This federal CMS regulation requires a broad range of Medicare/Medicaid-certified healthcare facilities to develop, implement, and periodically review emergency preparedness policies and procedures aligned with their risk assessments and communication plans. Policies must be reviewed at least every two years (annually for long-term care facilities). The regulation covers numerous facility types across healthcare sectors—including hospitals, hospices, home health agencies, dialysis centers, and PACE organizations—and is not specific to behavioral health, IDD, ABA, or foster care settings. Compliance staff must ensure documented review cycles and alignment with identified hazards.
View official sourceE-0013 (Rev. 204, Issued: 04-16-21; Effective: 04-16-21, Implementation: 04-16-21) §403.748(b), §416.54(b), §418.113(b), §441.184(b), §460.84(b), §482.15(b), §483.73(b), §483.475(b), §484.102(b), §485.68(b), §485.625(b), §485.727(b), §485.920(b), §486.360(b), §491.12(b), §494.62(b). (b) Policies and procedures. [Facilities] must develop and implement emergency preparedness policies and procedures, based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, and the communication plan at paragraph (c) of this section. The policies and procedures must be reviewed and updated at least every 2 years. *[For LTC facilities at §483.73(b):] Policies and procedures. The LTC facility must develop and implement emergency preparedness policies and procedures, based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, and the communication plan at paragraph (c) of this section. The policies and procedures must be reviewed and updated at least annually. *Additional Requirements for PACE and ESRD Facilities: *[For PACE at §460.84(b):] Policies and procedures. The PACE organization must develop and implement emergency preparedness policies and procedures, based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, and the communication plan at paragraph (c) of this section. The policies and procedures must address management of medical and nonmedical emergencies, including, but not limited to: Fire; equipment, power, or water failure; care-related emergencies; and natural disasters likely to threaten the health or safety of the participants, staff, or the public. The policies and procedures must be reviewed and updated at least every 2 years. *[For ESRD Facilities at §494.62(b):] Policies and procedures. The dialysis facility must develop and implement emergency preparedness policies and procedures, based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, and the communication plan at paragraph (c) of this section. The policies and procedures must be reviewed and updated at least every 2 years. These emergencies include, but are not limited to, fire, equipment or power failures, care-related emergencies, water supply interruption, and natural disasters likely to occur in the facility’s geographic area. Interpretive Guidelines applies to: §403.748(b), §416.54(b), §418.113(b), §441.184(b), §460.84(b), §482.15(b), §483.73(b), §483.475(b), §484.102(b), §485.68(b), §485.625(b), §485.727(b), §485.920(b), §486.360(b), §491.12(b), §494.62(b). NOTE: This does not apply to Transplant Programs. Facilities must develop and implement policies and procedures per the requirements of this standard. The policies and procedures are expected to align with the identified hazards within the facility’s risk assessment and the facility’s overall emergency preparedness program. We also recommend that facilities include strategies and succession planning as well as contingencies which support their response to any disaster or public health emergency (also see requirements at E-0024). Facilities should also consider updates to their emergency preparedness policies and procedures during a disaster, including planning for an emergency event with a duration longer than expected. For instance, during public health emergencies such as pandemics, the Centers for Disease Control and Prevention (CDC) and other public health agencies may issue event-specific guidance and recommendations to healthcare workers. Facilities should ensure their programs have policies in place to update or provide additional emergency preparedness procedures to staff. This may include a policy delegating an individual to monitor guidance by public health agencies and issuing directives and recommendations to staff such as use of PPE when entering the building; isolation of patients under investigation (PUIs); and, any other applicable guidance in a public health emergency. We are not specifying where the facility must have the emergency preparedness policies and procedures. A facility may choose whether to incorporate the emergency policies and procedures within their emergency plan or to be part of the facility’s Standard Operating Procedures or Operating Manual. We are also not specifying the type of documentation- i.e. hard copy, electronic or other system-based emergency plans. However, the facility must be able to demonstrate compliance upon survey, therefore we recommend that facilities have a central place to house the emergency preparedness program documents (to include all policies and procedures) to facilitate review. Furthermore, since the format of the documentation is at the discretion of the facility, surveyors can identify a facility’s reviews and updates of the emergency program through meeting minutes ( facilities need to be clear if the entire program or any specific policy was reviewed and updated); through electronic or hard copy signatures on the table of contents of the emergency program documentation; or another manner. Facilities should clearly document the date of review and update and what the update entailed. For ESRD and PACE Organizations, the policies and procedures must align with the risk assessment and also include specific policies related to fire, equipment or power failures, care-related emergencies, water supply interruption, and natural disasters likely to occur in the facility’s geographic area. Care related emergencies may be specific to the patient population served within these healthcare entities; as a result, the facility should ensure that in the event of any EID, there are policies and procedures in place which protect the health and safety of patients, to include but not limited to disinfection of patient stations for ESRDs and notification of transportation considerations with local government and community providers. We would expect ESRD and PACE Organizations to encompass care related emergencies within their policies and procedures. NOTE: This policy and procedure is required to be reviewed and updated annually for LTC facilities only. Survey Procedures Review the written policies and procedures which address the facility’s emergency plan and verify the following: • Policies and procedures were developed based on the facility- and community-based risk assessment and communication plan, utilizing an all-hazards approach. • Ask to see documentation that verifies the policies and procedures have been reviewed and updated at least every 2 years (annually for LTC facilities). Format is at the discretion of the facility.