Emergency Preparedness Final Rule

by  Wyn Staheli, Director of Content
February 23rd, 2017

Compliance has a new standard for emergency preparedness plans. On September 8, 2016, CMS issued the final rule titled  “Emergency preparedness requirements for Medicare and Medicaid participating providers and suppliers.” This rule creates emergency preparedness Medicare Conditions of Participation (COPs).

There are specific standards for each of the named types of providers and it is important to note that these regulations must be implemented by November 15, 2017.

These are the 4 basic requirements:

  1. Develop an emergency plan based on a risk assessment.

  2. Develop and implement policies and procedures based on the emergency plan and risk assessment.

  3. Develop and maintain a communication plan that complies with federal and state law.

  4. Develop and maintain training and testing programs. They must include initial and annual training as well as conducting drills and exercises or participating in actual incidents that test their plan. The rule made several major changes from the original CMS proposal. Among the changes: Hospitals will not have to conduct annual testing of their emergency generators. The proposal drew a number of protests, including from The Joint Commission and other agencies, which said the annual requirement was too costly and would have an unnecessarily adverse impact on the environment. Instead, CMS endorsed the current requirement of testing generators for four continuous hours once every three years.

CMS has stated that “individual physicians are not required, but are encouraged, to develop and maintain emergency preparedness plans.” So even though individual physicians are not specifically  mentioned in the ruling, keep in mind that HIPAA Security standards require a risk assessment which needs to include an emergency plan. The 4 basic requirements are a good standard when evaluating risk in the individual physician office.

Bottom line, by November 15, 2017, the following facilities must have a fully fleshed out and implemented emergency plan:


Emergency Preparedness Final Rule. (2017, February 23). Find-A-Code Articles. Retrieved from https://www.findacode.com/articles/emergency-preparedness-final-rule-29913.html

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