CMS’s Emergency Preparedness Requirements-Is Your Facility in Compliance?


Close-up of police siren

CMS’s Emergency Preparedness Requirements for Medicare and Medicaid Participating Providers and Suppliers went into effect in November 2016. Now, one year later, as of November 15, 2017, it’s required that the regulations be implemented or health care providers risk termination from the CMS program.

What do you need to have on hand to show compliance and what should you do if you have not yet complied?

What is Required to Be Compliant with CMS’s Emergency Preparedness Rule? 

Becoming compliant means that, as of Nov. 15, 2017, the 17 provider and supplier types that the rule applies to will need to have a plan in place to keep operations underway in a medically safe environment, and meet the needs of patients in their care. The issues providers face in an emergency are enormously challenging. They include information sharing, managing the supply chain, protecting and preserving patient records, planning for sheltering in place, having essential equipment available, evacuation plans, anticipating a patient surge, and managing fatalities.

Four core elements of CMS’s Emergency Preparedness Rule

To continue care in a safe environment and meet patients’ needs, the rule has four core elements that must be included in the Emergency Preparedness Program, and must be reviewed and updated annually:

  1. RISK ASSESSMENT AND PLANNING –Develop an emergency plan based on certain risk assessments that utilizes an “all hazards” approach. It needs to include strategies for addressing emergency events identified by the risk assessment, factor in patient population, and include a process for cooperation with local, tribal, regional, state and federal emergency preparedness officials. The plan needs to identify who will be responsible in a crisis and their essential functions.
  2. POLICIES AND PROCEDURES – Policies and procedures must be developed that are based on the emergency plan, the risk assessment, and the communication plan. Among other items, they need to address having things such as food, water, alternate sources of energy, and medical supplies to sustain patients and staff. There needs to be a system for emergency staffing strategies, tracking the location of on-duty staff and sheltered patients, and arrangements to transfer patients.
  3. COMMUNICATION PLAN – Develop a communication plan that, among other items, includes names and contact information for federal, state, tribal, regional, and local emergency preparedness staff and methods for sharing medical and other information.
  4. TRAINING AND TESTING PROGRAM – A training and testing program needs to be developed and maintained that addresses the above as well as identifying who needs to be trained, and how often to train. The training needs to be documenting.

Emergency Preparedness Consulting and Training

Hospitals and health care organizations without a plan in place by the November 15, 2017 deadline risk losing their Medicare and Medicaid reimbursement.  To meet the requirements, our team, headed up by emergency preparedness expert, Kimberly Baldwin, will provide solutions customized for each organization to comply with the rule’s requirements and its annual assessments and updates. We offer all-hazards risk assessments, emergency plans, training, drills, and all elements required to demonstrate compliance with the Emergency Preparedness rule. In addition, we have decades of industry experience in health care management consulting, IT strategies, and operational design.

For more information about how Wipfli/HFS can help you prepare, contact Michael Davis at, or Kim Baldwin,, or call 800.888.4966.

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