The CMS Emergency Management (EM) update is quite extensive and, therefore, covered in a two-part blog series. Continue reading for Part 1. Click here to read Part 2. Please contact us to ask questions or to schedule your consulting needs.

On Friday, June 2, CMS issued document SC-17-29, their State Operations Manual Appendix Z, Emergency Preparedness Interpretive Guidelines. This represents the CMS information on surveying their Emergency Preparedness Conditions of Participation (COPs) that is provided to the CMS surveyors. CMS will use E-tags to score emergency management.

The information in this blog represents summarization of important points of compliance as presented in this interpretive guidance as they apply to hospitals. It approximates the order addressed in the Interpretive Guidelines, but does not strictly follow. In some cases, similar topics are combined in the blog. Other provider types are also addressed in the CMS document, but will not be covered here. The entire CMS document is available here.


  • Compliance with the CMS COPs will begin November 15, 2017.
  • CMS will NOT survey a hospital specifically for Emergency Management. They will survey EM during initial, revalidation, recertification, or complaint surveys.
  • There are many expectations of hospital leadership in terms of familiarity with the EM program. These are included in survey procedures interspersed throughout the document and will be noted in the appropriate sections.


  • Leadership knowledge:
    • EM program
    • How the all-hazards approach was used
    • Hazards identified during the risk assessment (Hazard Vulnerability Analysis, HVA)
    • How the risk assessment was conducted, considering location
  • Document review:
    • Written Emergency Operations Plan (EOP) and associated documents
    • Risk assessment / HVA and risk assessment strategies
  • The EOP must include:
    • Facility and community based risk assessments (to include interruptions in communication and cyber attacks)
    • Identify all emergencies for which to plan
    • Continuity of Operations Plan (COOP), identifying essential business functions to be continued
    • Assessment of extent to which an emergency may cause facility to cease or limit operations
    • Contracts and memoranda of understanding (MOUs), including with other healthcare facilities
  • Contracts to re-establish essential utilities must include:
    • Timeframe in which contractors are expected to initiate service following an emergency
    • How services will be procured and delivered in the local area
    • A statement that the contractor will continue to supply services throughout and to the end of emergencies of varying duration

*MSL NOTE:  These statements may be very difficult to obtain from suppliers as they can’t predict how they will be affected by the same emergency.


  • Addresses broad range of reasonably expected emergencies, but not necessarily every possible threat
  • May use community-based risk assessments developed by other entities (hospital must retain a copy)
    • Must consider the facility location
  • If a healthcare organization does not reside in a building that it owns, there must be a discussion with the landlord to ensure continuity of care if the building is impacted


  • EOP must address populations served and unique vulnerabilities
  • Must also address all persons at risk
    • At risk populations have needs in one or more of the following:
      • Maintaining independence
      • Communication
      • Transportation
      • Supervision and medical care
      • Children
      • Senior citizens
      • Pregnant women
      • Physical and/or mental disabilities
      • Living in institutional settings
      • Diverse cultures
      • Racial or ethnic backgrounds
      • Limited or no English proficiency
      • Chronic medical disorders
      • Pharmacological dependence
    • Plan to identify patients needing assistance and means to transport them
  • Succession Plans to include:
    • Staff to assume authority in another’s absence
    • Person authorized in writing to act in absence of administrator responsible for operations
  • COOP includes:
    • Essential personnel and functions
    • Critical resources
    • Vital records
    • IT data protection
    • Alternate facility identification and location
    • Financial resources
  • Leadership knowledge:
    • Facility’s at risk patient population
    • Strategies to address vulnerable population needs
    • Services facility would provide
    • COOP
    • Succession plans


  • Leadership knowledge:
    • Describe cooperation / collaboration with emergency officials at all levels
  • Document review:
    • Efforts to contact and collaborate with other organizations and agencies
    • Mutually agreed upon transplant protocols between the Transplant Centers involved and the Organ Procurement Organization


  • Transplant Centers: “Any hospital that furnishes organ transplants and other specialty services for the care of transplant patients is defined as a transplant hospital.”
    • Transplant policies and procedures based on HVA and reviewed annually
    • At least one representative of the transplant center on the EM Committee
    • Transplant center and hospital describe coordinated planning
    • Written plans available in both the transplant center and hospital
    • Involved with Organ Procurement Organizations in developing protocols addressing responsibilities of both parties in an emergency
    • If transplant center transfers to another transplant center, both need to address:
      • Care provided to transferred patient
      • Circumstances under which patients are added to receiving center’s waiting list


  • Provisions stored in areas less likely to be affected by utility failure
    • Supply needs consider volunteers, visitors, and community members who may be in facility
  • Not required to upgrade electrical system, but it may be prudent
    • Policies and procedures to determine how required heating and cooling will be maintained with loss of primary power
    • Use of portable generator does NOT require testing and fuel storage per NFPA 110
      • Operations, testing, and maintenance per manufacturer and state and local requirements
  • Document review:
    • Subsistence needs: food, water, pharmaceuticals
    • Alternative energy sources
    • Sewage and waste disposal


  • When on-duty staff and sheltered patients will be relocated, documentation must:
    • Name and specific location of receiving facility or site
    • Be readily available, accurate, sharable
  • Document review:
    • Safe evacuation and needs of evacuees (patients, staff, families, etc.)
    • Staff responsibilities during evacuation
    • Designated transport services
    • Triage system for evacuation
    • Primary and alternate means of communication
    • Shelter in place of remaining patients, staff, etc.
    • Criteria for determining which patients and staff are sheltered
  • Staff knowledge:
    • Describe tracking system
    • Locate policies and procedures in EOP
  • Leadership knowledge:
    • Arrangements for evacuation transportation

Please proceed to Part 2.