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Operations

CMS Emergency Preparedness Requirements with CIHQ

About This Webinar

Providing healthcare professionals with the knowledge and practical guidance needed to implement effective, CMS-compliant emergency preparedness programs.

While organizations hope to never encounter a disaster, it is important o be ready should one ever occur. This webinar will educate individuals on the regulatory requirements for an emergency preparedness program, and examples of how to implement some of these requirements.

Presented by:

Handout

Questions?

Emergency preparedness programs must be comprehensive, structured, and regularly updated.
CMS requires four core components: plan, policies, communication, training/testing.
Hospitals must use an all-hazards approach covering all potential disaster types.
Risk assessments (Hazard Vulnerability Analysis) guide preparedness priorities.
Plans must reflect actual local risks—not theoretical or unlikely scenarios.
Cyber threats should now be considered a major growing risk.
Organizations must identify essential operations to maintain during disasters.
Continuity of operations planning ensures survival of critical functions.
Policies must provide detailed, actionable steps—not just high-level plans.
Hospitals must plan for supplies (food, water, medications) during emergencies.
A 96‑hour sustainability model is commonly used as a preparedness benchmark.
Backup systems must exist for power, communications, and critical services.
Communication failure is the most common cause of disaster response breakdown.
Multiple communication methods (radio, phone, etc.) must be available.
Hospitals must coordinate with community coalitions and external agencies.
Tracking patients and staff during evacuation is a required capability.
Disaster plans must include evacuation and shelter‑in‑place strategies.
Training must include staff, contractors, and volunteers.
Hospitals must conduct at least two emergency exercises annually.
After-action reviews must lead to real improvements—not just documentation.
Emergency preparedness requires continuous improvement and follow-through.

Statement	Source
CMS requires all healthcare facilities to comply with emergency preparedness regulations	CMS
Hospitals must maintain an all-hazards emergency preparedness plan	CMS
Most disaster response failures are related to communication breakdowns	Fema
Hospitals are expected to sustain operations for at least 96 hours during disasters (best practice)	AHQA
Cybersecurity incidents in healthcare have increased significantly in recent years	HHS
Emergency preparedness exercises improve response performance and reduce risk	CDC
After-action reviews are critical for improving disaster response systems	Fema
Continuity of operations planning ensures essential services during emergencies	Ready

Core Components

CMS requires four components:

Emergency plan
Policies and procedures
Communication plan
Training and testing program

Emergency Plan

Must follow an all-hazards approach based on risk assessment (HVA).

Includes:

Natural disasters
Man-made threats
Equipment failures
Cybersecurity risks

Plans must reflect realistic local risks and be reviewed every 2 years.

Continuity of Operations

Organizations must identify:

Essential functions
Leadership succession
Delegation of authority

Policies and Procedures

Detailed operational steps must include:

Food, water, and medical supplies
Evacuation and shelter-in-place
Patient tracking systems
Medical documentation protection
Volunteer integration

Communication Plan

Must include:

Staff and partner contact lists
Primary and backup communication methods
Coordination with external agencies

Contact info reviewed annually; plan updated every 2 years.

Training Program

Required for staff, contractors, and volunteers.
Includes:

General disaster response training
Role-specific training (e.g., decontamination, command roles)

Testing Program

Must conduct 2 exercises annually:

One full-scale
One additional exercise (tabletop or functional)

After-action reviews must lead to improvements.

Key Insight

Communication failures are the most common reason disaster response fails.

Final Message

Emergency preparedness requires continuous planning, training, testing, and improvement to maintain compliance and protect patients.

CMS Emergency Preparedness Requirements with CIHQ

About This Webinar

Presented by:

Billy Kinch

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