New DOH Emergency Regulations Include Mandatory Hospital Surge and Flex Response Plan

August 7, 2020

The New York State Department of Health (DOH) has released emergency regulations that describe authorities given to the DOH Commissioner during a declared disaster as part of a four-part Surge and Flex Health Coordination System. Under such a declaration, hospitals will be required to adopt a detailed emergency Surge and Flex Response Plan. The regulations are effective immediately, with certain aspects becoming operative in the event of a State Disaster Emergency Declaration. The required elements of a hospital’s plan are summarized below.

While GNYHA believes that our member hospitals and health systems can document that they are already meeting many of the Surge and Flex Response Plan’s requirements, we will seek clarity on several aspects of these regulations. Please carefully review them and reach out with any questions.

Requirement to Have and Regularly Update a Surge and Flex Response Plan

The regulations require all hospitals to have a Surge and Flex Response Plan that includes the following:

  • A bed surge plan that describes how the facility will increase staffed and operational bed capacity to a number set by the DOH Commissioner, up to a 50% increase within seven days from the emergency declaration and up to a 100% increase within 30 days
  • A personal protective equipment (PPE) surge plan that describes how the facility will increase its PPE supply for appropriate use in a pandemic and maintain the required 90-day supply within 30 days, based on a usage rate determined by the DOH Commissioner
  • A mass casualty plan that describes how the facility will receive and treat mass casualty victims from a secondary event, while addressing the continued need for surge capacity for the underlying State disaster declaration
  • A staffing plan that describes how the facility will identify and train backups for employees who may be unable to work
  • A capital plan that describes how the facility will ensure continuous operation of facilities and access to utilities, materials, electronic devices, equipment, vehicles, and communication systems

The regulations do not require hospitals to submit the plan. Instead, hospital chief executive officers must certify that they have reviewed and approved the plan, and that it is achievable. The regulations further stipulate that the plan should be reviewed and updated every six months, rehearsed twice a year, and that involved personnel must be appropriately trained. The regulations also discuss data collection requirements, including many metrics that are currently reported daily to HERDS, and provisions related to clinical laboratories.

Hospital Compliance

All hospitals already maintain emergency response plans, including surge plans for infectious disease outbreaks, mass casualty events, and other events that could cause an influx of patients, and comply with existing CMS Emergency Preparedness rules. In the wake of the COVID-19 patient surge earlier this year, facilities have been modifying and updating these plans based on innovations and lessons learned. Consequently, the requirement to have a Surge and Flex Response Plan can likely be met by combining and connecting existing documentation.

GNYHA Work with Members and Surge Planning Resources

Based on our work with members during the COVID-19 surge, GNYHA has developed the below resources that can be used as you develop your Surge and Flex Plans. GNYHA staff have also been conducting interviews with members on the management of the COVID-19 patient surge and modifications to future plans. Notes from these conversations can be shared with your facility if helpful to this effort.