As you may be aware, CMS added a new regulation for all Medicare suppliers including ASC’s, requiring very specific actions for Emergency Preparedness, known as the EP rule.

The rule requires all of us to comply by November 2017.  At first, my thought was, okay, I’ll look at the reg, update my processes a bit, and be golden.  Then I looked at the reg.  After some grumbling and not my most positive approach to the undertaking, I decided to learn more, and share what I learned.

Here is the skinny on the requirement: (credit: CMS)

  1. Perform a facility risk assessment, identify hazards, and create an all hazards emergency plan.
  2. Implement policies and procedures based on the emergency plan, risk assessment, and communication plan (see #3) which must be reviewed and updated at least annually.
  3. Develop and maintain an emergency preparedness communication plan that “complies with both federal and state laws”. Coordinate plan with community resources.
  4. Develop and maintain training programs, including initial training in policies and procedures and demonstrate knowledge of emergency procedures and provide training at least annually.
  5. Develop policies and procedures that address the provision of alternate sources to maintain temperatures, emergency lighting; and fire detection, extinguishing, and alarm systems.

Here is the CMS guidance on the Final Rule:

It is a bit of an undertaking.  To accomplish the task, I partnered with some of my ASC leader colleagues, dug through the regs and created a toolkit.  Here is what we did:

  1. Performed risk assessments to determine what are potential risks were for our facility (earthquake, fire, tornado, etc.)
  2. Pulled together our specific existing policies and created an Emergency Plan that addresses how we will address these potential threats, and for an all hazard response plan.
  3. Pulled all our facility documents that support our emergency systems.
  4. Identified our community resource entities and communicated our plan to those entities.
  5. Presented the plan to the Governing Board for approval, then created training for all staff and providers.

The process takes a bit of time, so my recommendation is that everyone start working on it as soon as possible.  CMS will survey for compliance once the final rule goes into effect.  If you don’t have the time or resources, or would like some help, we are offering our toolkit here.

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