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CMS Updates Guidance for Emergency Preparedness Regulations

Posted Apr 2, 20213 min Read

Regulatory & Clinical
CMS has posted a Quality, Safety, and Oversight Group (QSO) memo updating the State Operations Manual  Appendix Z outlining emergency preparedness (EP) requirements. It now reflects the revisions made within the 2019 final rule,  Medicare and Medicaid Programs; Regulatory Provisions to Promote Program Efficiency, Transparency, and Burden Reduction (CoPs) (CMS 3346-F). CMS has also added new guidance related to Emerging Infectious Disease outbreaks, including best practices, lessons learned, and general recommendations for planning and preparedness.

This guidance is effective immediately. CMS is currently working on relevant updates to the Emergency Preparedness Basic Surveyor Training Course, which will be available at a later date.

The changes are extensive, and members are encouraged to review the complete QSO memo. AHCA/NCAL has also provided a high-level summary.

Notable changes include:

  • For surveys of LTC facilities, health surveyors should consult with Life Safety Code (LSC) surveyors when concerns related to emergency power are identified to determine if a deficiency should be cited under EP standards or LSC standards.
  • Definitions for Community Partners, Functional Exercise, Mock Disaster Drill, and Workshop have been added. The definition for Full-Scale Exercise has been revised.
  • Reminders have been added where specific citations for LTC facilities differ from other providers in the guidance.
  • The EP program and its elements must be reviewed and updated annually for LTC facilities.
  • CMS is not requiring approval of the EP program or official “signoff,” but recommends facilities check with their State Agencies and local emergency planning coordinators as some states require approval of the EP plans as part of state licensure.




Please Contact Lori Davenport with member question