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Member Tool - April 1, 2020

Policies & Procedures


Andrew Hajde CMPE
Effective Nov. 15, 2017, the Centers for Medicare & Medicaid Services (CMS) final rule on Emergency Preparedness Requirements for Medicare and Medicaid Participating Providers and Suppliers applies to all 17 provider and supplier types.

This rule was established to ensure that adequate preparation and planning is in place for either a man-made or natural disaster. If your facility participates in the Medicare or Medicaid program, Emergency Preparedness (EP) rule compliance is required.


Per CMS there are four provisions — risk assessment and planning, policies and procedures, communication plan and training and testing program — that you are required to comply with as part of your emergency preparedness plan.
  1. Risk assessment and planning
    1. Develop an emergency plan based on a risk assessment. FEMA offers a risk assessment table for calculating an overall hazard rating for assets or operations.
    2. Perform risk assessment using an “all-hazards” approach, focusing on capacities and capabilities. As defined, “an all-hazards approach is an integrated approach to emergency preparedness planning that focuses on capacities and capabilities that are critical to preparedness for a full spectrum of emergencies or disasters, including internal emergencies and a man-made emergency (or both) or natural disaster. This approach is specific to the location of the provider or supplier and considers the particular type of hazards most likely to occur in their areas. These may include, 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 such as water and food.“
    3. Update emergency plan at least annually.
  2. Policies and procedures
    1. Develop and implement policies and procedures based on the emergency plan and risk assessment.
    2. Policies and procedures must address a range of issues including subsistence needs, evacuation plans, procedures for sheltering in place, tracking patients and staff during an emergency.
    3. Review and update policies and procedures at least annually.
  3. Communication plan
    1. Develop a communication plan that complies with both federal and state laws.
    2. Coordinate patient care within the facility, across health care providers, and with state and local public health departments and emergency management systems.
    3. Review and update plan annually.
  4. Training and testing program
    1. Develop and maintain training and testing programs, including initial training in policies and procedures.
    2. Demonstrate knowledge of emergency procedures and provide training at least annually.
    3. Conduct drills and exercises to test the emergency plan. Requirements include:
      • Facilities are expected to meet all training and testing requirements by the implementation date.
      • Participation in a full-scale exercise that is community-based or when a community-based exercise is not accessible, an individual, facility-based exercise.
      • Conduct an additional exercise that may include, but is not limited to the following:
        1. A second full-scale exercise that is individual, facility-based.
        2. A tabletop exercise that includes a group discussion led by a facilitator, using a narrated, clinically relevant emergency scenario and a set of problem statements, directed messages or prepared questions designed to challenge an emergency plan.
It’s not if but a matter of when your business will be affected by a natural/man-made disaster or weather-related event. Healthcare facilities are just as susceptible to adverse events as other businesses, and those events affect both operations and patient care. By following this checklist, your organization will be compliant with the CMS emergency preparedness requirements and maintain improved safety for both your staff and patients. Download Now: MGMA Emergency Planning Checklist

About the Author

Andrew Hajde
Andrew Hajde CMPE
Director, Content & Consulting MGMA Englewood, Colorado

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