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Emergency Preparedness


Staff Contacts:

Sarah Willson
Vice President of Clinical and Regulatory Affairs
swillson@mhanet.com
573/893-3700, ext. 1304

Jackie Gatz
Vice President, Grant Management and Safety
jgatz@mhanet.com
573/893-3700, ext. 1330

Jim Mikes
Vice President of Rural Advocacy and Regulation
jmikes@mhanet.com
573/893-3700, ext. 1393

CMS Defines Conditions Of Emergency Preparedness


The Centers for Medicare & Medicaid Services issued the emergency preparedness requirements for Medicare and Medicaid participating providers and suppliers final rule. The rule establishes consistent emergency preparedness requirements for health care providers participating in Medicare and Medicaid, increases patient safety during emergencies and establishes a more coordinated response to natural and human-caused disasters. The U.S. Department of Health & Human Services Office of the Assistant Secretary for Preparedness and Response worked closely with CMS in the development of the rule. This document provides links to numerous related resources applicable to a variety of providers and suppliers. The rule was published on Sept. 16, and the process implementation will begin Nov. 15. The regulation must be fully implemented by affected entities by Nov. 15, 2017.

This rule applies to 17 provider and supplier types as a condition of participation for CMS. The providers/suppliers are required to meet four core elements.
  • Emergency plan: 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.
  • Policies and procedure: 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 and long-term care 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.
  • Communication plan: 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 health care 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.
  • Training and testing program: Develop and maintain training and testing programs, including initial training in policies and procedures. Facility staff will have to demonstrate staff knowledge of emergency procedures and provide training at least annually. Hospitals must conduct two exercises annually to test the emergency plan, one of which must be a full-scale exercise. If a hospital has an actual incident, they should document the implementation of the emergency plan. This would meet the full-scale exercise requirement. If they do not have an actual incident, they may conduct drills and exercises that test the plan.

The reference chart below was developed by CMS to help providers know who is affected and where they can find their reference information. This quick reference chart is not meant to be an exhaustive list of requirements, nor should it serve as a substitute for the regulatory text. The 17 provider and supplier types are listed below and categorized based on whether they are inpatient or outpatient, as outpatient providers are not required to provide subsistence needs.

Affected Provider and Supplier Types
Inpatient Outpatient
Facility Type Final Rule Facility Type Final Rule Reference
Critical Access Hospitals Section II. N Ambulatory Surgical Centers Section II. E
Hospices Section II. F Clinics, Rehabilitation Agencies, and Public Health Agencies as Providers of Outpatient Physical Therapy and Speech-Language Pathology Services Section II. O
Hospitals Section II. C Community Mental Health Centers Section II. P
Intermediate Care Facilities for Individuals with Intellectual Disabilities (ICF/IID) Section II. D Comprehensive Outpatient Rehabilitation Facilities Section II. M
Long Term Care Section II. J End-Stage Renal Disease Facilities Section II. S
Psychiatric Residential Treatment Facilities (PRTFs) Section II. G Home Health Agencies Section II. L
Religious Nonmedical Healthcare Institutions (RNHCIs) Section II. D Hospices Section II. F
Transplant Centers Section II. I Organ Procurement Organizations (OPOs) Section II. Q
    Programs of All Inclusive Care for the Elderly (PACE) Section II. H
    Rural Health Clinics and Federally Qualified Health Centers (FQHCs) Section II. R

The CMS emergency preparedness survey and certification Web page has information on training and technical assistance available from CMS and includes a number of templates and checklists for emergency preparedness. CMS held a Medicare learning network national call on Oct. 5 to discuss the new rule. The slides, audio recording and transcript are all available for download. MHA has created a series of four on-demand educational videos, and has completed self-assessment checklists for acute and critical access hospitals. These checklists will walk you through the regulatory requirements found in the final rule.

CMS currently is developing an FAQ document and other technical resource materials, which will be posted on its emergency preparedness Web page. The interpretive guidance and state operations manual are expected to be released in the spring of 2017. CMS recently released a survey and certification memo regarding the implementation of the emergency preparedness CoPs. For more regulatory information, please contact Sarah Willson. For emergency preparedness technical assistance, please contact Jackie Gatz.

Missouri Hospital Association • P.O. Box 60 • Jefferson City, MO 65102
Phone: 573/893-3700 • Fax: 573/893-2809 • MHAnet
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