CMS’ New Emergency Preparedness Requirements Is your facility compliant? BY KARA NEWBURY

During the fall of 2016, the Centers for Medicare & Medicaid Services (CMS) released a final rule titled Emergency Preparedness

Requirements for Medicare and Med- icaid Participating Providers and Sup- pliers. The regulation became effec- tive on November 16, 2016, and as of November 15, 2017, the 17 health care provider and supplier types that must comply with the rule, including ASCs, began being held to these revised stan- dards during their Medicare surveys.


According to the CMS website, the new regulations “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 pre- paredness systems.” CMS breaks down a compliant emergency preparedness plan into four basic provisions, out- lined below. Each provision should be reviewed and updated at least annually.

Risk Assessment and Planning CMS encourages an “all-hazards” approach to emergency plan develop- ment. This describes integrated plan- ning to prepare for a wide range of man-made and natural emergencies, focusing on those most likely to occur for the specific provider location.

Policies and Procedures

Based on the risk assessment plan, facilities must develop policies and procedures that account for patient and staff needs in the case of identi- fied emergency scenarios. Evacuation plans and procedures for all facility occupants also should be defined. While most facilities must include contingency plans to transfer patients

to similar facilities during an emer- gency, ASCs are not required to make arrangements to transfer patients to other ASCs. Instead, ASCs should include a plan to transfer patients to a hospital via transfer agreement if patients require additional care during an emergency.

Communication Plan The rule requires facilities to have a written communication plan that describes how the facility will coordi- nate continued patient care within the facility, with outside health care pro- viders and with state/local public health departments in the event of an emer- gency. Facilities also should consider how they will interact with emergency management agencies in protecting the health and safety of their patients. Location-specific considerations, such as limited access to internet or phone capabilities for those facilities in rural areas, must be incorporated. Unlike in its hospital proposal, CMS

exempted ASCs from providing infor- mation regarding occupancy. Since the term occupancy usually refers to occu- pancy in an inpatient facility, ASCs would not need to provide for subsis- tence needs of their patients and staff.

Track the Latest Regulatory and Legislative News for ASCs

Visit ASCA’s website every week to stay up to date on the latest government affairs news affecting the ASC industry. Every week, ASCA’s Government Affairs Update newsletter is posted online for ASCA members to read. The weekly newsletter tracks and analyzes the latest legislative and regulatory developments concerning ASCs. GovtAffairsUpdate


Similarly, most facilities are required to track patients before, during and after emergencies, ASCs are required to track patients before and during emergencies only. If patients or staff are transferred for continued or additional care, the ASC must document the specific name and location of the receiving facility or other location for those patients and on- duty staff who are relocated during an emergency. If the ASC is able to close or cancel appointments, there is no need to track patients or staff.

Training and Testing This provision takes into account all three provisions above. Facilities are required to provide instruction to ensure that all staff and other facility workers are aware of emergency pre- paredness plan procedures. Drills and/ or exercises should then be conducted to practice policies and procedures, evaluate the effectiveness of the emer- gency preparedness plan and identify areas for improvement. ASCs are required to take part in

two annual emergency preparedness tests. The first exercise should be a full- scale exercise that is community-based, when available. If a community drill is not available, CMS will require an ASC to conduct an individual facility-based drill. For the second exercise, an ASC would be required to conduct either a second full-scale community or facility- based exercise or a tabletop exercise. According to Q&As released by CMS, a table-top exercise (TTX) is a “group discussion led by a facilitator, using a narrated, clinically-relevant emergency scenario and a set of prob- lem statements, directed messages or prepared questions designed to chal- lenge an emergency plan. It involves key personnel discussing simulated scenarios, including computer-simu- lated exercises, in an informal setting.

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