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Achieving Regulatory Compliance by Preparing for Crisis Response: A Workshop for Healthcare Leaders and their Emergency Managers

Hospitals, Skilled Nursing, Assisted Living, Home Health, ESRD and other facilities regulated by CMS appendix Z are some of the most heavily regulated disciplines in the United States. As healthcare leaders find themselves engaged in numerous surveys and certification processes throughout each year. This tends to shift the focus of healthcare leaders on preparing for survey, rather than on the preparedness for actual disasters. As a result, healthcare emergency managers face a regular challenge of finding a balance between survey readiness, and crisis response. In this workshop, we will use a series of presentations and corresponding interactive sessions to provide healthcare leaders and emergency managers the tools necessary to achieve a high level of survey readiness while creating comprehensive preparedness programs that are disaster ready. Live comparisons between survey and real-life scenarios will result in a greater understanding of how real-life events shape regulatory requirements.

Workshop Takeaways

1 – Understanding the World of Emergency Management Regulatory Standards
2 – Modification of Incident Command in the Healthcare Setting
2 – Facing the Real World, What Survey Doesn’t Prepare You For
3 – Fitting the Pieces Together
4 – Game Day: Creative Crisis Response Techniques for Healthcare Commanders

Agenda

  1. Regulatory standards for LTC preparedness and response

  2. Defining your EM committee

  3. The Emergency Preparedness Plan

    1. Risk assessments

    2. Plan components

      1. Base plan

      2. Functional annexes

      3. Incident specific appendices

  4. NIMS and Incident Command

    1. Modifications for Hospitals and Health Systems

    2. Modifications for LTC and smaller facilities

  5. Critical factors in crisis decision making

    1. The principles of crisis decision making

    2. Critical questions for decision makers

  6. Implementing a 120-hour rule for incoming weather and other events

  7. Plan maintenance.

    1. Annual CEMP / Plan review

    2. Testing your plans

  8. Training and exercise plans

  9. Types of exercises

  10. After action plans and corrective actions

    1. Real events matter

  11. Decontamination and Evacuation; the missing critical elements

  12. Putting it all together

ABOUT THE PRESENTERS:

Greg Santa Maria, DHSc, MA, NR-P, is the Executive Director of the South Dakota Health Care Coalition (SDHCC). In his role, he has oversight of the coalition ASPR HPP grant and works with four coalition chapters to enhance healthcare preparedness and response, protecting the residents of South Dakota. He has transitioned the SDHCC into one of the first healthcare coalitions with an Area Command, providing operational support to facilities during disasters. A visionary, Dr. Santa Maria speaks frequently at national conferences on innovative concepts in healthcare disaster management. 

In his previous role as Director of Public Safety at Sanford Health in Sioux Falls, he managed enterprise safety, security, and emergency management functions for 44 hospitals and more than 200 senior care locations in 26 states and nine countries. In that role, he coordinated responses to Ebola, H1N1, and multiple mass gathering events. In 2019, in response to Hurricane Dorian, he led an incident management initiative in Kissimmee, Florida, that resulted in the safe evacuation of 240 skilled nursing and assisted living residents from several facilities and then transitioned his organization to support a massive response to Coronavirus. Using his expertise in academic disaster research, he implemented an evidence-based emergency management program, creating an ESF-based corporate response plan that functioned successfully during several actual incidents and is now organizational practice.  

From 1996 to 2004, Dr. Santa Maria previously served as the program director for the Saint Vincents Hospital Paramedic Program in lower Manhattan, where he led the Saint Vincent’s Hospital Disaster and Terrorism Preparedness initiative. In 2002, he received a distinguished service award for his participation in the response to the terrorist attacks on the World Trade Center on September 11, 2001. He is a former paramedic representative to the NYC Regional Emergency Medical Advisory Committee, and he currently serves as a non-physician subject matter expert for the American Academy of Disaster Medicine.  

In his academic research, Dr. Santa Maria studied numerous large-scale international mass casualty incidents. Finding similar decision-making errors in each event, Dr. Santa Maria went on to create an awareness program for first responders in decision-making positions. This program assists responders in better understanding the dissociative effects of stress and the impact of amygdala hijack on decision-making in stressful situations. Dr. Santa Maria also studied the socioeconomic impacts of disasters and is working on a project enhancing disaster resilience among underserved and vulnerable populations.  

Dr. Santa Maria holds a master’s degree in emergency and disaster management and a doctorate in health science focused on global health and politics. He also proudly remains a Nationally Registered- Paramedic, an honor he has been proud of for 32 years. In his spare time, he plays guitar and writes songs for his German Shepherd Dog Brutus.

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Maria Griffin is a licensed nursing home administrator working with Harborview Health Systems as an Executive Director at their West Altamonte nursing facility. She has been in the long-term care field for over 20 years and an administrator for the last 14. Maria was a key decision maker in the command center for the Good Samaritan Society Kissimmee Village evacuation during Hurricane Dorian, where over 240 residents were safely relocated from a major flood threat. Maria participated in the after-action work from that event which enhanced response operations at the location. For the past 3 years, her focus has been assisting problem facilities to regain survey or financial stability working independently as a consultant. She currently serves as part of the Florida Health Care Association Emergency Management Committee and Regulatory Committee and continues actively working to enhance preparedness and response plans at her facilities. She has a master's degree in health administration, is a certified preceptor for administrators, and is a certified trainer with the John Maxwell Team. She is a mother of 2 boys Gabriel and Lucas, 2 dogs and a cat, and currently lives in Orlando, FL

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