individual, facility-based functional exercise following the onset of the emergency event." Every drill and event must also be written up. The agency must "analyze the HHA's response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the HHA's emergency plan, as needed." An exercise with no analysis does not satisfy (d)(2)(iii).

What Surveyors Are Told to Check

Appendix Z gives each tag its own survey procedures. The ones for home health agencies read like a record request:

• Patient plans (E-0017): record review for an individualized plan in each comprehensive assessment.
• Evacuation reporting (E-0018) and follow-up (E-0021): "Review the emergency plan to verify it includes procedures to inform State and local emergency preparedness officials about patients in need of evacuation," and ask the agency to describe how it tells officials about staff and patients it cannot reach.
• Contingency for assessments: Appendix Z asks "how will the HHA ensure the appropriate discipline/staff perform the required initial and comprehensive assessments when access to residences may be hindered due to an emergency?" It adds that some plans may request Section 1135(b) waiver flexibility during a declared public health emergency, which "requiring CMS pre-approval prior to use."
• The plan itself (E-0004): "Verify the facility has an emergency preparedness plan by asking to see a copy of the plan," and ask leadership "to identify the hazards ... that were identified in the facility's risk assessment and how the risk assessment was conducted."
• Testing (E-0039): "Ask to see documentation of the exercises," documentation of "the facility's analysis and response and how the facility updated its emergency program based on this analysis," and, if the agency did not join a community exercise, documentation of its "efforts to identify a full-scale community based exercise." Appendix Z recommends keeping "the past 2 cycles" of exercise documentation, "4 years for outpatient providers."

Practice, not rule: when the survey date is close, pull the risk assessment first, because everything depends on it. Then the dated reviews, the exercise records with the written analysis, and a handful of charts to find the individual emergency plan in the comprehensive assessment.

New agencies building from nothing can see the wider setup in how to start a home health agency.

Key Takeaways

• Section 484.102 has four required pieces: the emergency plan with a documented risk assessment, policies and procedures, a communication plan, and training and testing.
• Each piece must be reviewed and updated at least every 2 years. The 2019 final rule changed this from annual, so older templates are out of date.
• Home health has its own items: an individual emergency plan in each comprehensive assessment, procedures to tell officials about patients needing evacuation, and follow-up on staff and patients who cannot be reached.
• Exercises are tested at least annually. Analyze and document every drill, tabletop and real event. An actual emergency exempts the next required full-scale or functional exercise.
• Surveyors check records, not binders. Expect to be asked to show the patient-level plan in the chart.

Frequently asked questions

What are the four required parts of a home health emergency preparedness program?

Section 484.102 requires an emergency plan with a documented risk assessment, policies and procedures, a communication plan, and a training and testing program. Each of the four must be reviewed and updated at least every 2 years.

How often must a home health agency review its emergency plan?

At least every 2 years. That applies to the plan, the policies and procedures, the communication plan, and the training and testing program. A 2019 final rule changed the requirement from an annual review to a review at least every 2 years.

What exercises does a home health agency have to run?

Section 484.102(d)(2) requires exercises to test the emergency plan at least annually. One is a community-based full-scale exercise or, when that is not accessible, a facility-based functional exercise. The additional exercise can be a second full-scale or functional exercise, a mock disaster drill, or a facilitated tabletop exercise. Responses must be analyzed and documented.

Does the agency have to plan for each individual patient?

Yes. Section 484.102(b)(1) says individual plans for each patient must be part of the comprehensive patient assessment. Surveyors verify by record review that each patient has an individualized emergency plan documented in the assessment.

Does an actual disaster count as a test of the plan?

Partly. If the agency experiences an actual natural or man-made emergency that requires activation of the plan, it is exempt from its next required full-scale or functional exercise after the onset of the emergency. The agency still has to analyze its response and keep documentation of the event.

Sources

• 42 CFR 484.102: Condition of participation, emergency preparedness (amended at 84 FR 51825, Sept. 30, 2019). Paragraphs (a) through (e) quoted above.
• CMS, State Operations Manual Appendix Z, Emergency Preparedness for All Provider and Certified Supplier Types, Interpretive Guidance (Rev. 204, issued 04-16-21): tags E-0004 through E-0039 and the variability in testing requirements for outpatient providers.
• Federal Register, Medicare and Medicaid Programs; Regulatory Provisions To Promote Program Efficiency, Transparency, and Burden Reduction, 84 FR 51732 (Sept. 30, 2019): the change in review cycle for emergency preparedness programs.
• Related on this site: how to start a home health agency, HIPAA compliance for home health agencies, resumption of care.