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 CMS published in the Federal Register the Emergency Preparedness Requirements for Medicare and Medicaid Participating Providers and Suppliers Final Rule. The regulation became effective November 16, 2016. Health care providers and suppliers affected by this rule were to be compliant and implement all regulations one year after the effective date, on November 15, 2017.
On September 30, 2019 CMS published in the Federal Register the Medicare and Medicaid Programs; Regulatory Provisions To Promote Program Efficiency, Transparency, and Burden Reduction; Fire Safety Requirements for Certain Dialysis Facilities; Hospital and Critical Access Hospital (CAH) Changes To Promote Innovation, Flexibility, and Improvement in Patient Care Final Rule which revised some of the emergency preparedness requirements for providers and suppliers.
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. We would recommend reviewing the Power Point presentation in the downloads section for an overview of the recent 2019 changes.
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.
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). For the full Appendix Z, please see /Regulations-and-Guidance/Guidance/Manuals/downloads/som107ap_z_emergprep.pdf (PDF). CMS is working to update the Appendix in light of the recent changes.
Fact Sheet-CMS Releases Updated Emergency Preparedness Guidance (PDF)
Frequently Asked Questions Round Four Definitions (PDF)
Frequently Asked Questions (FAQs) Round One (PDF)
Facility Transfer Agreement - Example (PDF)
General Presentation - Overview of EP (PPTX)
17 Facility- Provider Supplier Types Impacted (PDF)
CMS Online Training for Emergency Preparedness (PDF)
Frequently Asked Questions (FAQs) Round Five (PDF)
Frequently Asked Questions (FAQs) Round Three Revised 6-1-17 (PDF)
Frequently Asked Questions (FAQs) Round Four (PDF)
CMS and NHPP Letter-Healthcare Coalitions (PDF)
Colorado Specific Healthcare Coalitions (PDF)