Do You Have the 4 Core Elements of an Emergency Preparedness Program? by Jay Anstine, JD

(Check out our latest update on emergency preparedness, based on the 2019 final rule.)

The motto of the Boy Scouts is Be Prepared.

On September 16, 2016 the Centers for Medicare and Medicaid Services (CMS) made Be Prepared a law. CMS published a final rule relating to new federal emergency preparedness requirements. This rule impacts seventeen different types of Medicare participating providers and suppliers.  The new regulation requires adequate planning and establishing of a more consistent response by providers and suppliers.

Under this new CMS rule, you must develop and maintain an “Emergency Preparedness Program.” This program needs to contain four core elements:

  1. Emergency Plan: Develop an emergency plan, updated at least annually, that is based on certain risk assessments and utilizes an “all hazards approach”. The emergency plan must also include strategies for addressing emergency events identified by the risk assessment, factor in patient population and capabilities to serve, and include a process for cooperation with local, tribal, regional, State, and Federal emergency preparedness officials.
  1. Communication Plan: Develop a communication plan, updated at least annually, that complies with Federal, State, and local laws and includes, among other items, the names and contact information for Federal, State, tribal, regional, and local emergency preparedness staff and methods for sharing medical and other information.
  1. Policies and Procedures: Policies and procedures must also be developed that are based on the emergency plan, the risk assessment, and communication plan. The policies and procedures must be reviewed and updated at least annually and address, among other items, subsistence needs for staff and patients (e.g., food, water, medical supplies), a system for tracking the location of on-duty staff and sheltered patients, emergency staffing strategies, and arrangements to transfer patients.
  1. Training and Testing Program. Develop and maintain a training and testing program based on the emergency plan, the risk assessment, the communication plan, and the policies and procedures. The training program requirements address topics such as who needs to be trained, the frequency of training, assessing knowledge, and documenting the training conducted.  The testing requirements address topics such as conducting full scale exercises, conducting additional testing, and the format of each testing type.

The exact CMS emergency preparedness program requirements will vary based on the characteristics of each provider and supplier type.  For example, there are additional requirements pertaining to emergency systems applicable to Hospitals, Long-Term Care Facilities, and Critical Access Hospitals.

This new regulation went into effect on November 16, 2016. Participating providers and suppliers have until November 16, 2017 to implement all regulations.

The seventeen provider and supplier types include:

  1. Hospitals
  2. Religious Nonmedical Health Care Institutions (RNHCIs)
  3. Ambulatory Surgical Centers (ASCs)
  4. Hospices
  5. Psychiatric Residential Treatment Facilities (PRTFs)
  6. All-Inclusive Care for the Elderly (PACE)
  7. Transplant Centers
  8. Long-Term Care (LTC) Facilities
  9. Intermediate Care Facilities for Individuals with Intellectual Disabilities (ICF/IID)
  10. Home Health Agencies (HHAs)
  11. Comprehensive Outpatient Rehabilitation Facilities (CORFs)
  12. Critical Access Hospitals (CAHs)
  13. Clinics, Rehabilitation Agencies, and Public Health Agencies as Providers of Outpatient Physical Therapy and Speech-Language Pathology Services
  14. Community Mental Health Centers (CMHCs)
  15. Organ Procurement Organizations (OPOs)Rural Health Clinics (RHCs) and Federally Qualified Health Centers (FQHCs)
  16. End-Stage Renal Disease (ESRD) Facilities
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