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12 min read

Emergency Preparedness 101: The Emergency Preparedness Program Plan

The Centers for Medicare and Medicaid Services (CMS) requirements for Emergency Preparedness (EP) establish national EP requirements for Medicare-participating facilities to plan adequately for natural and man-made disasters and coordinate efforts with Federal, state, tribal, regional, and local EP systems. These requirements focus on three key essentials necessary for maintaining access to healthcare during disasters or emergencies: safeguarding human resources, maintaining business continuity, and protecting physical resources. Successful adoption of the EP requirements will enable facilities, wherever they are located, to better anticipate and plan for needs, rapidly respond as a facility, as well as integrate with local public health and emergency management agencies and healthcare coalitions’ response activities, and rapidly recover following the disaster. This article discusses general information related to the Emergency Preparedness Program (EPP) plan itself. 

QUAD A facilities that fall under the CMS requirements for EP are required to develop and maintain an EPP that meets all the standards specified within SUB-SECTION D: Emergency Preparedness Plan. The EPP must describe a facility's comprehensive approach to meet the health, safety, and security needs of its staff and patient population during an emergency or disaster situation. The program must also address how the facility will coordinate with other healthcare facilities, as well as the community, during an emergency or disaster (natural, man-made, facility). The emergency preparedness program must be reviewed every two (2) years. This periodic review must be documented to include the date of the review and any updates made to the EPP based on the review. The format of the EPP is at the facility's discretion. Facilities are encouraged to continue reviewing and updating their EPP and train their staff accordingly, as the plan may change on a more frequent basis. 

A comprehensive approach to meeting the health and safety needs of a patient population should encompass the elements for EP planning based on an “all-hazards” approach that is specific to the location of the facility. For instance, a facility in a large flood zone or tornado-prone region should include these elements in its overall planning to meet the health, safety, and security needs of the staff and the patient population. Additionally, if the patient population has limited mobility, facilities should have an approach to address these challenges during emergency events. The term “comprehensive” is to ensure that facilities do not only choose one (1) potential emergency that may occur in their area but rather consider a multitude of events and be able to demonstrate that they have considered this during the development of their EPP. 

In addition, the EPP supports, guides, and ensures a facility's ability to collaborate with local EP officials. This approach is specific to the facility's location and considers particular hazards most likely to occur in the surrounding area. These include, but are not limited to:  

  • Natural disasters, such as: 
    • Earthquake
    • Tornado
    • Winter storms
  • Man-made disasters, such as: 
    • Active shooter
    • Hazardous material spills
    • Bomb threat
  • Facility-based disasters that include but are not limited to:  
    • Care-related emergencies
    • Equipment and utility failures, including but not limited to power, water, gas, etc.
    • Interruptions in communication, including cyber-attacks 
    • Loss of all or portion of a facility
    • Interruptions to the normal supply of essential resources, such as water, food, fuel (heating, cooking, and generators), and in some cases, medications and medical supplies (including medical gases, if applicable).  
  • Emerging infectious diseases (EIDs) such as Influenza, Ebola, Zika Virus, and others.  

When evaluating potential interruptions to the normal supply of essential services, the facility should take into account the likely durations of such interruptions. Arrangements or contracts to re-establish essential utility services during an emergency should describe the timeframe within which the contractor is required to initiate services after the start of the emergency, how they will be procured and delivered in the facility’s local area, and that the contractor will continue to supply the essential items throughout and to the end of emergencies of varying duration. However, we recognize that contracts may be subject to some issues in themselves as there are no guarantees that the contractor will be able to fulfill contract terms in the event of a disaster.  

Facilities should also be prepared to continue providing care in a safe setting if a contract cannot be fulfilled during the event. The EPP should consider contingency planning, such as evacuation triggers, in the event essential resources provided by the contractor cannot be fulfilled. Finally, facilities should also include in their planning and revisions of existing plans, contracts, and inventory of supply needs, availability of personal protective equipment (PPE), critical care equipment, and transportation options/needs to be prepared for surge events.  

The EPP must be in writing.

The requirements under the CMS EP Final Rule allow for documentation flexibility. While facilities are required to meet all the provisions applicable to their provider/supplier type, how they document their efforts is subject to their discretion. It is up to each individual facility to demonstrate their EPP in writing. Facilities that are part of a national chain or that have more than one (1) facility location that is using the same EPP, need to ensure that the EPP is specific to each location. Outpatient providers and suppliers are encouraged to keep documentation and their written EPP for a period of at least 4 years. This is recommended due to the requirements related to training and testing exercises. Testing exercises are required annually for outpatient providers; however, full-scale exercises are required every other year, with the opposite years allowing for the exercise of choice. To determine compliance, surveyors will review at least the past two (2) cycles (generally 4 years) of emergency testing exercises. Outpatient providers are not required to secure approval of the Emergency Program or official “sign-off.” However, it is recommended that facilities check with their State Agencies and local emergency planning coordinators (LEPCs), as some states require approval of emergency preparedness plans as part of state licensure.

The EPP sets the foundation for facility success in its response to an emergency so that it can rapidly respond, as well as integrate with local public health and emergency management agencies and healthcare coalitions’ EP response activities, and rapidly recover following the disaster or emergency. The State Operations Manual Appendix Z- Emergency Preparedness for All Provider and Certified Supplier Types Interpretive Guidance is an excellent resource for those Medicare-certified facilities requiring an EPP. Additionally, the US Department of Health & Human Services, Administration for Strategic Preparedness and Response, Emergency Preparedness Requirements for Medicare and Medicaid Participating Providers and Suppliers (CMS EP Rule) page provides excellent provider and supplier-specific resources. Continue to watch for future newsletter articles that continue to dive a little deeper into each EPP requirement.

Since 1980, QUAD A (a non-profit, physician-founded and led global accreditation organization) has worked with thousands of healthcare facilities to standardize and improve the quality of healthcare they provide – believing that patient safety should always come first.