Complying with the CMS Emergency Preparedness Rule


In September 2016, the final rule Emergency Preparedness Requirements for Medicare and Medicaid Participating Providers and Suppliers was published in the Federal Register, the federal government's publication for rules, proposed rules and notices. The rule applies to 17 provider and supplier types, which includes ASCs.

 Here are eight things to know about the rule and emergency preparedness that may help you begin or continue your efforts to bring your ASC into compliance.

1. Rationale. The Federal Register describes the purpose of the rule as follows:

“This final rule establishes national emergency preparedness requirements for Medicare- and Medicaid-participating providers and suppliers to plan adequately for both natural and man-made disasters, and coordinate with federal, state, tribal, regional and local emergency preparedness systems.

“It will also assist providers and suppliers to adequately prepare to meet the needs of patients, residents, clients and participants during disasters and emergency situations.

“Despite some variations, our regulations will provide consistent emergency preparedness requirements, enhance patient safety during emergencies for persons served by Medicare- and Medicaid-participating facilities, and establish a more coordinated and defined response to natural and man-made disasters.”

2. Does it apply to you? If your ASC is one of the roughly 5,500 Medicare-certified ASCs in the United States, it does.

Within the CMS Conditions for Coverage (CfC) is 42 CFR § 416.54, the CfC for emergency preparedness. It begins with the following: “The ASC must comply with all applicable federal, state and local emergency preparedness requirements. The ASC must establish and maintain an emergency preparedness program that meets the requirements of this section.”

3. Implementation date. While the regulation went into effect on November 16, 2016, ASCs have until November 16, 2017, to comply and implement all regulations.

That may seem like a lot of time, but preparing your ASC for the changes is not a quick process. You will want to take advantage of the time to work on preparation and not wait until the last minute.

4. Requirements overview. CMS identified four core elements central to an effective emergency preparedness program. They are summarized as following:

i) Risk assessment and emergency planning. Facilities are required to perform a risk assessment that uses an “all-hazards” approach prior to establishing an emergency plan. The risk assessment will identify the essential components for integration into the emergency plan. An all-hazards approach focuses on capacities and capabilities critical to preparedness for the full spectrum of emergencies or disasters. It is specific to the location of the provider and considers the particular types of hazards most likely to occur in their areas (e.g., care-related emergencies; equipment and power failures; communications interruptions, including cyberattacks; loss of part or all of a facility; and, interruptions in the normal supply of essentials, such as water and food).

ii) Policies and procedures. Facilities are required to develop and implement policies and procedures supporting the successful execution of the emergency plan and risks identified during the risk assessment. Article Image

iii) Communication plan. Facilities are required to develop and maintain a compliant emergency preparedness communication plan. Patient care must be well-coordinated within the facility, across healthcare providers, and with state and local public health departments and emergency management agencies and systems. During an emergency, providers must have a system to contact appropriate staff, patients’ treating physicians, and others in a timely manner to ensure continuation of patient care functions and that these functions are carried out in a safe and effective manner.

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