CMS Emergency Preparedness Requirements for
Ambulatory Surgical Centers
Requirement: Emergency Plans
Develop a plan based on a risk assessment using an “all hazards” approach, which is an integrated approach focusing on capacities and capabilities critical to preparedness for a full spectrum of emergencies and disasters. The plan must be updated annually.
SafePlans’ ERIP system streamlines the emergency plan development process. With ERIP, plans are easier to complete and maintain. Plans are accessible via secure Internet, print and the ERIP mobile app.
Requirement: Policies and Procedures
Develop and implement policies and procedures based on the emergency plan, risk assessment, and communication plan which must be reviewed and updated at least annually. System to track on-duty staff & sheltered patients during the emergency.
ERIP brings policies out of the typewriter age and into the modern era. Create, share and collaborate online, via the ERIP app and of course via PDF documents suitable for printing. As a procedure is updated, all stakeholders can be alerted via email, push notification on the ERIP app and text message.
Requirement: Communications Plan
Develop and maintain an emergency preparedness communication plan that complies with both federal and state laws. Patient care must be well coordinated within the facility, across health care providers and with state and local public health departments and emergency systems.
The plan must include contact information for other hospitals and CAHs; method for sharing information and medical documentation for patients.
Note: Will not need to provide occupancy information. Not required to develop arrangements with other ASCs and other providers to receive patients in the event of limitations or cessation of
operations. Not required to include
the names and contact information for
“other ASCs” in the communication
A Communications Plan developed in ERIP insures all stakeholders have access to an interactive communications plan that may be linked to communications resources such as mass notification systems.
Requirement: Training and Testing
Develop and maintain training and testing programs, including initial training in policies and procedures and demonstrate knowledge of emergency procedures and provide training at least annually.
Also annually participate in:
• A full-scale exercise that is facility-based
• An additional exercise of the facility’s choice.
Note: A community based drill is not required.
ERIP includes eLearning courses for staff and web-based tabletop scenarios. All staff training may be scheduled and tracked in ERIP.
Training and exercise requirements of the regulation call for individual-facility and/or full-scale community-based exercises. In January of 2017, CMS issued the below examples of exercise considerations:
• Cyber Security Attack
• Single-Facility Disaster (power-outage)
• Medical Surge
(i.e. community disaster leading to influx of patients)
• Infectious Disease Outbreak
• Active Shooter