Gerry Blass (gerry@complyassistant.com) is President and CEO at ComplyAssistant in Iselin, New Jersey. Dana Penny (dpenny@jewishhome.org) is Chief Compliance Officer at The New Jewish Home in New York, NY.
In the wake of COVID-19, healthcare organizations have seen an uptick in spot or surprise audits by their state departments of health (DOHs) for emergency preparedness plans with a specific focus on pandemic response. Similar to other Centers for Medicare & Medicaid Services (CMS) mandates for emergency preparedness,[1] every response is local, and health departments must handle many different emergencies, including expected, unexpected, and unimaginable threats. Collaboration between DOHs and healthcare providers is crucial during these times. Hence, state and local health departments’ current urgency is to ensure their regional healthcare providers are fully prepared for spot or surprise audits.
Is your organization ready in case that occurs? In this article, we cover steps your organization can and should take today to prepare in the event of a spot audit by your state’s DOH, beginning with how to build and publish an official pandemic response plan.
Change management and pandemic response
Following guidance from the Centers for Disease Control and Prevention (CDC),[2] many state health departments now require providers to develop an official pandemic response plan and publish it on their websites. The posted plan must include provisions for staffing, infection control, and enhanced communications and should answer a variety of questions, such as:
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How will you enable communications between patients and their families?
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If medical staff are in quarantine due to exposure, do they have the means to telecommute to conduct patient care?
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What training and communications processes are in place for staff, patients, and families?
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What infection control steps were taken? How do you plan to limit staff interaction? How will you minimize contamination between units?
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How will you ensure providers have easy access to patient records?
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What is your process for staying updated with recommendations from state and local health departments?
U.S. Department of Health & Human Services is currently focused on evaluating emergency preparedness plan (EPP) programs[3] —how well organizations assessed what they needed to do during the pandemic, what processes they followed, and how they will implement EPP practices in case of future incidents. Is the program organized, up to date, and ready to be followed the next time around? Department auditors want to see lessons learned, mitigation measures, and related due diligence through complete, current documentation.
