The Centers for Medicare & Medicaid Services (CMS) on June 2 made available several documents on its Final Rule on Emergency Preparedness, which has been part of the CMS Conditions of Participation since November 16, 2016. The 17 provider types to which the rule applies must comply with and implement all regulations by November 16, 2017. These CMS documents were shared with members via a June 6, 2017, e-mail communication:

  • An advance copy of a new Appendix Z of the State Operations Manual (SOM), which contains the interpretive guidelines and survey procedures for the Emergency Preparedness Final Rule
  • A letter directed to State Survey Agency Directors offering background and explanation of the above appendix
  • An Excel document that includes information from the Final Rule and the Interpretive Guidelines, and shows the applicability of these elements to the various provider types to which the rule applies

To assist members with compliance, we created a simplified hospital-only version of the CMS Excel document (attached). For each section of the Final Rule applicable to hospitals, the document contains the section title, the corresponding citation, the Final Rule regulatory text, and corresponding language from the Interpretive Guidance. Of note, the far right Interpretative Guidance column contains a “Survey Procedures” section that provides instructions in bullet form to surveyors on how they should assess compliance with that section.  Hospitals are encouraged to carefully review this information.

Additionally, GNYHA developed the table below to briefly describe sections within Appendix Z of the SOM (attached) that we believe are particularly useful to hospitals working to implement the final rule. Information in the Relevance column synthesizes details from each referenced section.

Requirement Area/Tag # Page #, Appendix Z Relevance
Definitions Pages 3-5 The definitions provide insight into CMS’s interpretation of key concepts and essential aspects of the final rule. Hospitals are encouraged to carefully review the provided definitions of full-scale and table-top exercises
E-0004, Develop and Maintain Emergency Preparedness Program Pages 7-9 CMS provides detail on components of the emergency plan, including conducting facility-based and community-based risk assessments, identifying continuity of business operations, and how the facility collaborates with local emergency preparedness officials. CMS also provides a list of facility-based disasters the plan should address.
 E-0006, Maintain Annual Emergency Preparedness Updates Pages 9-12 CMS provides further detail on the risk assessments that should form the foundation of the facility’s emergency preparedness plan, as well as a list of considerations for the plan.
 E-0007, Emergency Preparedness Program Patient Population Pages 12-14 CMS provides further detail about components that should be considered when specifying at-risk populations served. Facilities must consider at-risk patients and at-risk community members. The emergency preparedness plan must also address services the facility would provide during an emergency, and continuity of operations considerations.
E-0015, Sustenance Needs Pages 21-24 CMS presents the framework for addressing staff and patient sustenance needs. To be in compliance, facilities must demonstrate how needs for food, pharmaceuticals, medical supplies, and alternate energy sources will be met. Hospitals should review this section with Section E-0041.
E-0020, Policies and Procedures-Evacuation Pages Pages 28-32 CMS details expectations for evacuation that should include patients and staff, transportation arrangements, triaging systems, and primary and alternate means of communication.
 E-0037, Emergency Preparedness Training Program Pages Pages 52-56 CMS details expectations on initial and annual training, as well as for updating training based on exercises and real-world events. CMS provides latitude regarding the level of training required for staff in different roles.
 E-0039, Emergency Preparedness Testing Requirements Pages 57-61 CMS provides further detail on types of exercises facilities must complete, as well as when a facility-based exercise is allowable instead of a community-based exercise. CMS also details support and potential opportunities for community-based exercises.
 E-0041, Emergency Power Pages 62-67 CMS provides additional information about compliance related to emergency power systems aligned with NFPA 99 and 110.
E-0042, Integrated Health Systems  Pages 67-70 CMS provides additional detail on expectations of individual providers even when included within a broader integrated health system plan. CMS also further details expectations of the unified emergency preparedness plan for an integrated health system.

GNYHA Activities

GNYHA, in collaboration with New York City and State response agencies, is developing language for City and State protocols and processes that directly address specific requirements of the CMS Final Rule. This will be provided to hospitals for integration into existing Emergency Operations Plans, policies, and procedures.

Information on the CMS Rule is available on the GNYHA website in the Emergency Preparedness section. Please contact Jenna Mandel-Ricci with any questions about the CMS Final Rule on emergency preparedness.