The Centers for Medicare and Medicaid Services (CMS) requirements for Emergency Preparedness (EP) establish national EP requirements for Medicare-participating facilities to plan adequately for natural and man-made disasters and coordinate efforts with Federal, state, tribal, regional, and local EP systems. These requirements focus on three key essentials necessary for maintaining access to healthcare during disasters or emergencies: safeguarding human resources, maintaining business continuity, and protecting physical resources. Successful adoption of the EP requirements will enable facilities wherever they are located to better anticipate and plan for needs, rapidly respond as a facility, as well as integrate with local public health and emergency management agencies and healthcare coalitions’ response activities, and rapidly recover following the disaster.
The emergency preparedness program (EPP) must be in writing. However, how their efforts are documented is up to the facility’s discretion. The EPP must meet the following basic requirements:
- Facilities must develop and maintain an emergency preparedness plan that must be reviewed and updated at least every two (2) years (5-D-2).
- The plan must be based on and include a documented, facility-based, and community-based risk assessment, utilizing an all-hazards approach (5-D-3).
- The plan must include strategies for addressing emergency events identified by the risk assessment (5-D-4).
- The plan must address the facility’s patient population, including, but not limited to, the type of services the Provider/Supplier has the ability to provide in an emergency; and continuity of operations, including delegations of authority and succession plans (5-D-5).
- The plan must include a process for cooperation and collaboration with local, tribal, regional, State, and Federal emergency preparedness officials' efforts to maintain an integrated response during a disaster or an emergency (5-D-7).
- There must be EP policies and procedures that are developed and implemented based on the emergency plan set forth in standard 5-D-2, risk assessment in standard 5-D-3, and the communication plan in standard 5-D-21. The policies and procedures must be reviewed and updated at least every two (2) years. (5-D-9).
- There must be a communication plan that is developed and maintained that complies with Federal, State, and local laws and must be reviewed and updated at least every two (2) years (5-D-21).
- Lastly, the program must include a testing and training program based on the emergency plan set forth in standard 5-D-2, risk assessment in standard 5-D-3, policies and procedures in standard 5-D-9, and the communication plan in standard 5-D-21. The training and testing program must be reviewed and updated at least every two (2) years (5-D-29).
These basic requirements set the foundation for facility success to develop, implement, and maintain EPPs so that they can anticipate and plan for needs, rapidly respond as a facility, as well as integrate with local public health and emergency management agencies and healthcare coalitions’ EP response activities, and rapidly recover following the disaster or emergency situation. The State Operations Manual Appendix Z- Emergency Preparedness for All Provider and Certified Supplier Types Interpretive Guidance is an excellent resource for those Medicare-certified facilities requiring an EPP. Watch for future newsletter articles that dive a little deeper into each requirement.
Since 1980, QUAD A (a non-profit, physician-founded and led global accreditation organization) has worked with thousands of healthcare facilities to standardize and improve the quality of healthcare they provide – believing that patient safety should always come first.
