CMS Info & Updates

Changes to the CMS Emergency Preparedness Requirements for Healthcare Providers

By: Karen Garrison, Director of Aging Services

In 2017, Centers for Medicare and Medicaid (CMS) established wide-ranging Emergency Preparedness (EP) requirements referred to as “the Final Rule” for 17 distinct healthcare providers including hospitals, skilled nursing facilities, Home Health Agencies, PACE Programs, Federally Qualified Health Centers. These providers are charged with proactively planning for both natural and man-made disasters by developing a robust Emergency Preparedness Program and requires healthcare providers to adequately prepare to meet the needs of patients, clients, residents, and participants during disasters and emergency situations, striving to provide consistent requirements across provider types.

The “Final Rule” established national emergency preparedness requirements for healthcare providers that are in alignment with emergency preparedness concepts used by FEMA and incorporates national standards such as SEMS and NEMS. These new requirements focus on maintaining access to healthcare during emergencies: safeguarding human and physical resources and improving business continuity practices after a disaster. As service providers incorporate these requirements, they can anticipate and plan for service needs, rapidly respond as an organization, as well as integrate with local public health and emergency management agencies and healthcare coalitions’ response activities and recovery following a disaster.

There are four CMS components that make organization’s Emergency Preparedness Program compliant including: 1. conduct an annual risk assessment specific to your organization, 2. create provider specific emergency preparedness policies and procedures, 3. Develop a communication plan including contact information for vital staff, local emergency numbers as well as your organizations redundant communication devices and 4. Regular staff training and emergency preparedness exercises (one Tabletop and 1 Full Scale Community Exercise).

Since 2017, CMS has added or deleted a number of requirements for providers including:

March 2019: E-TAG -0004: Healthcare providers are now required to develop an Response Plan to address emerging infectious disease (EID) threats.  Examples of EIDs include Influenza, Ebola, Zika Virus and others.  All CMS providers must incorporate this response plan into their existing all-hazards emergency preparedness program plan.

The latest changes to the Emergency Preparedness Rule effective November 30, 2019:

Emergency Preparedness Requirements: Requirements for Emergency Plans: CMS is removing the requirement from the emergency preparedness rules for Medicare and Medicaid healthcare providers to contact and document local, tribal, regional, State, and Federal emergency preparedness officials, and that facilities document their participation in collaborative and cooperative planning efforts. 

Emergency Preparedness Requirements: Requirements for Annual Review of Emergency Program:  Providers will now be required to review their Emergency program biennially (former requirement called for an annual review), except for Long Term Care facilities, which will still be required to review their emergency program annually.

Emergency Preparedness Requirements for Training: We are revising the requirement that facilities develop and maintain a training program based on the facility’s emergency plan annually by requiring providers to conduct training biennially (every 2 years) after facilities conduct initial training for their emergency program. The notable exception is for Skilled Nursing Facilities (SNF’s) which will still be required to provide training annually. In addition, we are requiring additional training when the emergency plan is significantly updated.

Emergency Preparedness Requirements: Requirements for Testing: For inpatient healthcare providers such as hospitals and skilled nursing facilities, CMS is expanding the types of acceptable testing exercises that may be conducted.

For outpatient healthcare providers such as Federally Qualified Health Centers and Home Health Agencies, CMS has diminished the requirement for conducting two exercises a year to only one testing exercise annually, which may be either one community-based full-scale exercise, or an individual organizational – based functional exercise, every other year and in the opposite years. Healthcare providers may choose the testing exercise of their choice.

Since the implementation of these new emergency preparedness regulations in 2017, healthcare providers have come a long way in increasing their organizational resilience, capacity and working knowledge of how to prepare, respond and recover from all types of disasters. Going forward, no matter what requirements CMS adds or deletes from the Emergency Preparedness Final Rule, it is still imperative the all CMS Providers be continue to develop their emergency plans coupled with ongoing training and testing to ensure that all providers are able to be respond efficiently and with confidence to any emergency.

Source Material: CMS Website

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