Emergency Preparedness Rule

Quality, Safety & Oversight Group – Emergency Preparedness Regulation Guidance

Guidance for Surveyors, Providers and Suppliers Regarding the New Emergency Preparedness (EP) Rule

On September 8, 2016 the Federal Register posted the final rule Emergency Preparedness Requirements for Medicare and Medicaid Participating Providers and Suppliers. The regulation goes into effect on November 16, 2016. Health care providers and suppliers affected by this rule must comply and implement all regulations one year after the effective date, on November 15, 2017.

Purpose: To establish national emergency preparedness requirements to ensure adequate planning for both natural and man-made disasters, and coordination with federal, state, tribal, regional and local emergency preparedness systems. The following information will apply upon publication of the final rule:

• Requirements will apply to all 17 provider and supplier types.

• Each provider and supplier will have its own set of Emergency Preparedness regulations incorporated into its set of conditions or requirements for certification.

• Must be in compliance with Emergency Preparedness regulations to participate in the Medicare or Medicaid program. The below downloadable sections will provide additional information, such as the background and overview of the final rule and related resources.

CMS Updates Guidelines for Emergency Preparedness Final Rule

NOTICE ON TRAINING & EXERCISES: If a facility activates their emergency plan due to a disaster, the facility is exempt from one full-scale/individual based exercise for that year. However, the secondary requirement for a table-top exercise or exercise of choice still applies. Facilities must demonstrate completion of two exercises per annual year. Life Safety Code Note: As the EP Final Rule defers to the Fire Safety Final Rule which excluded chapters 7, 8, 12 and 13, the requirements in chapters 7,8, 12 and 13 are not required by CMS to be met by providers.

NOTE: Appendix Z updated as of 2/1/2019. The red italics show the changes made with this revision (see downloads section). For the full Appendix Z, please Click Here.

• The below downloadable sections will provide additional information, such as the background and overview of the final rule and related resources.

• Training Note: The download section includes a memorandum which provides guidance to surveyors on training. Following the same site, the TRAINING IS AVAILABLE TO THE PROVIDERS. When prompted, please select “I am a Provider” on the training website and search for the course.

If you have questions as to whether your healthcare facility is required to comply with the final rule, please refer to the downloads section below and the attachment labeled 17 Facility- Provider Supplier Types Impacted. Additionally, please contact your specific facility CFO, CEO, Human Resource Staff, etc. to determine what Medicare certified provider number you are associated/certified under, which will determine which requirements you need to comply with.

Additional information has been provided on the left side hyperlinks categorized by information from the EP Rule, such as the Emergency Preparedness Plan, Communication Plan, Policies and Procedures and Testing.

Additional Resources: ASPR TRACIE.

Brought to you by HHS ASPR, the Technical Resources, Assistance Center, and Information Exchange (TRACIE) was created to meet the information and technical assistance needs of regional ASPR staff, healthcare coalitions, healthcare entities, healthcare providers, emergency managers, public health practitioners, and others working in disaster medicine, healthcare system preparedness, and public health emergency preparedness.

Healthcare Coalitions

ASPR TRACIE is pleased to serve as a platform for developing and sharing resources that support the National Hospital Preparedness Program (NHPP) and its efforts to foster coalition development and operational readiness through the Health Care Preparedness and Response Capabilities. The resources below originate from a variety of sources including NHPP, external entities, or were developed by ASPR TRACIE at the request of NHPP or in response to stakeholder requests and needs. If you are unable to find what you are looking for, or if you would like to submit a resource for possible inclusion, contact our Assistance Center.