The rule is effective November 15, 2016 with an implementation deadline of November 15th, 2017.

The rule was published in the Federal Register on September 16, 2016. The final rule establishes emergency preparedness requirements for 17 Medicare and Medicaid participating providers and suppliers. The intent of the new conditions of participation is to ensure providers and suppliers are prepared to meet the needs of their patients, residents, and clients in the event of a disaster or emergency. A new appendix will be added to the SOM and a new set of tags will accompany it. CMS is anticipating that the surveyor guidance and training will be available in Spring 2017.

The three main goals of the requirements were to address systematic gaps in response to disasters, establish consistency, and to encourage coordination with local and state emergency preparedness agencies. In addition, the new rule also identifies four main elements crucial to an effective emergency preparedness program. The elements, outlined below, give you a quick at-a-glance look at what will be required of your facility.


Risk assessment and planning-All providers must use an all-hazards approach when developing an emergency preparedness plan. There must be a community-based risk assessment and a facility-based risk assessment. The plan would have providers plan and identify in advance, essentials functions and identify who is responsible for carrying out those functions in the event of a crisis. The emergency plan should identify essential risks that the provider may likely encounter, business functions that should continue, provider location, and so on.


Providers must develop policies and procedures based on the emergency preparedness plan. For example, the plan should include such things as a system of medical documentation that preserves resident information, protects confidentiality and secures and maintains the availability of records; a means for sheltering in place; a system to track the location of on-duty staff and sheltered residents, etc.


A communication plan that identifies and allows for an alternate means of communication, providing information to local and state authorities, sharing medical information, providing occupancy information, and the ability to provide assistance to other providers in the community.


Emergency preparedness program must contain a provision for training and testing which requires the facility to train their staff on the plan and to test the plan through drills. The conditions of participation for hospitals are the most comprehensive and thus will serve as a guide for all other providers and suppliers with the regulations modified based on provider type. In regards to long-term care there are additional requirements that should be addressed along with the requirements for a hospital. They are 1) “§ 483.73(a) (1), we proposed that in an emergency situation, LTC facilities would have to account for missing residents.” and 2) “483.73(c) (8) A method for sharing information from the emergency plan that the facility has determined is appropriate with residents and their families or representatives.’’