Would you like an objective assessment of your Emergency Preparedness Plan?

Health care providers and suppliers affected by the final rule Emergency Preparedness Requirements for Medicare and Medicaid Participating Providers and Suppliers were required to comply and implement all regulations by November 15, 2017.

Per CMS, the emergency preparedness requirements have a set of tags that are used to cite non-compliance for all 17 provider and supplier types included in the final rule. The tags for emergency preparedness are “E” Tags and accessible to both health and safety surveyors and LSC Surveyors. State survey agencies have discretion regarding whether the LSC or health and safety surveyors will conduct the emergency preparedness surveys.

Surveyors will…

  • Ask to see the written documentation of the facility’s risk assessments and associated
  • Interview facility leadership and ask which hazards (e.g. natural, man-made, facility,
    geographic) were included in the facility’s risk assessment, why they were included
    and how the risk assessment was conducted.
  • Verify the risk-assessment is based on an all-hazards approach specific to the
    geographic location of the facility and encompasses potential hazards.
    Click here to see the State Operations Manual Appendix Z Interpretive Guidance.

The facility based and community-based risk assessment, utilizing an all-hazards approach must evaluate the facility’s ability to maintain continuity of operations and its ability to secure required supplies and resources during an emergency or
natural disaster. Hazard Vulnerability Assessments (HVAs) are systematic approaches to identifying hazards or risks that are most likely to have an impact on a healthcare facility and the surrounding community. The HVA describes the process by which a provider or supplier will assess and identify potential gaps in its emergency plan(s).

The facility’s emergency preparedness plans as required under §483.73 should be integrated and compatible with the facility assessment.

Proactive Medical Review is Here to Help.

Contact your Proactive Consultant for assistance in reviewing or developing your Emergency Preparedness Plan, Facility Assessment, or to provide a mock survey.


Eleisha Wilkes, RN, RAC-CT

Eleisha Wilkes is a Registered Nurse with over fifteen years of experience in long term care. She has served as a Director of Nursing, Case Manager and Resident Assessment Coordinator with extensive responsibility and success in driving QA in the areas of person centered assessment and care planning through effective systems, staff development, and interdisciplinary team collaboration. She now serves as an RN Clinical Consultant with Proactive Medical Review & Consulting, LLC.

Proactive Medical Review | 812-471-7777