CMS Emergency Preparedness Final Rule helps your healthcare facility prepare for the worst

By Mike Zorich 

COVID-19 has, beyond a doubt, emphasized the importance of emergency planning for healthcare facilities. A valuable resource for organizations in need of improving their emergency readiness and responsiveness is the CMS Emergency Preparedness Final Rule. 

What is CMS Emergency Preparedness Final Rule? The new ruling was passed in 2017 by the Centers for Medicare and Medicaid Services (CMS) to mandate better emergency planning and support. In addition to employee training and emergency planning and execution, the rule emphasizes communication, which is essential for responding quickly to escalating situations and providing patients with a high level of care. 

Who is affected by CMS Emergency Preparedness Final Rule? The CMS Emergency Preparedness Final Rule includes 17 types of inpatient and outpatient healthcare providers and suppliers, including: 

• Critical Access Hospitals 
• Hospices (Inpatient and Outpatient) 
• Hospitals 
• Intermediate Care Facilities for Individuals with Intellectual Disabilities 
• Long Term Care 
• Psychiatric Residential Treatment Facilities 
• Religious Nonmedical Health Care Facilities (RNHCIs) 
• Transplant Centers 
• Ambulatory Surgical Centers (ASCs) 
• Clinics, Rehabilitation Agencies, and Public Health Agencies as Providers of Outpatient Physical Therapy and Speech-Language Pathology Services 
• Community Mental Health Centers (CMHCs) 
• Comprehensive Outpatient Rehabilitation Facilities (CORFs) 
• End-Stage Renal Disease (ESRD) Facilities  
• Home Health Agencies (HHAs)  
• Organ Procurement Organizations (OPOs)  
• Programs of All Inclusive Care for the Elderly (PACE)  
• Rural Health Clinics (RHCs) and Federally Qualified Health Centers 

In November 2019, changes to the CMS Emergency Preparedness Final Rule were made to remove unnecessary or burdensome regulations that could potentially divert resources away from patient care. As a result of these changes, facilities are no longer required to conduct an annual review of their emergency plan nor must they provide documentation of their attempts to contact emergency preparedness officials. It also relaxes the annual training requirements to a biannual schedule (with the exception of long-term care facilities).

The impact of the recent COVID-19 pandemic will likely lead to changes in the quantity and types of reviews required for emergency preparedness.

Core criteria of CMS Emergency Preparedness

The goal of the standard is for healthcare facilities to think in terms of worst-case scenarios for a myriad of threats, then find ways to address those threats. The following steps can help your facility prepare for such emergencies and work toward compliance with the Final Rule:

Perform an all-hazards risk analysis. The emergency preparedness plans for healthcare facilities are based on a multi-hazard assessment of risks including pandemics/epidemics, chemical and biological emergencies, nuclear fallout, cybersecurity breaches, and natural or weather-related disasters. Because each plan is unique to each facility, you should assess the specific hazards that are most likely to occur in your location. These risks may include power or equipment failures, interruptions to food and water supply, and communication disruption.

Establish an action plan to address risks. For each risk identified in the assessment, develop an action plan that handles those risks. The action plan should outline specific procedures and policies, including role-based activities and best communication practices.

Develop procedures and policies to handle risks. Creating and documenting procedures and policies brings the action plan to life and serves as the roadmap for key personnel to follow and ideally mitigate the impact of each risk.

Create a communication plan to support staff, patients, and the community. To ensure your facility meets the Final Rule communications compliance, make sure your communication plan:  

• Enables your staff to address situations immediately 
• Is tailored to the individuals in your hospital 
• Cooperates with local, state, and regional authorities 
• Can track the whereabouts of staff and patients 
• Has a backup plan for all critical communication points 

Train staff to implement the communication plan. Staff must not only be trained in handling risks, but also in executing proper communication strategies with local authorities and the public.  

Test the plan annually. Inpatient facilities should perform a full-scale exercise and at least one other exercise of their emergency preparedness plan each year. Outpatient facilities are required to do one exercise annually. 

Though no facility wants to undergo a worst-case scenario, preparedness can help you mitigate the impact of an incident and allow you to continue delivering quality care to your patients and protecting employees and the community at large.  

For more information on developing your emergency plan to align with the Final Rule, visit the CMS website. For more information on being prepared for any disaster, read IMEG’s free executive guide, “The Evolving Importance of Healthcare Resiliency.”