Emergency Preparedness: 

Oops! I Got Caught with my Pants Down
Sandra Nommensen, BSN, RN, Clinical Manger
Fresenius Kidney Care, Janesville
Disclosures
I have no disclosures to report. 
Objective
Review state regulations, preparations for 
certification, and dealing with citations.
Current Challenge
• Staff unsure what State is looking for.
• Unsure of new regulations
• Staff following old procedures
What is Emergency Preparedness
A Defined Plan
• A cycle that includes planning and organizing actions that reduce the 
harmful effects of potential hazardous situations, thus preventing or 
reducing the risk of injury to patients and staff and preserving 
continuity of care
 Protocol
• Create emergency plan and review annually
• Review any state survey recommendations
• Natural disasters
• Man‐made disasters
• Facility‐based disasters
• Complete staff training and drills 

“Preparing for Emergencies: A Guide for People on dialysis, 2004.”  CMS Publication No. 10150
Personal Account – What not to do
• Personal account of being ill prepared for all the new 
regulations
• Content of citations
• What the federal agencies looked at it
Etags
• E0004
• Emergency Plan (with all‐hazards risk assessment)
• Developed and updated annually

CMS website: “State Operations Manual: Appendix Z-Emergency Preparedness for All Provider and Certified Supplier Types Interpretive
Guidance, Table of contents (Rev., 169, Issued 06-09-2017)
Etags
• E0006 Plan
• Based on risk assessments
• Using all‐hazards approach

CMS website: “State Operations Manual: Appendix Z-Emergency Preparedness for All Provider and Certified Supplier Types Interpretive
Guidance, Table of contents (Rev., 169, Issued 06-09-2017)
Etags
• E0029
• Development of emergency communication plan
• Review and update annually

CMS website: “State Operations Manual: Appendix Z-Emergency Preparedness for All Provider and Certified Supplier Types Interpretive
Guidance, Table of contents (Rev., 169, Issued 06-09-2017)
Patient Perspective
• What to do for patients
• What to hand out to them
• What to have available in the unit for patients
Questions