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Frequently Asked Questions About the
Emergency Preparedness Definitions

After November 15, 2017, care providers are to be in full compliance with the Centers for Medicare and Medicaid Services (CMS) Emergency Preparedness Rule standards in the Federal Register. This means every agency must have an official disaster plan.

If you’re still a bit unclear about what this means for emergency preparedness, read on. We’ve compiled a list of frequently asked questions that should help.

And remember - if you use an SaaS solution like WatchPoint AtRisk Registry, it’s easy to ensure full compliance with the CMS standards, including the communications plan provision and all required policies and procedures.

CMS Standards | FAQ’s

Is there a specific format required for documentation, policies, and procedures?

No, CMS.gov states that there is not an exact format to follow. However, a facility must be able to provide clear, written documentation and explain where the plan is located.

“Continuity of operations” is part of what’s required. What does that mean?

Continuity of operations, also called business continuity, refers to an organization’s ability to operate smoothly in a disaster situation. There are four phases to continuity: Readiness/preparedness, activation, continuity operations, reconstitution. To dig into this in deeper detail, click here to see phe.gov’s explanations, which you are allowed to copy-and-paste into your plan.

What is the definition of “community”?

If you are trying to define the scope of your plan, it can be hard to pin down the meaning of “community.” The CMS says they intentionally do not define it to allow flexibility in creating broad plans that promote integrated responses. The term can generally mean a geographic area plus coalitions and the broader medical response community. Your definition of community should reflect a realistic risk assessment for emergency preparedness.

How is “training” defined?

A training program must encompass initial emergency preparedness training for all staff, ongoing training for new staff, and annual refresher training where staff must demonstrate knowledge on policies and procedures. “All staff” means all individuals directly employed by the organization. The plan must include: drills, exercises, delineation of responsibility, and levels of training by professional role.

Does a local official have to approve the emergency plan?

No, a local official does not have to sign off on it, however you are required to prove that you have coordinated with local officials. This proof should be provided through detailed documentation of communication and planning with the health department, emergency management, first responders, and other emergency preparedness professionals. You must develop a list of contact information, comply with federal and state law, and demonstrate collaboration at many levels.

Who monitors our compliance?

Compliance is monitored by the State Survey Agencies (SA) and Accreditation Organizations (AOs). CMS Regional Offices (ROs) are involved in monitoring for compliance for participation in Medicare.

What if a local agency won’t collaborate with me by the deadline?

You must document efforts your facility made to cooperate and collaborate with the department. Be sure to include details and dates. This does not release you from meeting the deadline, however you must provide it.

What if we miss the deadline? Is there leniency if we tried to meet the deadline, but just couldn’t?

Surveying for compliance begins November 15, 2017 and there will be no exceptions for meeting the deadline, according to the CMS. Typical Conditions of Participation (CoPs) and Conditions for Coverage (CfCs) apply to noncompliance. Surveyors will use the Interpretive Guidelines and Survey Procedures in the State Operations Manual (SOM), plus their specific training, to determine compliance.

What should we do if we’re afraid we won’t meet the deadline?

Contact a company that helps organizations ensure they will meet all requirements by the deadline. These companies do a point-by-point analysis and provide specific instructions for anything missing. Brightgray Solutions’ WatchPoint AtRisk Registry is a great solution for this situation.

Free Emergency Preparedness Guide