Emergency Preparedness

The Centers for Medicare & Medicaid Services (CMS) expects healthcare facilities, including ASCs, to be prepared for emergency situations.

Emergency Preparedness Plan

CMS breaks down a compliant EP plan into four basic provisions, outlined below. Each provision should be reviewed and updated at least every other year.

1. Risk Assessment and Planning

CMS encourages an “all-hazards” approach to EP development. This describes integrated planning to prepare for a wide range of man-made and natural emergencies, focusing on those most likely to occur for the specific provider location.

2. Policies and Procedures

Based on the risk assessment plan, facilities must develop policies and procedures that account for patient and staff needs in the case of identified emergency scenarios. Evacuation plans and procedures for all facility occupants should also be defined.

While most facilities must include contingency plans to transfer patients to similar facilities during an emergency, ASCs are not required to make arrangements to transfer patients to other ASCs. Instead, ASCs should include a plan to transfer patients to a hospital via a transfer agreement if patients require additional care during an emergency.

3. Communication Plan

The rule requires facilities to have a written emergency communication plan that describes how the facility will coordinate continued patient care within the facility, with outside healthcare providers and with state/local public health departments in the event of an emergency. Facilities should also consider how they will interact with emergency management agencies in protecting the health and safety of their patients. Location-specific considerations, such as limited access to internet or phone capabilities for those facilities in rural areas, must be incorporated.

Unlike hospitals, ASCs are exempt from providing information regarding their occupancy. Since the term "occupancy" usually refers to occupancy in an inpatient facility, ASCs do not need to provide for subsistence needs of their patients and staff. Similarly, CMS requires most facilities to track patients before, during and after emergencies but requires ASCs to track patients before and during emergencies only. If patients or staff are transferred for continued or additional care during an emergency, the ASC must document the specific name and location of the receiving facility or other location for those patients and on-duty staff who are relocated. If the ASC can close or cancel appointments, it does not need to track patients or staff.

4. Training and Testing

This provision affects all three provisions above. CMS requires all facilities to provide instruction to ensure that all staff or other facility workers are aware of EP plan procedures. Facilities should then conduct drills and/or exercises to practice policies and procedures, evaluate the effectiveness of the EP plan and identify areas for improvement.

Training Program

Under this requirement, training must be provided to all new and existing staff, individuals providing services under arrangement, individuals who provide services on a per diem basis and volunteers, and the training must be documented. Facilities must provide both initial training and reviews at least every two years in EP policies and procedures. It is up to the facility to decide what level of training each staff member will be required to complete based on an individual's involvement or expected role during an emergency. CMS recommends that for new hires, this be completed by the time the staff has completed the facility’s new hire orientation program.

ASCs have some flexibility as to the focus of this training, as long as it aligns with their emergency plan and risk assessment. CMS recommends training be modified periodically to incorporate lessons learned from recent exercises and any real-life emergencies that occurred since the last training. For example, staff should be trained on new evacuation procedures that were identified as a best practice during the last emergency drill, documented in the facility’s “After Action Report” (AAR) and incorporated into the center’s emergency plan during the program’s last review.

In Appendix Z, CMS advises that “facilities retain at a minimum, the past 2 cycles (generally 4 years) of emergency training documentation for both training and exercises for surveyor verification.”

Testing Requirements

CMS requires outpatient providers, including ASCs, to conduct one testing exercise annually, and at least every two years, that exercise must be a full-scale exercise. The first exercise should also be a community-based drill, if possible, but must be a full-scale exercise. For the purposes of this requirement, a “full-scale exercise is defined and accepted as any operations-based exercise (drill, functional, or full-scale exercise) that assesses a facility’s functional capabilities by simulating a response to an emergency that would impact the facility’s operations and their given community.”

For the years when a full-scale exercise is not required, an ASC must conduct either a facility-based drill or a tabletop exercise (TTX) or workshop that includes a group discussion led by a facilitator. According to 42 CFR 416.54(d)(2)(ii)(C), a table-top exercise (TTX) or workshop is a “group discussion led by a facilitator, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan.” It involves key personnel discussing simulated scenarios, including computer-simulated exercises, in an informal setting. TTXs can be used to assess plans, policies and procedures.

Examples of emergency scenarios that ASCs may consider for either of the required exercises include earthquakes, tornados, hurricanes, flooding, fires, cybersecurity attacks, single-facility disasters (power-outages), medical surges (i.e., community disasters leading to influx of patients), infectious disease outbreaks or active shooters. ASCs should assess which emergencies are most appropriate to them.

If the facility had an actual emergency, that could count as the test for the year, but it must be documented. Documentation may include, but is not limited to, a section 1135 waiver issued to the facility, time limited and event-specific; documentation alerting staff of the emergency; documentation of facility closures; meeting minutes that address time- and event-specific information. The facility also must complete an after-action review and integrate corrective actions into its emergency preparedness program.

Emergency Preparedness Resources

CMS Emergency Preparedness Rule Guidance

This is a CMS page with resources to help facilities as they implement this new rule. Included on this page is an Excel spreadsheet for surveyors that includes the Emergency Preparedness tags. While this document includes all facility types, ASCA has created an ASC-specific document so that our members can look at only the information that applies to ASCs.

CMS State Operations Manual – Appendix Z

The requirements in the final rule apply to all Medicare-certified providers and suppliers, and CMS has published interpretive guidelines in Appendix Z of the State Operations Manual (SOM) to aid compliance.

OCR Cybersecurity Guidance

Cybersecurity remains a threat, with high-profile ransomware attacks threatening a number of health care stakeholders. “Interruption in communication, including cyberattacks” are included in the elements that ASCs must consider when developing their EP plans.

The Office of Civil Rights (OCR) has developed a checklist that explains steps facilities should take in response to cybersecurity incidents. This includes both internal facility response procedures as well as steps to report cybersecurity events to the OCR, the Department of Health & Human Services and the Department of Homeland Security. These steps should be incorporated in the policies and procedures.

CDC Training and Educational Resources

The Centers for Disease Control and Prevention (CDC) provides some resources related to specific emergencies such as bioterrorism and chemical emergencies, as well as trainings targeted to specific audiences such as public health professionals and clinicians through CDC’s Clinician Outreach and Communication Activity (COCA) program. The CDC also links to other general Emergency Preparedness and Response Training Resources.

OSHA Preparedness and Response Resources

The Occupational Safety and Health Administration (OSHA) provides preparedness and response resources for a variety of emergency scenarios. There are resources pertaining to national disasters and weather, which should be considered as part of the all-hazards risk assessment. ASCs may also want to consider OSHA’s recommendations regarding planning for safe evacuations and deciding when to evacuate or shelter-on-place.

FEMA Emergency Preparedness Trainings

The Federal Emergency Management Agency (FEMA) supplies a number of training courses through its Emergency Management Institute (EMI). There are web-based training courses as well as a comprehensive course catalog that combines all FEMA emergency preparedness resources in one place.

Please contact Kara Newbury at knewbury@ascassociation.org with questions.