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

On September 8, 2016 the Centers for Medicare and Medicaid released information regarding the final CMS Emergency Preparedness Rule for facilities receiving CMS funding.  This long awaited and much debated new standard is meant to ensure a safer patient experience while supporting communities in the provision of healthcare during emergencies and disasters.  As a result, healthcare facility leaders have until November 16, 2017 to update their plans, policies, and procedures to meet the stringent new regulations.

Deadline for Implementation








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

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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ASCs and the CMS Emergency Preparedness Rule

When CMS finalized the Emergency Preparedness Rule last fall they raised the emergency preparedness bar considerably for Ambulatory Surgery Centers (ASC).  Like all of the 17 affected providers, ASCs must comply with the major components of the rule: Comprehensive...

read more

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