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CMS emergency preparedness final rule guidance

Summaries of Conditions of Participation (CoP) by facility type.

On September 8, 2016 the Centers for Medicare and Medicaid Services (CMS) established national emergency preparedness requirements for all health care providers and suppliers that participate in Medicare and Medicaid programs, the nation’s largest insurer. They did this to ensure that health care providers and suppliers are adequately prepared for natural and man-made disasters, and this includes coordinating with federal, state, tribal, regional and local emergency preparedness systems.

Providers and suppliers that wish to participate in Medicare and Medicaid must demonstrate they meet these emergency preparedness requirements https://federalregister.gov/a/2016-21404. For Medicaid-only facilities (other than ICF-IIDs and PRTFs), the Department of Healthcare Policy and Financing determines whether you are required to meet the Emergency Preparedness requirements.

If you have questions as to whether your healthcare facility is required to comply with the final rule, please refer to the list below. 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.  For Medicaid-only facilities (other than ICF-IIDs and PRTFs), the Department of Healthcare Policy and Financing determines whether you are required to meet the Emergency Preparedness requirements.

1. Hospitals

2. Religious Nonmedical Health Care Institutions (RNHCIs)

3. Ambulatory Surgical Centers (ASCs)

4. Hospices

5. Psychiatric Residential Treatment Facilities (PRTFs)

6. All-Inclusive Care for the Elderly (PACE)

7. Transplant Centers

8. Long-Term Care (LTC) Facilities

9. Intermediate Care Facilities for Individuals with Intellectual Disabilities (ICF/IID)

10. Home Health Agencies (HHAs)

11. Comprehensive Outpatient Rehabilitation Facilities (CORFs)

12. Critical Access Hospitals (CAHs)

13. Clinics, Rehabilitation Agencies, and Public Health Agencies as Providers of Outpatient

Physical Therapy and Speech-Language Pathology Services

14. Community Mental Health Centers (CMHCs)

15. Organ Procurement Organizations (OPOs)

16. Rural Health Clinics (RHCs) and Federally Qualified Health Centers (FQHCs)

17. End-Stage Renal Disease (ESRD) Facilities

CMS Resources

The entire CMS Emergency Preparedness Rule, published September 8, 2016, can be found here https://federalregister.gov/a/2016-21404 Some of the requirements were revised on September 30, 2019, to promote program efficiency, transparency and to reduce some of the excess burden to allow more time for patient/resident care. https://www.federalregister.gov/documents/2019/09/30/2019-20736/medicare-and-medicaid-programs-regulatory-provisions-to-promote-program-efficiency-transparency-and.

CMS Emergency Preparedness Home Page, https://www.cms.gov/Medicare/Provider-Enrollment-and-Certification/SurveyCertEmergPrep/index.html includes templates, provider checklists, sample emergency preparedness plans, disaster specific information, lessons learned, FAQs and more. CMS

CMS Emergency Preparedness Rule Homepage, https://www.cms.gov/Medicare/Provider-Enrollment-and-Certification/SurveyCertEmergPrep/Emergency-Prep-Rule

Appendix Z (State Operations Manual) (updated March 26, 2021)- Emergency Preparedness Rule Interpretive Guidance for All Provider and Certified Suppliers (updated on explains each requirement in more detail, how you can meet the requirement, and how inspectors may determine your compliance. In light of the coronavirus disease 2019 (COVID-19) public health emergency (PHE), CMS expanded on best practices, lessons learned, and planning considerations for emerging infectious diseases.https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/downloads/som107ap_z_emergprep.pdf

Emergency Preparedness Basic Training, is a 17-hour online course CMS Online Training for the Emergency Preparedness regulations, offers BOTH surveyor and providers the same training on the EP regulations This training intends to develop your proficiency with conducting EP surveys and to build your understanding of the way the EP regulations overlap across multiple provider types. https://qsep.cms.gov/ProvidersAndOthers/publictraining.aspx (listed under letter “E”)

Emergency Preparedness Provider Readiness is a 90-minute recorded webinar for providers that is an overview of the Emergency Preparedness Final Rule and what CMS has seen, as well as an overview of the 1135 Waiver Process. Additionally, the webinar also provides best practices and lessons learned from recent events and resources available. https://qsep.cms.gov/ProvidersAndOthers/publictraining.aspx (listed under letter “E”)

CMS Emergency Response Operations, https://www.cms.gov/About-CMS/Agency-Information/Emergency/EPRO/EPRO-Home Get information about current emergencies and how CMS can help you now. Learn about CMS responses to Coronavirus, hurricanes, wildfires, cyber-attacks and find the latest program guidance.

HIPAA Privacy Rule In Emergency Situations, Preparedness, Planning And Response, https://www.hhs.gov/hipaa/for-professionals/special-topics/emergency-preparedness/index.html

CMS’ HIPAA Decision Flowchart aids heath care facilities to make decisions about sharing protected health information, https://www.cms.gov/Medicare/Provider-Enrollment-and-Certification/SurveyCertEmergPrep/Downloads/OCR-Emergency-Prep-HIPPA-Disclose.pdf

CMS Templates and Checklists, https://www.cms.gov/Medicare/Provider-Enrollment-and-Certification/SurveyCertEmergPrep/Templates-Checklists.html