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.
CMS EP Rule
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:
- 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.
- Policies and procedures: Develop and implement policies and procedures based on the plan and risk assessment.
- 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.
- 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
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)
Key timeline elements of the CMS Emergency Preparedness Rule:
- February 20, 2014: Crisis Focus publishes the first article on the proposed CMS Emergency Preparedness Rule in the IAEM Bulletin.
- September 8, 2016: CMS Announces Final Emergency Preparedness Rule
- September 16, 2016: Emergency Preparedness Rule Published
- September 16, 2016: Conditions of Participation Published in eCFR
- September 23, 2016: Crisis Focus hosts an introductory Webinar for the Healthcare Industry on the Emergency Preparedness Rule
- Spring 2017: Interpretive Guidelines to be Published
- November 16, 2017: Full Compliance Required by 17 Provider Types
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...
read moreDid Harvey and Irma actually test the CMS Emergency Preparedness Rule?
The impact of record hurricanes Harvey and Irma have generated a lot of focus on emergency preparedness in healthcare. There have been countless articles whether it be by Becker’s Hospital Review, local media sources, KHN, or the recent article by Sheri Fink and Neil...
read moreA 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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