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January 23, 2020 (Cleveland)

New Medicare Conditions of Participation Affecting Emergency Preparedness Activities Are Finalized

Medicare Conditions of ParticipationIn a final rule announced last fall that became effective in late 2019, the Centers for Medicare and Medicaid Services (CMS) implemented changes to the Medicare Conditions of Participation (CoP), including some related to emergency preparedness. Overall, these changes are intended to remove burdensome, unnecessary or obsolete regulations while still retaining critical requirements to ensure patient safety.

The CoP changes include provisions related to ambulatory surgical centers, quality assurance and prevention improvement programs, and transplant centers, among others. Specific to emergency preparedness, however, are modifications related to the required schedule of review of training programs and communications plans; documentation of cooperative efforts; and annual emergency preparedness testing. An overview of the changes, reflective of information provided by the American Hospital Association, is presented below.


Previously, facilities were required to review emergency preparedness plans, including their communication plans, annually. They also were required to develop and maintain a training program and to conduct it at least annually. Under the revised rules, review of emergency preparedness and communications plans, as well as emergency preparedness training, may be conducted every two years. Long-term care facilities are excepted from this change, however, and must maintain an annual review and training schedule.


Under the new Medicare Conditions of Participation, facilities are no longer required document either their efforts to contact local, tribal, regional, state, and federal emergency preparedness officials or their participation in collaborative and cooperative planning efforts. However, CMS notes that facilities continue to be required to include in their plans a process for cooperating and collaborating with those officials.


In the changes, CMS offered clarification to the existing requirements for inpatient providers to conduct at least two exercises, with at least one of them being a full-scale exercise, each year. CMS clarified the types of exercises that may be conducted as well as what constitutes a full-scale exercise. CMS also addressed requirements for outpatient providers and clarified the testing exemption for facilities that have experienced an actual event.

In the final rule, in response to some of the 300 comments received when it was proposed, CMS declined to adopt a delay in the implementation of these changes, noted that it will continue to look for ways to improve quality and safety oversight, and will consider additional relief for outpatient providers in future rulemaking.

MORE: For more on regional emergency preparedness activities, including these recent changes to the Medicare Conditions of Participation, contact us.

TWEETABLE: New #Medicare Conditions of Participation affecting hospital emergency preparedness activities have gone into effect, modifying requirements related to plan review, training and testing.