Emergency Preparedness

For Medicare-certified ASCs, emergency preparedness (EP) plans and procedures must comply with a final rule published in September 2016 by the Centers for Medicare & Medicaid Services (CMS). This final rule established national emergency preparedness requirements for all 17 Medicare and Medicaid provider and supplier types. The rule creates mandatory elements and planning procedures that facilities must institute to account for facility occupant safety in the event of natural and man-made emergencies. Surveyors began surveying based on these requirements on November 15, 2017.

CMS breaks down a compliant emergency preparedness plan into four basic provisions, outlined below. Each provision should be reviewed and updated at least annually.

Emergency Preparedness Provisions

Risk Assessment and Planning

CMS requires facilities to use an “all-hazards” approach to emergency plan 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/supplier location.

Policies and Procedures

Based on the above risk assessment plan, facilities should 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.

Most facilities are required to include contingency plans to transfer patients to similar facilities during an emergency (§ 416.54(b)). However, the final rule referenced above exempted ASCs from this, so ASCs are not required to make arrangements to transfer patients to other ASCs. ASCs should include a plan to transfer patients to a hospital via transfer agreement (see sample here) if a patient requires additional care during an emergency.

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 health care 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 must also be incorporated, such as limited access to internet or phone capabilities for those facilities in rural areas.

ASCs are exempt from providing information regarding their occupancy as CMS proposed for hospitals. Since the term "occupancy" usually refers to occupancy in an inpatient facility, ASCs would not need to provide for subsistence needs of their patients and staff. Similarly, although most facilities are required to track patients before, during and after emergencies, ASCs are only required to track patients before and during emergencies. If patients or staff are transferred for continued or additional care, 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 during an emergency. If the ASC is able to close or cancel appointments, there is no need to track patients or staff.

Training and Testing

This provision takes into account all three provisions above. Facilities are required to provide education/instruction to ensure that all staff or other facility workers are aware of EP plan procedures. Drills or exercises should then be conducted to practice policies and procedures, evaluate the effectiveness of the EP and identify areas for improvement.

ASCs are required to take part in two annual emergency preparedness tests. The first exercise should be a community-based drill, if available. If a community drill is not available, CMS will require an ASC to conduct an individual facility-based drill. For the second exercise, an ASC would be required to conduct either a facility-based drill or a tabletop exercise.

Emergency Preparedness Resources

ASC EP Interpretive Guidelines Spreadsheet

ASCA has customized a CMS-developed spreadsheet that identifies all parts of the rule and interpretive guidelines applicable to ASCs. That document is available to our members here.

Agency 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 the document referenced above specifically for ASCs so that our members can look at only the information that applies to ASCs. That document is available here.

CMS SOM Interpretive Guidelines

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.

CMS Final Rule Presentation

CMS has posted a presentation that provides a general overview of the contents of the final rule. The presentation also includes timelines for compliance, some additional FAQs and an overview of the CMS Emergency Preparedness website.

OCR Cybersecurity Checklist

Cybersecurity has been a prevalent news topic recently, 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) provide a number of training and educational resources. There are 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. Additional resources are available through CDC’s Clinician Outreach and Communication Activity (COCA) program.

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 a number of good 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. There are web-based training courses that come out roughly every week, as well as a comprehensive course catalog that combines all FEMA emergency preparedness resources in one place.



Please write Alex Taira at ataira@ascassociation.org with questions.