Emergency Power Requirements & Preparedness Updates...Irma Experience Power Restoration •6.7 million homes and businesses lost power at the height of storm (September 11th) •75%

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Florida Health Care Association Quality Symposium

Emergency Power Requirements & Preparedness Updates

AGENCY FOR HEALTH CARE ADMINISTRATION

MOLLY MCKINSTRY, DEPUTY SECRETARY, HEALTH QUALITY ASSURANCE

KIM SMOAK, CHIEF OF FIELD OPERATIONS

APRIL 4, 2018

Partnerships

Strong and Effective Partnerships are

Critical to Emergency Preparedness

and Response

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Irma Experience Power Restoration

• 6.7 million homes and businesses lost power at

the height of storm (September 11th)

• 75% restored by September 15th (1.5

million)

• Logistics – generators and fuel

• Post-impact evacuation

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Health Care Facility Reported Impact

• Power Outage

• 350 Nursing Homes (683 licensed)

• 1,677 Assisted Living Facilities (3,109)

• 2,029 Total Facilities

• Evacuations

• 88 Nursing Homes

• 635 Assisted Living Facilities

• 862 Total Facilities

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Long Term Care Impact

• Half of Long Term Care Providers had No Power in

Excess of 2 Days

• 90 Long Term Care Providers Returned Post-

evacuation Before Full Power was Restored

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Emergency Power RulesRefer to Rules for Requirements

• Nursing Homes

• AHCA Rule 59A-4.1265

• HB 7099

http://ahca.myflorida.com/MCHQ/Health_Facility_Regulation/Long_Term_Care/d

ocs/Nursing_Homes/59A-

4.1265_EmergencyEnvironmentalControlFoNNursingHomes.pdf

• Assisted Living Facilities

• DOEA Rule 58A-5.036

• SB 7028

http://ahca.myflorida.com/MCHQ/Health_Facility_Regulation/Assisted_Living/do

cs/alf/58A-5.036EmergencyEnvironmentalControlForAssistedLivingFacilities.pdf

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http://ahca.myflorida.com/MCHQ/Health_Facility_Regulation/Long_Term_Care/docs/Nursing_Homes/59A-4.1265_EmergencyEnvironmentalControlFoNNursingHomes.pdf

http://ahca.myflorida.com/MCHQ/Health_Facility_Regulation/Assisted_Living/docs/alf/58A-5.036EmergencyEnvironmentalControlForAssistedLivingFacilities.pdf

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Emergency Power Rules: Time Line

Final Rules Ratified by the Legislature via Legislative Bills

March 26, 2018 Rules Effective Upon Governor

Scott’s Signature of Bills

April 25, 2018 Emergency Power Plans Due 30

Days after Effective Date of Rules

June 1, 2018 Emergency Power Plans

Implemented

January 1, 2019 Implementation Extension

Under Certain Conditions

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Emergency Power Rule Requirements

• Emergency power plan is part of the Comprehensive Emergency

Management Plans (CEMPs)

• Emergency power source maintained at the facility

• Must support internal temperatures of 81 degrees or less

• Safe temperatures at all times for residents

• Nursing homes - no less than 30 square feet per resident

• ALF – no less than 20 square feet per resident, may use 80% of

licensed capacity to calculate, resident choice/ facility monitors

• Facilities on same campus may share resources

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Emergency Power Fuel Nursing Homes

• Support internal temperatures for 96 hours

• 72 hours onsite fuel or piped gas

• Bring additional 24 hours of fuel onsite (to achieve 96

hours) upon declaration of an emergency

• If fuel storage is restricted by regulations and piped gas

is not available, must replenish 24 hours prior to

depletion

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Emergency Power Fuel Assisted Living Facilities

• Support internal temperatures for 96 hours

• 72 hours onsite fuel or piped gas for 17+ beds

• 48 hours onsite fuel or piped gas for 16 or less beds

• Bring additional fuel onsite (to achieve 96 hours) upon

declaration of an emergency

• If fuel storage is restricted by regulations, must replenish

24 hours prior to depletion

• Carbon monoxide detectors are required

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Nursing Home Deadlines

• Implement plans by June 1, 2018

• Extend until January 1, 2019 for certain delays

• Must still arrange for safe temperatures

• Have an alternative power source onsite or contract

for delivery within 24 hours of state of emergency

• May evacuate if in an evacuation zone

• Does not supersede evacuation orders

• Additional extensions by Rule Variance

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Nursing Home Review Process

• AHCA Office of Plans and Construction reviews nursing home mechanical plans

• Local Emergency Management Agencies review EPP for compliance – notify AHCA

• Facility must correct deficiencies in 10 days

• Facility notifies residents – submission/approval

• Facility provides AHCA consumer friendly summary

• AHCA posts summaries online

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OPC Generator Project Checklist

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http://ahca.myflorida.com/MCHQ/Health_Facility_Regulation/Long_Term_Care/Index_LTCU.shtml

http://ahca.myflorida.com/MCHQ/Health_Facility_Regulation/Long_Term_Care/Index_LTCU.shtml

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Assisted Living Facility Deadlines

• Implement plans by June 1, 2018

• Extend until January 1, 2019 for certain delays

• Must still arrange for safe temperatures

• Have an alternative power source onsite or

contract for delivery within 24 hours of state of

emergency

• May evacuate if in an evacuation zone

• Does not supersede evacuation orders

• Additional extensions by Rule Variance

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Assisted Living Facility Review Process

• Local Authority Having Jurisdiction reviews ALF

building/mechanical plans

• Local Emergency Management Agencies review

EPP for compliance – notify AHCA• Facility must correct deficiencies in 10 days

• Facility notifies residents–submission/approval

• Facility provides AHCA consumer friendly

summary

• AHCA posts summaries online

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Next Steps

• Local Emergency Management Coordination

• Local Collaboration to Address Preparedness

Concerns

• Facilities’ Comprehensive Emergency Management

Plan Status

• Improve Self-Sufficiency

• Greater Collaboration with Local Emergency

Management during Emergencies

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Comprehensive Emergency Management Plans

• CEMP Rules being revised for all AHCA Programs

• Align where possible with Federal Requirements

• Previous workshop comments will be considered

• Provide input on areas where guidance is needed, such as

enforcement

• Unique plans for each provider versus uniformity for

residential/ non-residential

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Facility Hardening

• Facility Hardening and Sustainability

• Support Appropriate Sheltering in Place

• Enable Safe Return after Evacuation

• Implementing Federal Rules for Emergency

Preparedness for Certified Providers

• Applies to nursing homes and other federal

certified providers (not ALFs)

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Blending State Federal Emergency Preparedness

• Federal emergency rules are separate from Comprehensive Emergency

Management Plans (CEMP)

• CEMP is approved by county but remember to have federal plan approved by

the facility’s governing body

• AHCA reviews federal regulations for compliance

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CMS 1135 Waiver Guidance

• The Federal Centers for Medicare and Medicaid Services (CMS) may

waive of certain federal regulations during an emergency through

CMS 1135 Waiver

• Requests for waivers are made through the State Survey Agency –

AHCA Division of Health Quality Assurance

• Facility policies and procedures must address 1135 Waivers

• The role of the facility under a waiver declared by the Secretary, in

accordance with section 1135 of the Act, in the provision of care and

treatment at an alternate care site identified by emergency

management officials.

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CMS 1135 Waiver Guidance

• The facility must demonstrate:

• Awareness of the 1135 process

• Steps required in the event of a CMS 1135 Waiver

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Emergency Preparedness Survey Observations

• In communities with different facility types - CEMP and fire plans cannot be combined because different care requirements exist for each type of facility (ALF versus SNF)

• Facilities must have an interim plan if the generator is not onsite (E0015)

• Multistory facilities must have plans for both vertical and full evacuation

• Policy required for electrical testing of patient care equipment

• Policy required for cool zones - indicate number of people that can be maintained

• Must documented succession to all key leadership roles

• Date all materials (policies, procedures, plans)

• Testing and training section should reference training after the After Action Report (AAR)

• Policies and plan should be revised based on the AAR

• If administrators cannot find the requested documents during survey, please let the survey team know so the survey can proceed

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Emergency PreparednessSurveyor Guidance

• Nursing homes with no federal preparedness plan will be cited for E-

0001 tag.

• Surveyors monitor for compliance with required elements.

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Emergency Status System

• Florida Health Stat Rewrite

• Emergency Status System (ESS)

• Phased Releases May, 2018 – July, 2018

• Provider/ AHCA/ DOH and Partner

Enrollment

• Targeted Training

• Real-Time Provider Updates

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Emergency Status System

• Facility Information (address, beds, special

programs)

• Contact Staff Names / Phones

• Resident/Patient Characteristics

• Generator Details / Status

• Impact/ Damage

• Needs – General

• Contact Made – Calls/ Visits

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AHCA.myflorida.comFloridaHealthFinder.gov

Laura MacLafferty, ECO Kim SmoakHealth Facility Regulation Chief Field Operations Chief

Scott WaltzPlans and Construction Chief

Nursing Homes: Assisted Living Facilities:Bernard Hudson Keisha WoodsManager Long Term Care Unit Manager Assisted Living Unit

[email protected][email protected]

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Emergency Regulations

Karen Goldsmith

Goldsmith & Grout, P.A.

P.O. Box 2011

Winter Park, Fl 32920

[email protected]

cellphone: 407.312.4938

mailto:[email protected]

Comparison federal to state for nursing homes:

Fed Requirements:

• E 0001 Establishment of the Emergency Program (EP)

• E 0004 Develop and maintain emergency plan – requires all hazards

approach

• E 0006 Maintain and update regularly – aside from the requirements in

the new regulation if the regulation requires some change because

of the uniqueness of your facility must make change

• E 0007 Facility’s population must be considered

• Persons at risk

• Unique vulnerabilities

• Type of services offered

• Continuity of operations

• E 0009 Must take into account collaboration with local, state and federal

officials during a disaster

• E 0013 Policies and Procedures – rule will change some of them and you

may need temporary changes to others

• E 0015 Subsistence for residents and staff including food, water, medial

and pharmaceutical supplies; temperatures; alternate sources of

energy

• E 0015 continued:

• Refers to E 0041 for long term care facilities:

• Required to base emergency power and stand-by systems on emergency plan,

risk assessment, and policies and procedures

• These will be different when all is completed and you are on generator power

during an emergency and what you are going to do during implementation

• State law superseded the provisions of this regulation which permit provider to

determine level of generator support as those standards are set out in the new

regulation

• For more information go to NFPA

• E 0041 continued

• Does contain some of the same language as the rule as to not requiring full

facility temperature control but state rule requires min. 30 feet per resident

• NFPA 110 contains certain requirements that are not in the regulation

• Requires routine maintenance and testing under NFPA 110

• Permits fuel sources as gas, diesel, propane and natural gas

• Must have fuel sufficient to maintain generator operations as determined

necessary or could include fuel delivery in an emergency

• Must consider what would prohibit delivery in an emergency

• E 0041 continued

• Note difference between federal rule and state rule on fuel:

• State: the acquisition of sufficient fuel and safe maintenance of that fuel on-site at the

facility for 96 hours of life safety systems, critical systems and temperature control:

• 72 hours must be stored on-site

• Piped natural gas is ok and meets this requirement

• Local ordinance may allow maintenance of less must maintain on the premises

the maximum allowed and a reliable method of replenishing at least 24 hours

before you run out

• Federal seems to have a little more flexibility however

• Has a provision that in areas where natural gas has a high probability of being

interrupted that the facility maintains sufficient fuel on the premises

Other federal emergency tags applicable to nursing homes:

• E 0018 Procedures for tracking staff and residents

• E 0020 Policies and procedures, including evacuation

• E 0022 Sheltering policies and procedures

-- If you are the shelter, will you be able to handle those you are

sheltering?

-- If you are sheltering elsewhere, do they?

• E 0023 Medical docs

• E 0024 Volunteers

• E 0025 Arrangements with other facilities

• Prearranged transfer agreements

• What is their circumstance

• Are they within an area where you could shelter

• E 0026 Roles under a Waiver

• E 0029 Communication Plan

• E 0030 Contact information

• E 0031 Contact information of governmental authorities

• E 0032 Communication – primary and alternate means

• E 0033 Methods of sharing information

• E 0034 Sharing information on occupancy needs

• E 0035 Family notification

• E 0036 Training and Testing

• E 0037 Training Program

• E 0039 Testing (exercises)

• E 0041 Emergency power -- see slides above

• E 0042 Integrated health systems

SEEKING AN EXTENSION

Preparation:

• Must meet deadlines in regulations

• Regulation effective March 26, 2018 so all

• Get your ducks in a row

• Do a timeline on what you have done

• Prepare a timeline on what is left to be done

• Make both of these realistic

• Odds are down the road you are going to also need an extension so prepare as if

that is a foregone conclusion

• Most attorneys have a checklist of what information should be gathered

• We are preparing the requests for an extension with this is mind

How to get an extension:

• Request must show:

• Delay in necessary construction

• Delay in delivery of ordered materials

• Zoning or Regulatory approval processes

• Must also show that “during the extension period, a nursing home must make

arrangements pending full implementation of its plan that the residents are

housed in an area that meets the safe indoor air temperature requirements of

[this rule] for a minimum of 96 hours

• If not located in an evacuation zone must have either an alternative power source

onsite or a contract in place to have source and fuel delivered when requests

• Within 24 hours of issuance of state of emergency for certain events must have power

source and 96 hours of fuel delivered

• If in an evacuation zone as defined by 252, F.S. must either:

Fully evacuate

Or meet the requirements in the previous slide

• Extension expires January 1, 2019

• Must report progress monthly to AHCA

Variances:

• If need time beyond January 1, 2019 must seek a variance

• Permitted under F.S. 120.542

• System we used when emergency rule came out

• Must show that person subject to the rule:

• Can comply otherwise with the intent of the rule – not likely here (waiver)

• Have achieved intent by some alternative means – also not likely (waiver)

• Application of the rule would create a substantial hardship or would violate

principles of fairness

• Substantial hardship:

• Demonstrated economic, technological or other type of hardship

• Principles of fairness:

• “Literal application of a rule affects a particular person in a manner significantly

different from the way if affects other similarly situated persons….”

• These can be time-limited

• These can be conditioned as we saw on the variances for the emergency rule

SENIOR CARE FACILITY

GENERATOR LOGISTICS

Procurement & Installation Process

04/05/2018

STEP 1Engineering & Design

3 Weeks

STEP 2Pricing & Procurement

3 Weeks

STEP 3Order & Delivery/Permitting

24 Weeks

STEP 4Construction & Installation

8 Weeks

STEP 5Commissioning

TIMELINE FOR A CUSTOM SYSTEM

38 WEEK PROCESS

$

LOGISTICAL CHALLENGES

• Design Of The System - What Is Included On

Emergency Power



Emergency Power

• Retrofit & Special Allocation In The Electric Room


Emergency Power


• Fitting The Generator On The Site



Emergency Power



• Primary Wiring & Conduits From The Electric Room

To The Generator

✓ Add A Minimum Of Two Automatic Transfer

Switches & Two Electrical Distribution Panels

✓ Code Requires A Separate Two-Hour Rated

Electrical Equipment Room To House Emergency

Power Gear

✓ Run New Feeders From Current Distribution Gear

To New Emergency Power Gear.

✓ There Will Be A Certain Extent Of Necessary

Demolition, Core Drilling, Overhead & Wall

Mounted Electrical, Etc.


BASIC REQUIREMENTS


Emergency Power


• What Is Included On Emergency Power



To The Generator

• Construction Permits & Installation

✓ Agency For Health Care Administration

✓ Building

✓ Zoning

✓ Fire Department

✓ Air & Water (Environmental)

✓ Land Development

✓ Planning Commission/Loss Of Parking

✓ County Commission/Set-Back Requirements

PERMITTING FROM




Emergency Power




To The Generator


• Refuel Agreements

• Generator Procurement

• Construction Logistics – Limited Space, Shutdown Of

System Required During Changeover. Check &

Double Check.

• Commissioning & Maintenance

AS THE PROCESS EXISTS TODAYAS THE PROCESS EXISTS TODAY

8.5 MONTHS8.5 MONTHS

AS THE PROCESS EXISTS TODAY

8.5 MONTHS

NO PROCUREMENT DELAYSNO PROCUREMENT DELAYS

4.5 MONTHS4.5 MONTHS

NO PROCUREMENT DELAYS

4.5 MONTHS

IDEAL, EFFICIENT SCENARIOIDEAL, EFFICIENT SCENARIO

3 MONTHS3 MONTHS

IDEAL, EFFICIENT SCENARIO

3 MONTHS


Emergency Power




To The Generator




• Construction Logistics


✓ Limited Space

✓ Shutdown Of System Required During Changeover

CONSTRUCTION LOGISTICS


Emergency Power


• What Is Included On Emergency Power



To The Generator




• Construction Logistics

• Commissioning & Maintenance

✓ Equipment Compatibility

✓ Facilities Staff Need To Understand Care & Maintenance

✓ Routine Refueling & Oiling

COMMISSIONING & MAINTENANCE


Bedroom Floor

Bedroom Floor

Bedroom Floor

Admin Area

Utility Area

PENTHOUSE MECH

GENERATOR

Electrical Closet Serving Common Areasw/new distribution boards

Common Areas supported by Generator

Bedroom areas not servedBy generator

New 2-hr enclosure for automatic transfer switches

New Distribution boards for Life Safety and Essential Power (AHU’s other generator-backed equipment)

Ex’g Normal Power Room

New feeders to distribution boards

ATS #1: Life Safety

ATS #2: Essential Power (chillers, AHU’s and other equipment)

Reimbursement and Payment

Tom Parker

Florida Health Care Association

Director of Reimbursement

(850)224-3907

[email protected]

Cost to Profession

• There have been multiple projections done to estimate total cost of

the requirement

• Total estimated cost to nursing homes $108 million

• Range from $60,000-$700,000

• Total estimated cost to ALF’s $243 million

• Range from $9,350-$550,000 per facility

• There are a variety of ways centers can acquire financing and other

programs that will help pay for the purchase

Medicaid Reimbursement

• The new Medicaid PPS that takes effect October 1 significantly

increases rates for capital improvement projects such as adding a

generator

• Rate increase driven by size of the facility, age of the building, total

amount of the generator project

• To be counted in rates for October 1 the project will have to be

complete by April 30 and reported to AHCA

Medicaid Reimbursement continued

• Hypothetical Example

• 120 bed nursing home

• 60% Medicaid

• 25 years old

• $200,000 generator

• Rate increase of $0.80 per day

Medicaid Reimbursement continued

• Rate increase of $0.80 per day

• Additional Reimbursement of $19,650 per year

• Medicaid portion paid off in approximately 6 years

• Total cost paid back in approximately 10 years

• About twice as fast as the current system

Tax Package

• The Legislature included a tax break for purchases of any

equipment to generate emergency energy (HB 7087)

• Covers generators purchased from July 1, 2017 through

December 31, 2018

Tax Package

• Exemption is limited to $15,000 in tax ($225,000 generator

cost)

• May be applied at time of purchase or refunded after the

fact

• Department of Revenue will adopt necessary rules to

implement

Power Company Programs

• Several power companies offer programs that involve design,

install, monitor, and maintenance

• Require little to no upfront capital

• 10-15 year leases with buyout provisions at the end of the term

• Power company owns, operates, maintains, and remotely monitors

the system

• Handle permitting, installation, engineering, and environment

issues

Power Company Programs continued

• Automated systems that turn on with seconds of the power outage

• Maintain fuel contracts to provide refueling in the event of an extended

outage

• Often avoid the complex electrical problems associated with buildings

being built over many years

• Several power companies across the state offer this included Duke

Energy and Gulf Power. Others like FPL currently working on something

similiar

PACE Program

• Property Assessed Clean Energy

• Program that is used for financing home and commercial property

improvements

• Administered at the local level, and used for various projects

including protecting against natural disasters

• 100% financing available based on equity in the property and

ability to pay

PACE Program

• The amount financed is added to your property taxes and paid

over time

• Not available state-wide but is available in 85 cities and 10 counties

• Offers competitive interest rates

• 5-20 year terms available based on the project

• Have funded over $20 million in projects in Southeast PACE region

Documents

Emergency Power Requirements & Preparedness Updates...Irma Experience Power Restoration •6.7 million homes and businesses lost power at the height of storm (September 11th) •75%