MDH Reviews Emergency Preparedness Expectations for Assisted Living Facilities: Appendix Z

Posted on April 7, 2022 by Bobbie Guidry

In a series of weekly webinars over the past several weeks, the Minnesota Department of Health (MDH) provided detailed information about emergency preparedness expectations for assisted living settings and what to anticipate when surveyed. You can review the five emergency preparedness presentations on the MDH website.

Some providers have asked what MDH is looking for when they ask about the 1135 waiver response. According to MDH, policies and procedures must address the role of the facility under a waiver declared by the secretary or the president. Assisted living settings must develop and implement policies and procedures that describe its role in providing care at alternate care sites during emergencies. Considerations may include:

• Resident population
• Supplies/equipment
• Staffing
• Physical environment

Policies and procedures should address potential transfers of residents and timelines of residents at alternate facilities.

MDH is looking to verify if the facility has included policies and procedures in its emergency plan describing how care and treatment would be provided at an alternate care site if needed due to a disaster or emergency declaration.

In last week's webinar, MDH shared that in assessing compliance for emergency preparedness, surveyors may request the following:

• A list of the licensee’s contact information to confirm that all required contacts are included in the communication plan
• Evidence that the licensee reviews and updates all contact information at least annually
• A list of the resource contact information to confirm that all required resource contacts are included in the licensee's communication plan - including the Office of the State Long-Term Care Ombudsman
• To review the licensee's communication plan to verify the inclusion of primary and alternate means for communicating with the licensee's staff, Federal, state, tribal, regional, and local emergency management agencies
• To see any communications equipment or communication systems the licensee listed in their communication plan
• Leadership to describe how they ensure contact information remains current
• To review the communication plan to verify the licensee developed policies and procedures to address the methods it will use to release patient information, including the general condition and location of patients
• To review the licensee's communication plan to verify it includes a means of providing information about the licensee's occupancy, needs, and ability to provide assistance during an emergency to the authority having jurisdiction, the Incident Command Center, or designee
• For staff to demonstrate how the licensee shares emergency plan information with residents, their families or representatives
• To Interview residents and families/representatives and ask if the licensee provided information regarding the emergency plan
• To review the communication plan to verify the inclusion of a method for sharing information the licensee deems appropriate from the emergency plan

Additionally, the survey form related to emergency preparedness and more survey tools that you can use for survey preparation and self-audits can be found on the MDH website: Assisted Living Forms and Self-Audit Tools.