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What the CMS Emergency Preparedness Rule Means for ASCs

By March 2, 2017June 11th, 2019ASC Management
CMS Emergency Preparedness Rule

The Final Rule outlining Emergency Preparedness Requirements for Medicare and Medicaid Participating Providers and Suppliers became effective November 15, 2016.  Ambulatory surgery centers (ASCs) are one of 17 providers and supplier types that must comply with and implement all regulations by November 15, 2017.  The purpose of the 186 page rule is to institute national emergency preparedness requirements and increase patient safety during emergencies.  It also establishes a more coordinated response to natural, technological, and human-caused disasters.

ASCs are required to meet the following four core elements for conditions of participation.  There is a fifth element applicable for integrated ASC health systems who elect to participate in a coordinated emergency management program.

Establishing and maintaining an emergency preparedness program that meets the requirements outlined in the rule, include but are not limited to, the following elements:

1. Develop and maintain an Emergency Management/Operations Plan. Review and update annually. The plan must:

a. Be based on and include a documented facility and community-based risk assessment using an all hazards approach.

b. Include strategies for addressing emergency events identified by the risk assessment.

c. Address patient populations served by the plan. This includes, but is not limited to, the type of services the ASC can provide in an emergency and continuity of operations such as delegation of authority and succession plans.

d. Include a process for cooperation and collaboration with local, tribal, regional, state and federal emergency preparedness officials’ efforts to maintain an integrated response during a disaster/emergency. Integration includes documentation of the ASC’s efforts to contact such officials and its participation in collaborative planning efforts.

2. Establish corresponding policies and procedures.

a. Must be based on the emergency plan, risk assessment, and communication plan.

b. Must be reviewed and updated at least annually.

c. Must minimally address the following elements: tracking sheltered or relocated patients and on-duty staff during an emergency, evacuation from the ASC, a means for sheltering in place, a system of medical documentation, the use of volunteers and other staffing strategies, and the role of the ASC in the provision of care and treatment as an alternate care site.

d. Additional specific requirements pertaining to policies and procedures are available in the Federal Register, Vol. 81, No. 180.[1]

3. Communications Plan

a. Must comply with federal and state laws. It needs to be reviewed and updated at least annually and include the seven elements outlined in the rule.  For more information on the seven elements, refer to page 165 via the hyperlink referenced below.

4. Training and Exercise Program

a. Develop a training program based on the emergency plan, risk assessment, policies and procedures, and communication plan. This should include initial and ongoing training on policies and procedures. Your training program should be reviewed and updated at least annually.

b. Maintain documentation of all emergency preparedness training and demonstrate staff knowledge of emergency procedures.

c. Conduct at least two exercises annually. One should be a community-based full scale exercise if possible. The other should be a facility-based full scale or table top exercise.

d. Develop a documented after action report and improvement plan. Implement improvement items identified and maintain documentation of same.

5. Integrated Health Care Systems

a. ASCs in a system containing multiple separately certified health care facilities that elect to have a unified and integrated emergency preparedness program must meet the five elements outlined in the Integrated Health Care Systems section of the rule.

Accreditation Status:

A facility’s accreditation status is a significant factor in determining the burden to an ASC in terms of both the workload and the associated costs required to meet the new CMS requirements.  The final rule calculates anticipated burden hours and cost estimates for each of the four core elements based on accreditation status.  ASCs accredited by the American Osteopathic Association/Healthcare Facilities Accreditation Program (AOA/HFAP) and American Association for Accreditation of Ambulatory Surgery Facilities (AAAASF) currently have minimal emergency preparedness requirements. Therefore, their anticipated burden is higher.  The Joint Commission (TJC) and the Accreditation Association for Ambulatory Health Care (AAAHC) accreditation standards contain more extensive emergency preparedness requirements. Although ASCs with TJC or AAAHC accreditation will likely incur some work to meet the requirements, their anticipated burden is lower than AOR/HFAP and AAAASF accredited facilities.

What are the next steps for your ASC?

  1. Review the section of the Final Rule that pertains to ASCs on pages 77-82 by clicking on the following link:
  2. Schedule an initial meeting to start work on performing a thorough risk assessment (also known as a Hazard Vulnerability Analysis or HVA).
  3. Complete a gap analysis by cross-walking your existing Emergency Management Program with the final CMS rule to identify areas that do not meet the requirements. Your existing Emergency Management Program should include your Emergency Management/Operations Plan, response plans, policies and procedures, as well as your training and exercise program.
  4. Develop relationships with other ASCs and share your work with one another.
  5. Find local and national resources for the Final Rule at
  6. Take advantage of technical resources which can be found at Click on “CMS Emergency Preparedness Rule: Resources at Your Fingertips” and refer to pages 15-16 for plans, tools, templates, and links to other resources.     
  7. Develop a relationship with your local hospital(s), public health agency, and the Office of Emergency Management. This may be accomplished directly and/or through your regional Health Care Coalition.
  8. Health Care Coalitions are currently evolving in Colorado. Contact your local Hospital Emergency Preparedness Coordinator, Local Public Health Agency, or Office of Emergency Management to determine how to get involved in your designated coalition.[2]

Julie Zangari – Emergency Preparedness Coordinator of Peak One Surgery Center

Michaela Halcomb – Administrator of Peak One Surgery Center 


[2] A Health Care Coalition resource specific to Colorado is:


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