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Jake Keator
November 16, 2021

Updated 2021 CMS Preparedness Guidelines

In September 2016, CMS released the Emergency Preparedness Requirements for Medicare and Medicaid Participating Providers and Suppliers Final Rule. This rule required all health care suppliers and health care providers, including ASC’, to become compliant and implement all regulations to participate in Medicare and Medicaid.

These guidelines were once again updated in March 2021. Below is an overview of the rule, including reasoning, updated guidelines, guidance overview and other helpful tips.


The Federal Register describes the purpose of the rule as follows:

“This final rule establishes national emergency preparedness requirements for Medicare- and Medicaid-participating providers and suppliers to plan adequately for both natural and man-made disasters, and coordinate with federal, state, tribal, regional and local emergency preparedness systems. It will also assist providers and suppliers to adequately prepare to meet the needs of patients, residents, clients and participants during disasters and emergency situations.

Despite some variations, our regulations will provide consistent emergency preparedness requirements, enhance patient safety during emergencies for persons served by Medicare- and Medicaid-participating facilities, and establish a more coordinated and defined response to natural and man-made disasters,” states.

Updated Guidelines

The March 2021 updated guidelines include:

“Emergency program: Decreasing the requirements for facilities to conduct an annual review of their emergency program to a biennial review. However, based on industry feedback, long-term care (LTC) facilities will continue to review their emergency program annually.

Emergency plan: Eliminating the requirement that the emergency plan include documentation of efforts to contact local, tribal, regional, state, and federal emergency preparedness officials and a facility’s participation in collaborative and cooperative planning efforts.

Training: Decreasing the training requirement from annually to every two years. Nursing homes will still be required to provide annual training.

Testing (for inpatient providers/suppliers): Increasing the flexibility for the testing requirement so that one of the two annually required testing exercises may be an exercise of the facilities choice; and

Testing (for outpatient providers/suppliers): Decreasing the requirement for facilities to conduct two testing exercises to one testing exercise annually.”

In addition to the March 2021 update, Appendix Z saw changes in February 2019 to include the phrase “Emerging Infectious Diseases (EID’s),” to the definition of the all-hazards approach.

“We are taking the opportunity further expand upon the interpretative guidelines where applicable to include best practices and planning considerations for preventing and managing EID’s in light of lessons learned during the onset of the COVID-19 public health emergency (PHE),” a March 2021 CME press release states.

Requirements Overview

When originally releasing it’s final rule CMS identified four core elements vital to an effective emergency preparedness program. These are listed below:

  1. i) Risk assessment and emergency planning. Facilities are required to perform a risk assessment that uses an “all-hazards” approach prior to establishing an emergency plan. The risk assessment will identify the essential components for integration in the emergency plan. An all-hazards approach focuses on capacities and capabilities critical to preparedness for the full spectrum of emergencies or disasters. It is specific to the location of the provider and considers the particular types of hazards most likely to occur in their areas (e.g.., care-related emergencies equipment and power failures; communications interruptions, including cyberattacks; loss of part or all of a facility; and, interruptions in the normal supply of essentials, such as water and food).
  2. ii) Policies and procedures. Facilities are required to develop and implement policies and procedures supporting the successful execution of the emergency plan and risks identified during the risk assessment.

iii) Communication plan. Facilities are required to develop and maintain a compliant emergency preparedness communication plan. Patient care must be well-coordinated within the facility, across healthcare providers, and with state and local public health departments and emergency management agencies and systems. During an emergency, providers must have a system to contact appropriate staff, patients’ treating physicians, and others in a timely manner to ensure continuation of patient care functions and that these functions are carried out in a safe and effective manner.

  1. Training and testing. Facilities are required to develop and maintain an emergency preparedness training and testing program. This must include initial training for new and existing staff in emergency preparedness policies and procedures and annual refresher trainings. Facilities must also conduct drills and exercises to test the emergency plan to identify gaps and areas for improvement.
  2. iv) Healthcare system participation. If your ASC is part of a healthcare system with a unified and integrated emergency preparedness program, you may participate in the program along with the healthcare system. Doing so adds some requirements, which may include the following:
  • Your ASC must actively participate in the development of the emergency preparedness program.
  • Development and maintenance of the program should take into account your ASC’s unique circumstances, patient populations, and services.
  • Your ASC must be capable of actively using the emergency preparedness program and is in compliance

To read the March 2021 CME press release in full, including its additional resources click here.


  • Ensuring compliance with this rule is not a one-person job. Be sure to delegate positions and duties to multiple staff members. Administrators will likely fill multiple positions and mange multiple duties.
  • Be sure to check you state requirements and accreditation standards. Some states may require additional checks and preparations on top of the above-described final rule. Ensure you are meeting state and accreditation standards as well.
  • Never assume your current plan will always work. Continually reevaluate your emergency preparedness plan and issue updates as needed. This should be considered a “living document,” and should be revisited annually.