Centers for Medicare & Medicaid Services Releases Emergency Preparedness Interpretive Guidelines

Effective November 15, 2017, Medicare and Medicaid Participating Providers and Suppliers must comply with and implement all regulations posted in the final Emergency Preparedness Requirements.   On June 2, 3017 CMS released an advanced copy of the State Operations Manual (SOM) Emergency Preparedness Interpretive Guidelines to clarify the survey protocols that will be implemented to ensure compliance with the Emergency Preparedness Requirements (per CMS, the final version may vary slightly).  The new requirements are extensive and represent a more comprehensive approach to emergency preparedness.  The requirements call for providers and suppliers to focus on building their capacity to handle a full spectrum of emergencies, rather than providing specific plans for every conceivable emergency situation. 

The requirements were developed to assist the 17 required providers and suppliers identified in the final rule in planning adequately for both natural and man-made disasters and coordinating with Federal, state, regional, and local emergency preparedness systems.  A provider or supplier’s Emergency Preparedness Program (EPP) must represent a comprehensive approach to meet the health, safety, and security needs for its facility, staff, patient population, and community prior to, during, and after an emergency or disaster.  The requirements include four core elements: an emergency plan based on a risk assessment that incorporates an all hazards approach; corresponding policies and procedures; a communication plan; and a training and testing program.

Key Program Elements and Survey Protocols

Emergency Plan and Risk Assessment

  • The emergency plan provides the framework for the EPP and is based on facility and community risk assessments.  The risk assessment identifies and documents potential hazards that are likely to impact the geographic region, community, facility, and patient population.   The focus of the all-hazards approach to risk assessment identifies the capacities and capabilities that are critical to preparing for a full spectrum of emergencies or disasters in the area, including, but are not limited to, care-related emergencies, equipment, and power failures, interruptions in communications, including cyber-attacks, loss of a portion or all of a facility, and interruptions in the normal supply of essentials (e.g. water and food). For nursing facilities, the risk assessment must also include missing residents.  The emergency plan must be reviewed and updated at least annually.
  • Surveyors will review the emergency plan and interview administrative staff on how the risk assessment was conducted, as well as the rationale used to identify the hazards included in the plan.  

Policies and Procedures

  • Policies and procedures are developed and implemented based on the emergency plan and risk assessment.  Policies and procedures must address a range of issues, including subsistence needs, evacuation plans, procedures for sheltering in place and tracking patients and staff during an emergency. Policies and procedures must be reviewed and updated at least annually.
  • Surveyors will review policies and procedures to assure they have been developed based on the risk assessment and to confirm they have been reviewed and updated as needed and on an annual basis.

Communication Plan

  • A communication plan includes provisions for coordinating patient care at the facility, across health care providers, and with State and local public health departments and emergency systems. For long term care providers, the plan must outline the approach to sharing information from the emergency plan with residents and their families and representatives. 
  • Surveyors will verify that all appropriate contacts are included in the communication plan by asking to see a list of contacts with their information. In addition, facilities will be asked to show evidence that the contact information has been reviewed and updated at least annually.  Residents or families may be asked if they have been given information regarding the facility’s emergency plan.

Training and Testing Program

  • The training program includes the mechanism for the initial and annual training in policies and procedures to all staff, individuals providing services under arrangement, and volunteers.  This includes agency staff who would be expected to assist during an emergency.  Facility staff must demonstrate knowledge of emergency procedures.
  • A facility must conduct drills and exercises to test the emergency plan, including a full-scale community-based exercise or, if a community-based exercise is not accessible, an individual, facility-based exercise.  A second full-scale individual, facility based exercise is also required (tabletop exercise).  The facility -based exercise would include, hazards specific to the facility based on the geographic location; patient population; facility type with potential involvement of the surrounding community. 
Surveyors may request copies of the initial and annual training programs, interview staff regarding their knowledge of emergency procedures and review personnel records for documentation of training. Documentation of the annual table top and full-scale drills will be reviewed, including the facility’s analysis of and response to the drills conducted.
It is imperative that providers review the guidelines for full compliance with the updated regulations.  CMS maintains an active website with technical resource material for Survey and Certification Emergency Preparedness (
If you have any questions about the Emergency Preparedness regulations or the development of your plan please contact Deborah Lynch, RN, LNHA at or 212-697-3000.