Health Care

Emergency Preparedness

Is Your Facility in Compliance?

The Medicare and Medicaid Programs Emergency Preparedness Requirements for Medicare and Medicaid Participating Providers and Suppliers Final Rule establishes national emergency preparedness requirements for participating providers and certified suppliers to plan adequately for both natural and man-made disasters and coordinate with Federal, state, tribal, regional, and local emergency preparedness systems.

The Final Rule also assists providers and suppliers 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 and supplier-types, with some variations. The new emergency preparedness Final Rule is based primarily off of the hospital emergency preparedness Condition of Participation (CoP) as a general guide for the remaining providers and suppliers, then tailored to address the differences and or unique needs of the other providers and suppliers (e.g. inpatient versus out-patient providers).

Four core components of CMS’s Emergency Preparedness Rule

To continue care in a safe environment and meet patients’ needs, the rule has four core components 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 a hazard vulnerability assessment (HVA) or a risk assessment 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, sheltering 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 documented.

Emergency Preparedness Consulting and Training

Hospitals and healthcare organizations without the core components in place risk losing their Medicare and Medicaid reimbursement. To meet the requirements, our team will provide solutions customized for your organization to comply with the rule’s requirements, 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 healthcare management consulting, IT strategies, and operational design.

For more information, contact Michael Davis at