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.
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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
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...
read moreASCs 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 moreTraining, Exercises, and CMS
With the deadline for implementation and compliance with the new CMS Preparedness Rule quickly approaching, many provider types have started seeking additional clarification and guidance regarding the training and exercise requirements. For those not familiar with...
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