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6 Tips to Align Your Emergency Preparedness Plan with CMS Regulations

The very active 2017 hurricane season found too many organizations unprepared. To prevent gaps in patient care during and after major disasters like hurricanes, and other natural or manmade disasters, the new regulation from the Centers for Medicare & Medicaid Services (CMS) — Emergency Preparedness Requirements for Medicare and Medicaid Participating Providers and Suppliers — will take effect November 16, 2017.

As an audit element on the annual survey for each of the 17 healthcare CMS provider and supplier types, the new CMS emergency preparedness plan rule threatens to drop non-compliant organizations from CMS accreditation and reimbursement.

While each of the 17 healthcare provider categories will have unique guidelines for emergency preparedness, all will be required to incorporate:

  • A risk/hazard vulnerability assessment
  • Emergency plan policies and procedures
  • A communications plan
  • Emergency preparedness training and testing


6 TIPS for right-sizing your emergency preparedness plan
Creating an emergency preparedness plan isn’t as simple as it sounds. It requires lots of advance planning. Here are a few best practices to help launch your new compliant CMS emergency preparedness plan, or make your existing plan even better.

  1. Pick the low hanging fruit. Make sure egress signs are visible, and there’s backup lighting to help patients exit during a power loss. Consider what you’d need to do to keep the lights and AC on during a power loss, including evaluating the option to add a generator. Operationally, lock back and side doors and designate one entrance after hours.
  2. Perform an “all-hazards” vulnerability assessment. This site-specific assessment evaluates hazards potentially affecting your facility. For coastal areas, hurricanes will be top of the list, while in Missouri, it could be a tornado. Consider an active shooter scenario. In what ways does your facility need to become more resilient?
  3. Develop an emergency plan. Based directly off your vulnerability assessment, your umbrella plan should include specific policies and procedures that address evacuation, internal and external staff and volunteers, food, water, medical supplies and equipment transfer and record keeping – if you must evacuate, certain medical records need to go with you. Consider supply chain management and critical services. Does your medical supplies subcontractor have an emergency contingency plan? Can they still supply you with critical services/products that you need in a crisis?
    Additionally, know the specific requirements for your type of facility to incorporate in your plan. For example, outpatient providers are not required to have policies and procedures for the provision of subsistence needs; home health agencies and hospices are required to inform officials of patients in the community; long-term care and psychiatric residential treatment facilities must share information from the emergency plan with residents and family.
  4. Create a good communications plan. With multiple stakeholders, a communications plan will be critical to continuity of operations before, during and after a crisis. Consider how you’ll communicate about the disaster with: patients, their caregivers, staff, medical providers you rely on, outside services like housekeeping, laundry, food services and your supply chain, including pharmacies, medical equipment and dry goods suppliers; not to mention civil authorities.
  5. Training and testing. An emergency plan is only successful if it’s tried and true. Practice for different scenarios – do table top exercises and drills. Coordinate with nearby medical facilities if you’ll need to transfer acute patients. Should the entire area lose power, what’s your Plan B? Similarly, consider one plan for each type of catastrophic event. Get civil authorities involved in your training. Keep good records of your training and when issues arise, problem solve immediately – before the real disaster.
  6. Annual review. Host annual training sessions and plan reviews. A staff that doesn’t practice the rules will forget them. A plan that isn’t updated based on internal and external changes will fail.


Get started now

Being non-compliant with CMS’ emergency preparedness plan rule will put you at risk for termination of participation. Should you transport a patient from your nursing home and forget their critical medications, the results could be significantly worse. Preparing for a disaster must happen now. Don’t wait until it’s too late to make patient safety a priority and test staff response. Contact your HUB broker for help with conducting an all-hazards risk assessment, reviewing your current emergency preparedness plan or developing a more effective one.

If you have any questions, please contact your HUB Advisor

Barry Montgomery | HUB International Insurance Services | 214-979-6242  | |