On November 16th, 2016, the Centers for Medicare & Medicaid Services (CMS) issued the Emergency Preparedness Requirements for Medicare and Medicaid Participating Providers and Suppliers Final Rule. Health care providers and suppliers affected by this rule must comply and implement all regulations one year after the effective date of November 15th, 2017 to establish consistent emergency preparedness requirements for healthcare providers participating in Medicare and Medicaid, increase patient safety during emergencies, and establish a more coordinated response to natural and man-made disasters.

The U.S. Department of Health and Human Services Office of the Assistant Secretary for Preparedness and Response (ASPR) worked closely with CMS in the development of the rule. The Federally Qualified Health Center (FQHC) must comply with all applicable Federal, State, and local emergency preparedness requirements. The FQHC must establish and maintain an emergency preparedness program that meets the requirements of this section. The emergency preparedness program must include, but not be limited to, the following elements:

1. Risk Assessment/Emergency Plan
   1. Be based on and include a documented, facility-based and community-based risk assessment, utilizing an all-hazards approach.
   2. Include strategies for addressing emergency events identified by the risk Assessment.
   3. Address patient population, including, but not limited to, the type of services the RHC/FQHC has the ability to provide in an emergency; and continuity of operations, including delegations of authority and succession plans.
   4. Include a process for cooperation and collaboration with local, tribal, regional, State, and Federal emergency preparedness officials’ efforts to maintain an integrated response during a disaster or emergency situation, including documentation of the RHC/FQHC’s efforts to contact such officials and, when applicable, of its participation in collaborative and cooperative planning efforts.
   5. Must be reviewed and updated annually.
2. Policies and Procedures
   
   1. Safe evacuation from the RHC/FQHC, which includes appropriate placement of exit signs; staff responsibilities and needs of the patients.
   2. A means to shelter in place for patients, staff, and volunteers who remain in the Facility.
   3. A system of medical documentation that preserves patient information, protects confidentiality of patient information, and secures and maintains the availability of Records.
   4. The use of volunteers in an emergency or other emergency staffing strategies, including the process and role for integration of State and Federally designated health care professionals to address surge needs during an emergency.
   5. Must be reviewed and updated annually.
3. Communication Plan
   1. Names and contact information for the following:
      1. Staff
      2. Entities providing services under arrangement
      3. Patients’ physicians
      4. Other RHCs/FQHCs
      5. Volunteers
   2. Contact information for the following:
      1. Federal, State, tribal, regional, and local emergency preparedness staff
      2. Other sources of assistance
   3. Primary and alternate means for communicating with the following:
      1. RHC/FQHC’s staff
      2. Federal, State, tribal, regional, and local emergency management agencies.
   4. A means of providing information about the general condition and location of patients under the facility’s care as permitted under 45 CFR 164.510(b)(4).
   5. A means of providing information about the RHC/FQHC’s needs, and its ability to provide assistance, to the authority having jurisdiction or the Incident Command Center, or designee.
   6. Must be reviewed and updated annually.
4. Training and Testing
   1. Training program. The RHC/FQHC must do all of the following:
      1. Initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles.
      2. Provide emergency preparedness training at least annually.
      3. Maintain documentation of the training.
      4. Demonstrate staff knowledge of emergency procedures.
   2. Testing. The RHC/FQHC must conduct exercises to test the emergency plan at least annually. The RHC/FQHC must do the following:
      1. Participate in a full-scale exercise that is community-based or when a community based exercise is not accessible, an individual, facility-based. If the RHC/FQHC experiences an actual natural or man-made emergency that requires activation of the emergency plan, the RHC/FQHC is exempt from engaging in a community-based or individual, facility-based full-scale exercise for 1 year following the onset of the actual event.
      2. Conduct an additional exercise that may include, but is not limited to the following:
         1. A second full-scale exercise that is community-based or individual,
            facility-based.
         2. A tabletop exercise that includes a group discussion led by a facilitator, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages or prepared questions designed to challenge an emergency plan.
      3. Analyze the RHC/FQHC’s response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the RHC/FQHC’s emergency plan, as needed.
   3. Must be reviewed and updated annually.
5. Integrated Healthcare Systems
   
   If an RHC/FQHC is part of a healthcare system consisting of multiple separately certified healthcare facilities that elect to have a unified and integrated emergency preparedness program, the RHC/FQHC may choose to participate in the healthcare system’s coordinated emergency preparedness program. If elected, the unified and integrated emergency preparedness program must do all of the following:
   1. Demonstrate that each separately certified facility within the system actively participated in the development of the unified and integrated emergency preparedness program.
   2. Be developed and maintained in a manner that takes into account each separately certified facility’s unique circumstances, patient populations, and services offered.
   3. Demonstrate that each separately certified facility is capable of actively using the unified and integrated emergency preparedness program and is in compliance with the program.
   4. Include a unified and integrated emergency plan that meets the requirements of paragraphs (a)(2), (3), and (4) of this section. The unified and integrated emergency plan must also be based on and include all of the following:
      1. A documented community-based risk assessment, utilizing an all-hazards approach.
      2. A documented individual facility-based risk assessment for each separately certified facility within the health system, utilizing an all-hazards approach.
   5. Include integrated policies and procedures that meet the requirements set forth in paragraph (b) of this section, a coordinated communication plan, and training and testing programs that meet the requirements of paragraphs (c) and (d) of this section, respectively

Introductory Courses

• IS – 100.C: Introduction to the Incident Command System
• IS – 120.C: An Introduction to Exercises
• IS – 700.B: An Introduction to the National Incident Management System
• IS – 800.C: National Response Framework, An Introduction

Intermediate Level Courses

• IS – 130.A: How to be an Exercise Evaluator
• IS – 200.B: ICS for Single Resources and Initial Action Incidents
• IS – 240.B: Leadership and Influence
• IS – 241.B: Decision Making and Problem Solving
• IS – 242.B: Effective Communication

Continuity of Operations

• IS – 546.A: Continuity of Operations Awareness Course
• IS – 547.A: Introduction to Continuity of Operations

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