Emergency Preparedness Rule
Quality, Safety & Oversight Group- Emergency Preparedness Regulation Guidance
Guidance for Surveyors, Providers and Suppliers Regarding the New Emergency Preparedness (EP) Rule
On September 8, 2016 the Federal Register posted the final rule Emergency Preparedness Requirements for Medicare and Medicaid Participating Providers and Suppliers. The regulation goes into effect on November 16, 2016. Health care providers and suppliers affected by this rule must comply and implement all regulations one year after the effective date, on November 15, 2017.
Purpose: To establish national emergency preparedness requirements to ensure adequate planning for both natural and man-made disasters, and coordination with federal, state, tribal, regional and local emergency preparedness systems. The following information will apply upon publication of the final rule:
- Requirements will apply to all 17 provider and supplier types.
- Each provider and supplier will have its own set of Emergency Preparedness regulations incorporated into its set of conditions or requirements for certification.
- Must be in compliance with Emergency Preparedness regulations to participate in the Medicare or Medicaid program. The below downloadable sections will provide additional information, such as the background and overview of the final rule and related resources.
Additional information has been provided on the left side hyperlinks categorized by information from the EP Rule, such as the Emergency Preparedness Plan, Communication Plan, Policies and Procedures and Testing.
Note: For Medicaid-only facilities (other than ICF-IIDs and PRTFs), please contact your State Medicaid Agency to determine whether you are required to meet the Emergency Preparedness requirements under the Final Rule.
If you have questions as to whether your healthcare facility is required to comply with the final rule, please refer to the downloads section below and the attachment labeled 17 Facility- Provider Supplier Types Impacted. Additionally, please contact your specific facility CFO, CEO, Human Resource Staff, etc. to determine what Medicare certified provider number you are associated/certified under, which will determine which requirements you need to comply with.
NOTICE ON TRAINING & EXERCISES: If a facility activates their emergency plan due to a disaster, the facility is exempt from one full-scale/individual based exercise for that year. However, the secondary requirement for a table-top exercise or exercise of choice still applies. Facilities must demonstrate completion of two exercises per annual year.
Training Note: The download section includes a memorandum which provides guidance to surveyors on training. Following the same site, the TRAINING IS AVAILABLE TO THE PROVIDERS. When prompted, please select "I am a Provider" on the training website and search for the course.
Life Safety Code Note: As the EP Final Rule defers to the Fire Safety Final Rule which excluded chapters 7, 8, 12 and 13, the requirements in chapters 7,8, 12 and 13 are not required by CMS to be met by providers.
The below downloadable sections will provide additional information, such as the background and overview of the final rule and related resources.
NOTE: Appendix Z updated as of 2/1/2019. The red italics show the changes made with this revision (see downloads section).
- Facility Transfer Agreement - Example [PDF, 56KB]
- 17 Facility- Provider Supplier Types Impacted [PDF, 89KB]
- Frequently Asked Questions (FAQs) Round One [PDF, 312KB]
- Frequently Asked Questions (FAQs) Round Two Revised 6-1-17 [PDF, 40KB]
- Frequently Asked Questions (FAQs) Round Three Revised 6-1-17 [PDF, 221KB]
- Frequently Asked Questions (FAQs) Round Four [PDF, 24KB]
- Frequently Asked Questions Round Four Definitions [PDF, 48KB]
- Frequently Asked Questions (FAQs) Round Five [PDF, 81KB]
- General Presentation - Overview of EP [PPTX, 3MB]
- Surveyor Tool- EP Tags [XLSX, 62KB]
- CMS Online Training for Emergency Preparedness [PDF, 114KB]
- CMS and NHPP Letter-Healthcare Coalitions [PDF, 299KB]
- Colorado Specific Healthcare Coalitions [PDF, 140KB]
- QSO19-06-ALL [PDF, 474KB]
- SOM Appendix Z [PDF, 799KB]
- Page last Modified: 02/06/2019 2:01 PM
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