CMS Emergency Preparedness Plan: Policies and Procedures for Continuity

by | Jul 8, 2019

This post has been updated to reflect clarifications released February 2019 and revisions proposed September 2018. It was originally published April 20, 2017


Healthcare facilities need to regularly review and update their emergency preparedness plans to comply with the Center for Medicare and Medicaid Services (CMS) emergency preparedness rule. In a series of blog posts, we address each of the key areas covered by the CMS emergency preparedness requirements. This post looks at policies and procedures that are needed to comply with the CMS emergency preparedness rule.

The first critical step for any healthcare organization engaged in emergency management is risk assessment. An all-hazards assessment of probable risks faced by a facility provides the foundation for all the steps that follow.

The second step, discussed in detail below, is creating policies and procedures based on the risk assessment. Your documented emergency plans — such as an Emergency Operations Plan (EOP) or Continuity of Operations Plan (COOP) — must include policies and procedures to respond to the following:

1. Meeting subsistence needs

One of the critical emergency preparedness lessons from Hurricane Katrina was the importance of providing for the subsistence needs of those who had been sheltered in place. Stores of subsistence provisions — food, water, medical supplies, and pharmaceuticals — must be maintained at appropriate levels. A well-cataloged inventory can track supply levels and expiration dates to avoid waste.

2. Maintaining safe and sanitary conditions

These provisions need to be kept available for emergency situations when the power is out and water isn’t running. An alternate power source is critical for maintaining the appropriate temperature for heat- or cold-sensitive supplies and to maintain habitable conditions. In addition to power, heating and cooling, your emergency preparedness policies and procedures should address emergency lighting, fire detection and extinguishing, and managing waste, including sewage, solid waste, recyclables, chemical, biomedical waste, and waste water. Clarifications to the CMS emergency preparedness rule published February 1, 2019, emphasize that when facilities cannot maintain safe conditions, including a temperature consistent with patient and staff safety, they must have a relocation/evacuation plan. The 2019 update also explains in greater detail the requirements pertaining to both portable and permanent emergency power generators.

3. Keeping track of patients and staff

Being able to locate your personnel is essential in a disaster situation. Documenting the location of each member of your staff in the event of evacuation ensures continuity of care and helps manage human resources in a time of flux. Though the CMS emergency preparedness final rule removed a emergency preparedness requirement for facilities to track patient location after an emergency, hospitals must have a clear record of their location during an emergency.

Most importantly, healthcare providers must be able to share location information with patients’ family and friends as well as emergency responders and agencies. The CMS emergency preparedness rule allows facilities to choose whether to share that information electronically or via hard copy, but the reality is that real-time information management on a large scale is best managed by an electronic solution.

4. Preserving and sharing patient records

Care teams must have ready access to patient records to maintain continuity of care, even when a patient is transferred to another facility or alternate care site. The CMS emergency preparedness rule requires that healthcare facilities’ emergency preparedness plans include procedures to secure the availability of patient records.

As with patient location, the CMS emergency preparedness rule does not require that this information be saved or accessed electronically, but most healthcare facilities will find it efficient to do so, especially since the CMS emergency preparedness requirements explicitly state that record keeping and sharing must be compliant with HIPAA, even in an emergency.

5. Providing continuity of care in multiple scenarios

 A hazard vulnerability analysis (HVA) will help facilities identify the circumstances under which patients and staff will evacuate, when they will shelter in place, and when they will receive patients from other facilities. Emergency preparedness policies and procedures should make clear the criteria for deciding which personnel and patients will shelter in place when those circumstances arise.

Apart from the needs already listed, facilities must anticipate alternate means of communication and alternate staff roles. A centralized virtual communication center and database of certifications/skills can help facilitate quick decisions and deployment of resources when the usual chain of command is disrupted.

6. Collaborating effectively with community partners

All facilities must have a plan to address medical surges, including emergency preparedness policies and procedures addressing the use of volunteers and, for facilities that provide continuous care, receiving patients from other facilities.

The emergency preparedness plan must also address the role of the hospital under a 1135 waiver, when certain Medicare, Medicaid or Children’s Health Insurance Program (CHIP) requirements may be waived during a public health emergency to make it easier to use and staff alternate care sites.

The CMS emergency preparedness rule explicitly states that CMS encourages providers to collaborate with local officials and facilities to plan a community-wide response to assure continuity of care.

CMS emergency preparedness plan templates

CMS does not provide a CMS emergency preparedness plan template, though it does provide an after-action and improvement plan template. Third-party resources for preparedness planning promoted by CMS (PDF) include the following plus others:

In response to a request for technical assistance with disaster preparedness plan templates that would meet the CMS emergency preparedness rule requirements, ASPR TRACIE identified several resources (PDF) including:

More CMS emergency preparedness plan templates and examples you may find helpful include CMS Emergency Preparedness Rule Toolkit: Hospitals (PDF), updated October 2019 by the Wisconsin Department of Health Services, which provides one of the most comprehensive CMS emergency preparedness plan templates available at no charge.

LiveProcess has on-demand webinar series on the topic of CMS emergency preparedness planning. Although designed for long-term care organizations, these emergency preparedness best practices also apply to other types of healthcare facilities. Best practices emergency management planning will largely address the CMS requirements.

The CMS emergency preparedness regulations explain that CMS intentionally did not provide detailed requirements for emergency preparedness policies and procedures. Instead, CMS is asking facilities to rely on a thorough assessment of their location, staff, and patient population to determine the measures that would be most effective. 

Our solutions

LiveProcess Emergency Manager is a proven system for emergency preparedness planning, mass notification and mobilization, real-time coordination and tracking.  Hospitals and health systems, ambulatory centers, home health agencies, nursing homes, and public agencies use Emergency Manager to prepare for and respond to disaster events and for everyday coordination.

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terry-zysk-100x100Terry Zysk, CEO of LiveProcess, has more than two decades of experience in leading organizations that provide innovative solutions to the healthcare industry.