Centers for Medicare/Medicaid Services Emergency Preparedness Rule Guidance
The Centers for Medicare and Medicaid Services (CMS) issued the Emergency Preparedness Requirements for Medicare and Medicaid Participating Providers and Suppliers Final Rule to establish consistent emergency preparedness requirements for healthcare providers participating in Medicare and Medicaid, increase patient safety during emergencies, and establish a more coordinated response to natural and human caused disasters.
The rule was published on September 16, 2016 and is effective as of November 15, 2016. The regulations must be implemented by affected entities by November 15, 2017. This rule applies to 17 provider/types as a condition of participation for CMS. The providers/suppliers are required to meet four core elements with specific requirements adjusted based on the individual characteristics of each provider and supplier.
If you are unsure where to begin, the Start Here tab contains a great overview of the CMS Emergency Preparedness Requirements courtesy of the Association of Asian Pacific Community Health Organizations (AAPCHO). Each of the remaining tabs below represents a core requirement and contains resources that may assist you in achieving compliance.
The information provided should not be considered a comprehensive report on CMS regulations, interpretive guidance or compliance. Frederick County is not responsible or liable for any indirect, incidental, consequential, special or exemplary violations of CMS compliance. For specific questions regarding CMS, the emergency preparedness rule or compliance, contact the Centers for Medicare and Medicaid Services.
Affected providers/supplies must develop an emergency plan based on a risk assessment and using an “all-hazards” approach, which will provide an integrated system for emergency planning that focuses on capacities and capabilities.
- ASPR TRACIE Topic Collection: Emergency Operations Plans/ Emergency Management Program This site is maintained by the U.S. Department of Health and Human Services and contains many resources for developing an Emergency Operation Plan.
- Frederick County Hazard Mitigation Plan An "all-hazards" approach to emergency planning is best practice. However, understanding what hazards are most likely to occur in your area can be beneficial and will help with your facility risk assessment.
- Risk Assessment Template Editable Microsoft Excel template courtesy of Kaiser Permanente and the Central Maine Regional Healthcare Coalition.
- The Federal Emergency Management Agency offers free online independent study courses through the Emergency Management Institute. Recommended courses include:
Tip - Plans Versus Procedures
The distinction between plans and procedures can be confusing. One way to determine what is part of an Emergency Operations Plan (EOP) is to ask the question "what does the entire audience of this EOP need to know?". Specific details and instructions for individuals or groups are typically part of the procedures often known as SOPs or Standard Operating Procedures. SOPs can be an annex to the EOP or referenced. For example, an EOP that assigns responsibility for putting out fires to the fire department would not detail what should be done at the scene or what fire equipment is most appropriate. Those details would be part of the fire department's SOP's.
Provider/suppliers are required to develop and implement policies and procedures based on the emergency plan and risk assessment that are reviewed and updated at least annually. For hospitals, Critical Access Hospitals (CAHs), and Long-Term Care (LTC) facilities, the policies and procedures must address the provision of subsistence needs, such as food, water and medical supplies, for staff and residents, whether they evacuate or shelter in place. Policies and procedures are the who, what, where, when, and how that complement your Emergency Operations Plan.
- CMS Emergency Preparedness Rule Toolkits The Wisconsin Department of Health Services developed toolkits that provide facilities that fall under the new rule an overview of the requirements for their provider type, as well as some sample templates that can be used in their planning efforts. In topic areas where there was not a tool or template readily available, the toolkit offers planning worksheets that feature a list of example questions to help facilities think through relevant issues that can help them draft their plans and policies. Toolkits exist for: Ambulatory Surgery Centers; End State Renal Disease Facilities (Dialysis); Intermediate Care Facilities for Individuals with Intellectual Disabilities (ICF/IID); Long Term Care: Skilled Nursing Facilities; Home Health Agencies; Hospices; Hospitals; Rural Health Clinics (RHCs) and Federally Qualified Health Centers (FQHCs); and Clinics, Rehabilitation Agencies, and Public Health Agencies as Providers of Outpatient Physical Therapy and Speech-Language Pathology Services.
Tip - Policy vs Procedure
Policy—Go from Point “A” to Point “B”.
Procedure—Begin at Point “A” go to Point “B” by doing x, then y, then z.
Providers/supplies must develop and maintain an emergency preparedness communication plan that complies with federal, state and local laws. Patient care must be coordinated within the facility, across healthcare providers, and with state and local public health departments and emergency management systems to protect patient health and safety in the event of a disaster. Consider and plan for how and what you will communicate with employees, suppliers, providers, patients, families, and others before, during and after an emergency.
- ASPR TRACIE Technical Resources/ Communications This site is maintained by the U.S. Department of Health and Human Services and contains many resources for developing a Communication Plan.
- Health Care Emergency Communication Plan Central and West Central Minnesota Healthcare Coalitions has created a PowerPoint outlining CMS's requirements for a communication plan including special considerations healthcare facilities must be aware of particularly in regards to HIPAA.
Providers/Suppliers must develop and maintain training and testing programs, including initial training in policies and procedures. Facility staff will have to demonstrate knowledge of emergency procedures and provide training at least annually. Facilities must conduct drills and exercises to test the emergency plan or demonstrate activation of the plan in an actual incident that tests the plan.
Currently, there are no exercises sponsored by the Division of Emergency Management or Health Department to help you meet this requirement. Should one become available, it will be posted here.
The following resources may help you meet the testing and training component of the CMS rule:
- Tabletop Exercise Template This template offers an easy starting point for developing a table-top exercise for your facility. It is intentionally generic, allowing you to customize to meet your needs.
- Safe Evacuation Tabletop Exercise This comprehensive tabletop exercise was developed by the California Association of Health Facilities Disaster Preparedness Program. Remember, you can always add or remove components to meet your facility's needs.
- Who do I contact if I have questions on whether the Preparedness Rule applies to me?
- Does Frederick County require a copy of our facility's emergency plan?
- Where can I find information on community based exercises?
- I am required to coordinate with the local emergency management and health department. Who do I contact?
- What are the CMS requirements for my facility?