Emergency Preparedness Requirements from the Centers for Medicare & Medicaid Services (CMS)


In 2016 the Centers for Medicare and Medicaid published the final CMS Emergency Preparedness Rule for facilities receiving CMS funding.  This new standard is meant to ensure a safer patient experience while supporting communities in the provision of healthcare during emergencies.  As a result, healthcare facility leaders had until November 16, 2017 to update their plans, policies, and procedures to meet the stringent new regulations.  Crisis Focus understands the complexity and challenge of planning for these new standards and has an expert team on staff to support your organization through the process.

Key Emergency Preparedness Rule Resources

Background Information

Compliance Requirements, Facility Type Listing, and Timeline Information.


This short article describes the Emergency Preparedness Rule as documented in the Federal Register.

Conditions of Participation

Review this complete list of the 17 Conditions of Participation (CoPs) documents for your review and planning purposes.

Interpretive Guidelines

Interpretive guidelines don’t exist from CMS at this time, however this resource will get you started while you wait for the additional documentation.

Crisis Focus Service Offerings


Program Assessment



Workshop Delivery



Program Development



Training Program Design



Plan Development



Exercise Design



Risk Analysis / HVA



After Action Reporting


What is required:


  1. Emergency plan: Based on a risk assessment, develop an emergency plan using an all-hazards approach focusing on capacities and capabilities that are critical to preparedness for a full spectrum of emergencies or disasters specific to the location of a provider or supplier.
  2. Policies and procedures: Develop and implement policies and procedures based on the plan and risk assessment.
  3. Communication plan: Develop and maintain a communication plan that complies with both Federal and State law. Patient care must be well-coordinated within the facility, across health care providers, and with State and local public health departments and emergency systems.
  4. Training and testing program: Develop and maintain training and testing programs, including initial and annual trainings, and conduct drills and exercises or participate in an actual incident that tests the plan.

Critical Access Hospitals

Long Term Care Facilities

Intermediate Care Facilities

Psychiatric Residential Group Facilities

Rural Health Clinics/ Federally Qualified Health Clinics (RHC/FQHC)

Religious Nonmedical Health Care Institutions (RNHCIs)

Transplant Centers

Hospice Agencies

Ambulatory Surgical Centers

Programs for All-Inclusive Care for the Elderly (PACE)

Home Health Agencies

Comprehensive Outpatient Rehab Facilities (CORF)

Community Mental Health Centers (CMHC)

Organ Procurement Organizations (OPO)

Clinics for Rehabilitation and Therapy

End State Renal Disease “Dialysis Centers” (ESRD)


Conditions of Participation Links can be found here.

Key timeline elements of the CMS Emergency Preparedness Rule:

Recent CMS Crisis Blog Posts

CMS Takeaway: Make the most of Real World Events

When faced with real-world disasters the CMS Emergency Preparedness CoP may be the last thing on your mind, but don’t let it drift too far down the list of priorities.  Real-word events are what the #CMSEPRule is designed to prepare for, so making sure you keep...

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A Primer on Hospital Evacuation

With the dire situation surrounding #Harvey, there are a lot of individuals conversing on social media around the evacuation of hospitals prior to events. Below are my thoughts on an evacuation decision framework, not a proclamation of what should have been done. My...

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