CMS Guidelines 2017
Emergency Management Sep 12, 2017

2017 CMS Emergency Preparedness Guidelines: 4 Steps To Compliance

With new guidelines from CMS, organizations are faced with new challenges to stay compliant. Read on for some suggestions to build your now plan.

New emergency preparedness guidelines have been passed down by CMS for all Medicaid and Medicare providers. This means a massive headache for a lot of healthcare compliance professionals leading up to the November 2017 deadline. New rules can mean changes to well worn processes and procedures and added stress on managers, employees, and patients alike. But there is some good news – these guidelines are designed to make your organization safer, more efficient, and better at communicating, especially around emergency situations.

Getting started on your program planning can seem very overwhelming, but the best way to approach these new CMS guidelines is to find a way to make them work best for your organization. If you’re creating a plan and setting up emergency notifications for compliance purposes anyway, why not take the opportunity to put great systems in place and use them to their full advantage? We’re going point by point through the guidelines with tips on how to make these systems work for you.

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4 Steps to CMS Compliance
We’ve created a simplified checklist to help ease the pain of prepping your plan. Click the button below to download it now!

1. Build A Plan: Healthcare Emergency Management Planning

This is the first item addressed in the new regulations and the best place to start when building your CMS guidelines compliance strategy. You should begin with research, gathering all relevant material on local emergency requirements, important contact information, etc. The assessment checklist published by CMS (download here) recommends gathering the following information:

  • Copies of any state and local emergency planning regulations or requirements
  • Facility personnel names and contact information
  • Contact information of local and state emergency managers
  • A facility organization chart
  • Building construction and Life Safety systems information
  • Specific information about the characteristics and needs of the individuals for whom care is provided

The CMS guidelines also require your emergency plan to include a continuity of operations plan for several types of hazardous situations. They specify that facilities should develop this COOP plan with an all-hazards approach, taking into consideration for the following sorts of events: hurricanes, floods, tornadoes, fire, bioterrorism, pandemic, etc. If the event could disrupt the flow of service in any way it must be planned for.

You should also collaborate with local emergency services, analyze all hazards, collaborate with suppliers, and set up a hierarchy for decision criteria for your emergency plans.

2. Improving Hospital Efficiency With Policies and Procedures

This portion of the requirements will be highly tailored to your organization. In a call hosted by CMS going over the regulations as a whole, they stated the following about the policies and procedures requirement:

“Once an all-hazards approach has been conducted and a facility starts to put their emergency plan together, of course, this goes without saying, any type of facility has to develop policies and procedures to implement a plan of any kind. But it will be based on the risk assessment and emergency plan. And, again, policies and procedures will be required to be reviewed and updated on an annual basis. ”

This portion of the regulation is left pretty open ended, allowing your organization to create a program that works best for you. It includes 2 main items:

  1. Policies and procedures must be developed and maintained – so ongoing policies are key to staying compliant
  2. Policies and procedures must be reviewed and updated on an annual basis

The key to fulfilling this requirement is to fully develop and document your policies and procedures with a schedule for review, update, and maintenance built in to remain compliant. Use the flexibility of this requirement to build policies and procedures that work well for your organization and make ongoing compliance as easy as possible.

3. Develop An Emergency Communications Plan: Hospital Communications Systems Implementation

A systematic communications plan is incredibly important for any medical facility. As you develop your plans to meet this criteria, consider how a complete critical communications plan could benefit your organization as a whole rather than only working for compliance purposes. CMS puts a lot of emphasis on communication planning within your organization as well as with concerned parties outside of your organization.

Your communication plan must:

  • Coordinate patient care within a facility
  • Coordinate across health care providers
  • Coordinate with State and local public health departments
  • Coordinate with management systems
  • Comply with both Federal and State laws

This type of communications plan will require your organization to gather, store, and update a large amount of contact information for those who will need to receive your emergency communications. A notifications system or software solution will help you gather and maintain this data in a safe, efficient manner. Putting an emergency notification system in place will help automate your processes around sending these communications as well. Using a software solution is a great option for easily setting up a communications plan to be easy to maintain and keep up to date with compliance standards.


4. CMS Guidelines and Your Training and Testing Program

To meet the Training and Testing portion of the new CMS Guidelines your facilities must complete the following two items:

  1. Initial training for new and existing staff in emergency preparedness policies and procedures
  2. Annual refresher training so that staff can demonstrate knowledge of emergency procedures

It seems that CMS left this section more open ended intentionally. In the Testing and Training section of the final rule, CMS addresses some comments made in regard to the lack of specificity in this area of the rule. They state that this allows for a more tailored approach that works best for the facility and the hazards that your organization specifically faces.

The purpose of this requirement is to ensure that the processes you’ve put in place work well and are fully compliant. If you’ve put solid systems in place for the other three portions of the emergency program, especially in the planning and communication areas, your training exercises and program testing will be greatly simplified. Consider the ongoing annual training requirements when developing the rest of your emergency program to keep remaining compliant easy and efficient for your facility.


Through all four parts of these guidelines you can notice a theme – CMS puts a lot of emphasis on not only developing solutions for these items, but making a plan for maintaining them as well. A smart approach to meeting these requirements would be to factor in the long term sustainability of your emergency preparedness program to meet the compliance deadline and stay compliant as well. This means that your job with regards to these requirements does not end this November – it continues indefinitely. The key to remaining compliant will be simplifying your processes and procedures in a way that takes the burden off of you and your team.

If you’re not sure where to start, consider this quick list:

  • Develop an idea of what you’d like your plan, communications, and training to look like – ensure that you’re fulfilling all 4 branches of these regulations (download our 4 Steps To Compliance Checklist to stay on track )
  • Find software and processes that make implementing and maintaining compliance as easy as possible
  • Set a detailed timeline to get your organization fully compliant by November 2017
  • Extend your timeline past the compliance deadline to include opportunities to review your processes and ensure that your organization is remaining compliant

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