The Centers for Medicare & Medicaid Services (CMS) rules now require healthcare providers to participate in emergency preparedness activities. The rule applies to 17 different provider and supplier types, including outpatient surgery, home health agencies, physical therapy offices, and others.

The finalized CMS rule was published September 16, 2017 and enforcement began on November 15, The Rule requires affected groups to implement four standard components:

  • Emergency Plan: Develop an emergency plan using an all-hazards approach and based on a risk assessment
  • Policies and Procedures: Develop and implement needed policies and procedures based on the emergency plan and risk assessment
  • Communication Plan: Develop and maintain a communication plan that includes provisions for coordinating patient care at the facility, across healthcare providers, and with State and local public health departments and emergency systems
  • Training and Testing Program: Develop and maintain training and testing programs, including initial and annual trainings, and conduct drills and exercises or participate in an actual incident that tests the plan

The finalized CMS rule was published September 16, 2017 and enforcement began on November 15, 2017.


Graphic showing the four provisions for all provider types: Risk assessment and Planning, Policies and procedures, Communication plan, Training and testing

The Rule requires affected groups to implement four standard components:

  • Emergency Plan: Develop an emergency plan using an all-hazards approach and based on a risk assessment
  • Policies and Procedures: Develop and implement needed policies and procedures based on the emergency plan and risk assessment
  • Communication Plan: Develop and maintain a communication plan that includes provisions for coordinating patient care at the facility, across healthcare providers, and with State and local public health departments and emergency systems
  • Training and Testing Program: Develop and maintain training and testing programs, including initial and annual trainings, and conduct drills and exercises or participate in an actual incident that tests the plan

At this time the Multnomah County Health Department, the Office of Emergency Management Department and the NW Oregon Health Preparedness Organization (HPO) have limited resources for direct collaboration in plan development and training and testing of specific health sector emergency preparedness plans. However, there are many resources to help you meet your CMS Emergency Preparedness Rule requirements.

Where is the best place to start?

The Technical Resources, Assistance Center, and Information Exchange (TRACIE) was developed by the U.S. Department of Health & Human Services to meet the information and technical assistance needs of healthcare system preparedness and public health emergency preparedness. The TRACIE website has many resources to help you meet CMS Emergency Preparedness Rule requirements.

The document “CMS and Disasters: Resources at Your Fingertips” provides a brief overview of the requirements and where to find additional resources Website:

Yale New Haven CMS Crosswalk provides a comprehensive listing of the CMS requirements connecting to the accreditation regulatory organization based on the provider type and national fire codes for that type.

Here are some other resources to help you meet each of the four standard components of the Rule: Risk Assessment and Planning, Policies and Procedures, Communications Planning, and Training and Testing. Following those are list of other general resources to help you on your way.