The Centers for Medicare and Medicaid Services (CMS) issued the Emergency Preparedness Requirements for Medicare and Medicaid Participating Providers and Suppliers Final Rule to establish consistent emergency preparedness requirements for healthcare providers participating in Medicare and Medicaid, increase patient safety during emergencies, and establish a more coordinated response to natural and human caused disasters.
The rule was published on September 16, 2016 and is effective as of November 15, 2016. The regulations must be implemented by affected entities by November 15, 2017. This rule applies to 17 provider/types as a condition of participation for CMS. The providers/suppliers are required to meet four core elements with specific requirements adjusted based on the individual characteristics of each provider and supplier.
If you are unsure where to begin, the Start Here tab contains a great overview of the CMS Emergency Preparedness Requirements courtesy of the Association of Asian Pacific Community Health Organizations (AAPCHO). Each of the remaining tabs below represents a core requirement and contains resources that may assist you in achieving compliance.
The information provided should not be considered a comprehensive report on CMS regulations, interpretive guidance or compliance. Frederick County is not responsible or liable for any indirect, incidental, consequential, special or exemplary violations of CMS compliance. For specific questions regarding CMS, the emergency preparedness rule or compliance, contact the Centers for Medicare and Medicaid Services.
Affected providers/supplies must develop an emergency plan based on a risk assessment and using an “all-hazards” approach, which will provide an integrated system for emergency planning that focuses on capacities and capabilities.
Tip - Plans Versus Procedures
The distinction between plans and procedures can be confusing. One way to determine what is part of an Emergency Operations Plan (EOP) is to ask the question "what does the entire audience of this EOP need to know?". Specific details and instructions for individuals or groups are typically part of the procedures often known as SOPs or Standard Operating Procedures. SOPs can be an annex to the EOP or referenced. For example, an EOP that assigns responsibility for putting out fires to the fire department would not detail what should be done at the scene or what fire equipment is most appropriate. Those details would be part of the fire department's SOP's.
Provider/suppliers are required to develop and implement policies and procedures based on the emergency plan and risk assessment that are reviewed and updated at least annually. For hospitals, Critical Access Hospitals (CAHs), and Long-Term Care (LTC) facilities, the policies and procedures must address the provision of subsistence needs, such as food, water and medical supplies, for staff and residents, whether they evacuate or shelter in place. Policies and procedures are the who, what, where, when, and how that complement your Emergency Operations Plan.
Tip - Policy vs Procedure
Policy—Go from Point “A” to Point “B”.
Procedure—Begin at Point “A” go to Point “B” by doing x, then y, then z.
Providers/supplies must develop and maintain an emergency preparedness communication plan that complies with federal, state and local laws. Patient care must be coordinated within the facility, across healthcare providers, and with state and local public health departments and emergency management systems to protect patient health and safety in the event of a disaster. Consider and plan for how and what you will communicate with employees, suppliers, providers, patients, families, and others before, during and after an emergency.
Providers/Suppliers must develop and maintain training and testing programs, including initial training in policies and procedures. Facility staff will have to demonstrate knowledge of emergency procedures and provide training at least annually. Facilities must conduct drills and exercises to test the emergency plan or demonstrate activation of the plan in an actual incident that tests the plan.
Currently, there are no exercises sponsored by the Division of Emergency Management or Health Department to help you meet this requirement. Should one become available, it will be posted here.
The following resources may help you meet the testing and training component of the CMS rule: