Disclaimer: CMS published an advanced copy of the Interpretive Guidelines in early June.  Our analysis and a link can be found here.  The action steps and recommendations in the following blog post still provide solid guidance for providers early in their compliance journey but was published prior to the IG release.

We have been living with the final CMS Emergency Preparedness Rule for a couple of months now and health care providers are getting comfortable with the idea that they are going to have to step up their Healthcare Emergency Management Game.  CMS has rolled out a comprehensive website and supplanted resources from ASP&R TRACIE to help people prepare, but we are waiting on the Interpretive Guidelines.  The Interpretive Guidelines (IG) are documents developed by CMS to instruct the surveyors how to consistently probe and assess for compliance of each CoP or CfC.  Many agencies rely on the IGs to guide and ultimately validate compliance activities.

A lot of the conversation amongst compliance officers within the 17 affected provider types surrounds how to comply when the IGs are not published.  CMS said in the informational call in October it would be in the Spring, and this was confirmed again at the recent National Healthcare Coalition Conference in DC a few weeks ago.

Interim Actions

The question is what do we do in the interim, and the answer is cliché, don’t lose sight of the forest for the trees.  We posted earlier on Where to Start, organizations should be completing their Risk Assessment and moving forward with their planning teams.  If the core tenants of the provider specific CoPs are being addressed then the organization will likely only need to make minor tweaks to its program after the publication of the IGs.  In the meantime a concerted effort around developing a comprehensive emergency plan and focusing on key relationships, such as those with health care coalitions is essential.

Key Areas of Speculation

  • The area for most speculation surrounds the exercise and evaluation section, specifically the definition of a full-scale exercise.  If a provider moves forward with a table top exercise in the spring, they can prepare for a full-scale exercise or a functional exercise in the fall, once the clarity comes.
  • There is some speculation on how a provider’s suppliers will be included or impacted by expectations of preparedness especially regarding subsistence planning and delivery of essential functions.  Providers should be addressing a vendors preparedness in their contracts to guarantee availability of services.

Regardless of where you are in the evolution of your Emergency Management Program, you should not be waiting on the IGs to be published, there is a plenty of guidance between ASP&R, the CoPs, and experts in the field of where to start.


Crisis Focus, LLC has focused expertise in healthcare emergency management, including CMS compliance. Please visit Crisis Focus’ CMS Emergency Preparedness resource page or contact us for more information.

An earlier version of this post originally appeared on Jody Moore’s LinkedIn Account and is cross-posted here as a resource.