Ultimate Guide: How to Build your CMS Compliant Emergency Plan

By September 12, 2017 Emergency Management
Emergency Preparedness Plan Ultimate Guide

The Center for Medicare and Medicaid Services (CMS) is requiring all Medicare and Medicaid suppliers/providers to have an emergency preparedness plan in place by November 15, 2017. The new guidelines are to further ensure patients, residents, clients and participants are safe and informed during natural and man-made critical events.

Before an emergency plan is created, facilities should gather all relevant information that could apply. This information includes, but is not limited to:

  1. State and local emergency planning regulations and requirements
  2. Facility personnel names and contact information
  3. Contact information of local and state emergency managers
  4. Specific information about the characteristics and needs of the individuals being cared for
  5. Building construction details

Once you’ve gathered the necessary information you’ll be ready to begin creating your plan. Ready? Let’s get started.

Step-By-Step Guide: What Should an Emergency Plan Entail?


1. Analyze All-Hazards

Emergency plans should encompass an all-hazards approach. An all-hazards approach takes into account all man-made and natural disasters and emergencies that can strike a facility.  Types of hazards can include:

  • Care-related emergencies
  • Fires
  • Active Shooters
  • Equipment and power failures
  • Interruptions in communication
  • Loss of a portion or all of a facility

Your emergency plan should determine the specific action to be taken for each hazard. Such actions should include:

  • Appointed staff responsible for executing the plan and their duties
  • Description of supplies, equipment, and maintenance needed to sustain operations and deliver care. 3-10 days worth of supplies is recommended according to the U.S. Department of Health and Human Services
  • Include a Continuity of Operations Plan (COOP), although a facility may not be in harm’s way, the suppliers, utility providers or staff members may be
  • Efficient communication procedures to receive emergency warning/alerts as well as outwardly communicate with staff, families and patients during a critical situation

You should consider the way your organization will want to communicate around these different types of events. Simply planning how to communicate will leave you to figure out exactly what you want to say when disaster strikes. Instead, craft your messaging and communications plan as a whole before the event happens.

A mass notifications software solution can help you organize the way you plan for and communicate around these events. Having a place to store your contact records and communications templates will save your organization time and frustration.

2. Communication Infrastructure

Proper communication before, during and after an emergency is the key to your emergency preparedness plan. Proper communication will inform staff, residents and family members of the disaster at hand and where and what they should be doing during the event. Top factors to incorporate into your emergency communication infrastructure:

  • Established contingencies for facility communication in the event of telephone failures. Resort to sources such as walkie-talkies, ham radios, emergency notification systems, etc.
  • It is crucial to communicate what is occurring and what the action plan is to residents and their families. This will include how they are being evacuated, where they and their belongings are being taken and confidence the relocation will be able to meet their healthcare needs
  • Ensure families know beforehand how and when they will be notified regarding evacuation plans and how, where and when they can plan to meet their loved ones
  • Provide a dedicated method where family members can receive updates

Communicating on this scale can be logistical nightmare. Massive amounts of contact information to manage and potential technical issues with the communication itself can leave you in a challenging situation. CMS requires annual full scale testing and review/update of all policies and procedures. Whether it’s a drill or the real deal, one day you’ll have to deploy an actual message to stay compliant.

Learn More: HOW TO COMMUNICATE WITH HEALTHCARE EMPLOYEES THE RIGHT WAY

3. Shelter-in-Place

Transporting patients during extreme or hazardous conditions is risky. Evacuation for medical patients should only be taken if the shelter-in-place results in greater risks than evacuation. To develop and effective shelter-in-place plan:

  • Determine whether the facility is strong enough to withhold severe weather conditions
  • Determine if the building can be secured from hazards
  • Establish procedures on how and when to communicate with emergency management agencies
  • Maintain sufficient resources for the facility (power, water supply, food, medical supplies, etc.)

4. Evacuation Route

All staff should know the primary, as well as the alternate, evacuation routes from the building. Once a standard route is established, there needs to be an effective plan in place. Top items your plan should include:

  • Assigned individual who is responsible for running evacuation plans
  • Pre-determined evacuation locations at ‘”like'” facilities. Ensure one facility is at least 50 miles away in case the first option is unable to accept evacuees
  • Pre-designed maps with identified evacuation routes and travel time
  • Food and water supply designated for evacuation
  • Fixed logistics to transport medications
  • Procedures for safely transporting resident/patient medical records
  • Set method created to account for all individuals during and after the evacuation
  • Procedure describing missing patient/residents during an evacuation
  • Determine how residents will be identified during an evacuation (name, social security number, photograph, date of birth, etc.) and how this information along with medication/medical equipment will be secured
  • Document and report final re-location details to the clearing house established by the state or partnering agency

 5. Transportation and Vendors

Obtain assurances with transportation vendors and other contractors in your emergency plan who will have the ability to fulfill their commitments in time of disaster. Ensure you contract with the correct type of transportation and vendors that will fit your facilities’ criteria. Additionally, collaborate with local emergency management agencies such as EMS, police and fire departments to ensure development of an effective emergency plan.

It is also important to note that as a healthcare facility, staff and volunteers that are employed by your chosen vendors and facilities should be trained on the particular areas and conditions that apply to your facility. The goal here is to help minimize transfer trauma.

6. Facility Re-entry Plan

Disasters can cause a lot of upheaval to facilities. It is important to have a plan when re-entering the facility to ensure inspection and safety are up to par and no harm is to come.

  • Assign who will authorize re-entry
  • Lay out the inspection requirements
  • Decide how it will be determined when it is safe to return to the facility

7. Needed Provisions

Keep up to date with the provisions you have on hand and if additional will need to be delivered. Know what particular items your facility and patients need a surplus of and how quickly they run through the items.  If there becomes a shortage, have a back-up plan of where and how timely you can retrieve the necessary items. Examples of items to have on hand:

  • Water
  • Food
  • Batteries
  • Medication
  • Flashlights
  • Bandages
  • Oxygen

8. Residents Re-located

Emergency situations are difficult on everyone. In particular for those who are not in control or familiar with their surroundings. It is important to work with residents so they are able to feel safe and cared for. Include in your emergency preparedness plan, guidelines around how staff/volunteers should empathetically speak with residents around their new location and given care.


Review your emergency plan and review it often. Ensure your staff is fully trained, knowledgeable and up to date on the plan. Your staff will be the team who needs to confidently guide residents and others to safety. Exercises such as periodic reviews and practice drills will allow staff to stay on top of what to do and any updates that have been made to the facility’s emergency preparedness plan. In addition, training should address the psychological and emotional aspects on caregivers, families and residents.

An emergency plan should be designed to fit a particular facility and that facility’s requirements regarding type of care provided and geographical location. Internal annual reviews will allow the most accurate and up-to-date information and regulations be included in the emergency plan. The Federal Emergency Management will provide guidelines on how to update an existing emergency plan.

For more information about the new CMS regulations, click below to read more:

2017 CMS EMERGENCY PREPAREDNESS GUIDELINES: 4 STEPS TO COMPLIANCE
ULTIMATE GUIDE: HOW TO BUILD YOUR CMS COMPLIANT EMERGENCY PLAN