Physician Relationships

Complying with the CMS Emergency Preparedness Rule

Eight things to know about the rule and emergency preparedness that may help you begin or continue your efforts to bring your ASC into compliance.

Contributor: Mary Ann Gellenbeck

In September 2016, the final rule Emergency Preparedness Requirements for Medicare and Medicaid Participating Providers and Suppliers was published in the Federal Register, the federal government’s publication for rules, proposed rules and notices. The rule applies to 17 provider and supplier types, which includes ASCs.

Here are eight things to know about the rule and emergency preparedness that may help you begin or continue your efforts to bring your ASC into compliance.

1. Rationale. The Federal Register describes the purpose of the rule as follows:

“This final rule establishes national emergency preparedness requirements for Medicare- and Medicaid-participating providers and suppliers to plan adequately for both natural and man-made disasters, and coordinate with federal, state, tribal, regional and local emergency preparedness systems.

“It will also assist providers and suppliers to adequately prepare to meet the needs of patients, residents, clients and participants during disasters and emergency situations.

“Despite some variations, our regulations will provide consistent emergency preparedness requirements, enhance patient safety during emergencies for persons served by Medicare- and Medicaid-participating facilities, and establish a more coordinated and defined response to natural and man-made disasters.”

2. Does it apply to you? If your ASC is one of the roughly 5,500 Medicare-certified ASCs in the United States, it does.

Within the CMS Conditions for Coverage (CfC) is 42 CFR § 416.54, the CfC for emergency preparedness. It begins with the following: “The ASC must comply with all applicable federal, state and local emergency preparedness requirements. The ASC must establish and maintain an emergency preparedness program that meets the requirements of this section.”

3. Implementation date. While the regulation went into effect on November 16, 2016, ASCs have until November 16, 2017, to comply and implement all regulations.

That may seem like a lot of time, but preparing your ASC for the changes is not a quick process. You will want to take advantage of the time to work on preparation and not wait until the last minute.

4. Requirements overview. CMS identified four core elements central to an effective emergency preparedness program. They are summarized as following:

i) Risk assessment and emergency planning. Facilities are required to perform a risk assessment that uses an “all-hazards” approach prior to establishing an emergency plan. The risk assessment will identify the essential components for integration into the emergency plan. An all-hazards approach focuses on capacities and capabilities critical to preparedness for the full spectrum of emergencies or disasters. It is specific to the location of the provider and considers the particular types of hazards most likely to occur in their areas (e.g., care-related emergencies; equipment and power failures; communications interruptions, including cyberattacks; loss of part or all of a facility; and, interruptions in the normal supply of essentials, such as water and food).

ii) Policies and procedures. Facilities are required to develop and implement policies and procedures supporting the successful execution of the emergency plan and risks identified during the risk assessment.

iii) Communication plan. Facilities are required to develop and maintain a compliant emergency preparedness communication plan. Patient care must be well-coordinated within the facility, across healthcare providers, and with state and local public health departments and emergency management agencies and systems. During an emergency, providers must have a system to contact appropriate staff, patients’ treating physicians, and others in a timely manner to ensure continuation of patient care functions and that these functions are carried out in a safe and effective manner.

iv) Training and testing. Facilities are required to develop and maintain an emergency preparedness training and testing program. This must include initial training for new and existing staff in emergency preparedness policies and procedures and annual refresher trainings. Facilities must also conduct drills and exercises to test the emergency plan to identify gaps and areas for improvement.

5. Possible requirements if you’re part of a healthcare system. If your ASC is part of a healthcare system with a unified and integrated emergency preparedness program, you may participate in the program along with the healthcare system. Doing so adds some requirements, which may include the following:

  • Your ASC must actively participate in the development of the emergency preparedness program.
  • Development and maintenance of the program should take into account your ASC’s unique circumstances, patient populations, and services.
  • Your ASC must be capable of actively using the emergency preparedness program and is in compliance.

6. Team involvement. Emergency preparedness is not a one-individual responsibility. Responsibilities should be divvied up amongst various members of your team.

The administrator will likely wear multiple hats, possibly filling multiple roles. Then it will be necessary to engage other members of the staff to fill additional positions and responsibilities.

While you may need to assign some roles, first see if members of your team are interested in taking on the emergency preparedness leadership positions you need to fill. That will help with buy-in.

7. Check state requirements and accreditation standards. Depending upon what state your ASC is located in and which accreditation organization your ASC uses, you may have requirements your ASC must meet in addition to CMS regulations.

For example, your state or accreditation organization may not allow tabletop drills. While a tabletop drill technically simulates the event, since it does not require physical simulation or use of equipment, it may not be viewed as an acceptable substitute for an emergency exercise.

If CMS regulations, state regulations and accreditation standards all address the same issue, you must follow the rules which are most stringent in order to be in compliance.

8. Keep current. An emergency preparedness plan and program should be treated as living documents, receiving regular reviews and updates, when necessary.

If members of your emergency preparedness team leave the ASC, you will need to replace them and update your documentation to reflect the new positions and these team members’ contact information.

If you add a new specialty, your documentation will need to reflect how you will maintain care of those patients in the event of an emergency.

If you expand your facility, you will need to take into account how the new space affects your response plan.

Also, make sure to keep an eye out for Life Safety Code changes and other industry updates that could affect emergency preparedness. If your ASC is a joint venture with a management and development company and/or hospital, make sure emergency preparedness is a regular topic of discussion.

Get to Work

Depending upon how far along you are with meeting the emergency preparedness rule, you may still have a lot of work to do. There are a few steps you can take to help move you forward and closer to compliance. They are:

  • Review any forms, policies, disaster supplies and other documentation concerning your emergency preparedness to assess your current state of preparation.
  • Assign a few staff members to help. As stated earlier, emergency preparedness requires teamwork.
  • Develop a plan for bringing your preparedness up to par, and have it approved at the committee and governing board level.
  • Complete an exercise. By running a drill and analyzing your ASC’s performance, you may identify areas and opportunities for improvement.
  • Seek out resources. If you have a management company or hospital partner, find out how they can help. There are ample resources available from national and state associations, federal and state agencies, publications and even other providers. At a minimum, you may be able to use such resources as guides or templates to fill in plan gaps.