THCA Notes

Volume XXXI, Number 11
November 2016

Summary of Emergency Preparedness Requirements for Medicare and Medicaid Participating Providers and Suppliers

Members Impacted

These include Skilled Nursing Facilities (SNF), Nursing Facilities (NF) and Intermediate Care Facilities for Individuals with Intellectual Disabilities (ICF/IID). This final rule is not applicable to Assisted Living Providers. The rule was released on Friday, September 16, 2016, and can be found here.


The four main components of the requirements are consistent with the National Preparedness Cycle. The emergency plan, policies and procedures, communication plan and the training and testing program all must be reviewed and updated at least annually. Annual reviews will allow a center to identify gaps and areas for improvement to the center’s emergency plan. Policies and procedures are to be based on the emergency plan, risk assessment, and the communication plan. The policies and procedures will operationalize a center’s emergency plan. Components of the final requirements focus on an integrated response during a disaster or emergency situation. Surveyors will be provided training on the emergency preparedness requirements and interpretative guidance will be developed for each provider and supplier types.

Below is an overview of the six main components of the rule with suggested next steps for providers to take to help prepare for the November 2017 implementation date.

Emergency Plan

The final rule states that the emergency plan must be based on and include a documented, facility-based and community-based risk assessment, utilizing an all-hazards approach, including missing residents. Strategies for addressing emergency events identified by the risk assessment, resident population, the type of services the center has the ability to provide in an emergency; and continuity of operations must be included in the plan. For ICF/IID members, the rule explains that the emergency plan must address the special needs of its client population. Centers will need a process for cooperation and collaboration with local, tribal, regional, State, or Federal emergency preparedness officials’. Centers will need to include documentation of their efforts to contact officials and of their participation in collaborative and cooperative planning efforts.

Next steps: Review your emergency operation plan (EOP). Does it reflect the specific high-risk hazards for your area and the needs of your unique population (i.e. secured perimeters, technology-dependent residents/clients). Contact your local emergency preparedness and response agencies and ask to speak to the contact for the medical-health emergency planning in your area. Ask for a copy of the local hazard vulnerability analysis so you can be aware of the hazards identified for your surrounding community. Start a business continuity plan if you don’t have one. A template is available here.

Policies and Procedures

The final rule outlines the provision of subsistence needs for staff and residents, whether they evacuate or shelter in place, will need to include: (1) food, water, medical, and pharmaceutical supplies. (2) Alternate sources of energy to maintain- temperatures, emergency lighting, fire detection, extinguishing, and alarm systems, sewage and waste disposal.

The final rule clarified that centers will need to include a system to track the location of on-duty staff and sheltered residents in the center’s care during and after an emergency as well as a system for medical documentation. Safe evacuation and shelter in place procedures will need to be included. Evacuation policies and procedures will need to consider care and treatment needs of evacuees, staff responsibilities, transportation and identification of evacuation location(s). Centers will also need to include arrangements with other LTC facilities and other providers to receive residents in the event of limitations or cessation of operations.

Next steps: Identify potential LTC centers, other providers and community resources that your center has a relationship with or will need to establish a relationship with to develop arrangements with in the event of an emergency. Develop procedures for the care of multiple emergency admits including staff, space and equipment. This is called “Surge Capacity” and planning tools are available here.

Communication Plan

A center’s emergency preparedness communication plan must comply with Federal, State, and local laws. The communication plan must include name and contact information for nine key groups including volunteers. The final rule states that centers will need to provide a primary and alternate way for communicating with center staff and Federal, State, tribal, regional, or local emergency management agencies. The communication plan in the final rule outlines eight components the plan must include and does not require specific timeframes for center communications in the emergency preparedness requirements.

Next steps: Review the eight components and the nine key groups and begin to plan how to incorporate this information into your EOP. Also consider the question of way alternate way for communication with staff and emergency agencies you will use should cell phone service be unavailable.

Training and Testing

Centers will need to conduct initial training in emergency preparedness policies and procedures to all new and existing staff, contract staff, and volunteers. Training must be documented and staff must be able to demonstrate knowledge of the emergency procedures.

Center’s must conduct exercises to test the emergency plan at least annually, including unannounced staff drills using the emergency procedures. Centers will need to participate in a full-scale exercise that is community-based if not accessible then an individual, facility based. An additional exercise will need to be conducted by the center such as a second full-scale exercise that is community-based or individual, facility-based or 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. Testing will need to include an analysis of the center’s response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the emergency plan, as needed.

Emergency and Standby Power Systems *Does not Apply to ICF/IID Communities.*

The final rule adopts the Health Care Facilities Code (NFPA 99, Life Safety Code NFPA 101 and NFPA 110) for the location of the emergency generator and the Health Care Facilities Code, NFPA 110, and Life Safety Code for the emergency power system inspection, testing, and maintenance requirements. For centers that maintain an onsite fuel source to power emergency generators must have a plan for how it will keep emergency power systems operational during an emergency.

Next steps: Identify your center’s emergency power source and identify its capacities such as will it power the entire building, including HVAC, refrigeration, medical equipment needed for life support etc.

Integrated Healthcare Systems

The final rule added if a center is part of a healthcare system consisting of multiple separately certified healthcare facilities that elects to have a unified and integrated emergency preparedness program, the LTC facility may choose to participate in the healthcare system’s coordinated emergency preparedness program. If the center chooses to utilize an integrated emergency preparedness program the program must show that each participating facility actively participated in the development of the emergency preparedness program. The program must take into account each separately certified facility’s unique circumstances, patient populations, and services offered. All participants must demonstrate that they are capable of using the program and that it is in compliance with the policies and procedures, communication plan and training and testing components of the emergency preparedness regulation.

Next steps: Explore the availability of full-scale exercises planned for your community in which your center could participate. The local emergency planner for medical/health response should be able to help with this. Additionally, the local acute care hospitals may know of up-coming exercises that are open to your participation. Templates for drills and exercises are available here.

Helpful Resources

  • CMS, Medicare Learning Network will be hosting a webinar on the new requirements, Wednesday October 5th 2016 at 1:20 ET. For more information, please click here.
  • Overview session at AHCA/NCAL National Convention entitled, “The New CMS Rules: Raising the Bar on Emergency Preparedness” on Tuesday, October 18 at 10:00 AM – 11:00 AM ET by Jocelyn Montgomery, RN and Director of Clinical Affairs, California Association of Health Facilities, Sacramento, California
  • CMS will create a webpage for the rule here. Additionally, the Office of the Assistant Secretary for Preparedness & Response (ASPR) has also created a resources webpage for the final rule.

For more information about emergency communication planning:

Additional information and resources regarding the application of the HIPAA Privacy Rule during emergency scenarios can be located at: