Changes to CMS Final Rule on Emergency Preparedness due to Regulatory Provisions

December 16, 2019

This September, the Centers for Medicare & Medicaid Services (CMS) introduced Regulatory Provisions To Promote Program Efficiency, Transparency, and Burden Reduction, which revises some of the emergency preparedness requirements for providers and suppliers. These changes are designed to reduce the burden on providers and are effective as of November 29. Originally published in September 2016, the CMS Emergency Preparedness Final Rule went into effect in November 2017.

GNYHA has summarized the major revisions in the table below. We have also attached a recent presentation by Caecilia Blondiaux of CMS’s Division of Acute Care Services, Quality, Safety, and Oversight Group, which also summarizes and synthesizes the changes. While the CMS Emergency Preparedness Rule page has not yet been updated to reflect the changes, based on information provided by CMS, it should be updated shortly. Please note that while the revisions are technically effective, surveyor training and updates to Appendix Z are not yet complete. Additionally, The Joint Commission and other accreditation organizations have not yet incorporated these changes and may continue to have standards that exceed those of CMS. Because it may take time for survey mechanisms to fully incorporate the recent revisions, facilities may choose to continue to meet the previous requirements for the next several months. If facilities have specific questions, staff are urged to send an e-mail to

Requirement Area Major Change
Review and Updates Plans, policies, procedures, and communication plan review and updating is reduced to at least every two years from at least annually (remains annually for long-term care facilities). Reviews/updates should still occur as needed.
Risk Assessment and Planning Facilities must have a process for cooperation and collaboration with local, regional, State, and Federal emergency preparedness officials’ efforts to maintain an integrated response. Facilities should be able to describe the process, and while documentation is suggested, it is no longer required.
Training and Testing Program For inpatient providers, CMS has expanded the types of acceptable testing exercises that may be conducted to include: functional exercises and workshops as defined by the Homeland Security Exercise and Evaluation Program, and mock disaster drills. Also, for inpatient providers, one of the two annually required exercises can be an exercise of their choice. A community-based full-scale exercise is no longer required.

For outpatient providers, facilities are required to only conduct one testing exercise annually. However, the facility must conduct a full-scale or individual facility-based exercise every two years, with an exercise of their choice the other year.

Participation in Health Care Coalitions CMS does not specify a facility’s level of involvement in health care coalitions. However, if a facility uses coalition-led activities to meet requirements, they should be documented.
Sustenance CMS does not specify quantities within any provisions.
Life Safety Code (LSC) vs. Emergency Preparedness (EP) Many inpatient providers, including hospitals and nursing homes, have life safety from fire protection conditions of participation that require compliance with the LSC. The LSC typically requires an emergency power system to provide limited emergency power. Therefore, if a surveyor determines a deficiency associated with an EP requirement that goes beyond what the LSC requires, CMS recommends that the health surveyor performing EP evaluations consult with their LSC colleagues to review this determination.
News Attachments