CMS COMPLIANCE: Emergency Preparedness

What We Do For Healthcare Providers

Your Crisis Team provides expert guidance in emergency preparedness to help you successfully navigate complex CMS Emergency Preparedness Conditions of Participation.

Scroll to Learn More

Passionate

Members of Your Crisis Team have responded to events where loss of life and property were clearly the result of a lack of emergency preparedness planning. Your Crisis Team was founded to meet this need and foster resilience.

Experienced

We know how bad it can be – so you don’t have to find out the hard way. Our team of specialists don’t just look good on paper – they have been vetted in the field – by real events. These perspectives are critical in understanding the realities healthcare providers, like you, face when creating, activating and operationalizing your emergency operations plans.

Answers

CMS Healthcare Compliance can be intimidating. Your Crisis Team has demystified the process and will help you identify where you are and then walk you through the steps towards compliance.

Healthcare Providers We Support

 Hospitals

Home Health Agencies

Long-Term Care / Nursing Homes

Clinics, Rehabilitation Agencies, Public Health Agencies

Ambulatory Surgical Centers

Community Mental Health Centers

Comprehensive Outpatient Rehabilitation Facilities

Federally Qualified Health Centers

Hospices

Intermediate Care Facilities for Individuals with Intellectual Disabilities

Organ Procurement Organizations

Programs of All-Inclusive Care for the Elderly

Psychiatric Residential Treatment Facilities

Religious Nonmedical Healthcare Institutions

Rural Health Clinics

Transplant Centers

End-Stage Renal Disease Facilities

 

CMS Compliance Services for Healthcare Providers

Online Training
Understand the role of Risk Assessment in CMS Conditions of Participation
Lead your colleagues in compiling risk assessment data for your facility
Lead your colleagues in determining emergency capabilities for your facility
Follow-up review of risk assessment is conducted two weeks after training

Online Training:  How to conduct an effective Risk Assessment for your healthcare facility

The first step in emergency preparedness is to assess the risks that your community and your facility face. This process involves several people from your facility discussing the specific threats you face, including natural disasters, technological emergencies, and malicious attacks. Not only do you need to know what can happen, but also what problems they can cause: structural damage, power outage, access problems, supply shortages, etc.

This, in turn, determines the capabilities you must develop and strengthen as part of your emergency plan (i.e., the ability to continue serving patients even without commercial power; the ability to evacuate to a safer location; the ability to shelter in place for an extended period, etc.)

Your Crisis Team provides an online tutorial and booklet to guide you through the process. We also connect you with local resources who may have already identified the risks in your community.

Emergency Operations Plans Review

We will review your emergency preparedness plans against the CMS Conditions of Participation, identify any gaps, make recommendations and provide guidance for you to bring your plans into compliance.

You will receive a custom report, showing the CMS Emergency Preparedness Conditions of Participation line by line, along with relevant content from your current plan, whether your plan meets or fails to meet the rules, and recommendations for compliance and improving your plan.

Since part of CMS planning requires you to develop relationships with, and gather information from, resources in your community, we will identify and help introduce you to these resources.

Another key part of compliance includes training your staff on how to carry out the emergency procedures in your plan. You must keep good records. In addition to training new employees, all staff need training annually. We will review your current records and help you document the time you invest in training moving forward.

Receive a customized report – your step-by-step guide for CMS compliance
Introduction to local, partner resources
Assist in documenting your training activities
2-3 hour tabletop exercise conducted remotely at your facility
You receive an After-Action Report / Improvement Plan
HSEEP and CMS-compliant

Tabletop Exercise

Your facility is required to participate in two exercises each year.

One of these required exercises can be a tabletop exercise. A tabletop exercise is a low-stress exercise, designed to test plans, policies, and procedures. We can conduct a tabletop exercise for you, in person or online. During a tabletop exercise, we will present to you a scenario. You will get a chance to talk about your plans, review them, and see how your plans would allow you to manage the situation we describe. Our role is to design the exercise (including all HSEEP documentation), facilitate the discussion, and then evaluate your ability to meet the emergency preparedness capabilities that CMS requires.

You will receive an “After-Action Report/Improvement Plan” which will summarize the exercise, your actions, and identify strengths as well as areas of improvement.

This exercise is designed and monitored by a US Department of Homeland Security certified “Master Exercise Practitioner.” This is the highest possible certification for anyone conducting readiness exercises in the U.S.

On-Site Training Series: Elopement Prevention & Response for LTC/ICF

A full day of training and exercises on prevention and mitigation of, and response to, incidents of missing individuals from LTC ICF/IID facilities, including:

  • Understanding different types of missing person incidents at healthcare facilities and reasons why residents/clients wander
  • Assessing your facility’s likelihood, impact, and preparedness regarding missing residents/clients, as required by the Centers for Medicare and Medicaid Services (CMS) under §483.73(a)(1) and §483.475(a)(1)
  • Discussing available prevention and mitigation strategies, including electronic tools such as Project Lifesaver; staff training; and alarm/alert systems
  • Developing key elements of policies and procedures for missing resident/client incidents
  • Training in initial search operations and incident management for missing resident/client incidents
  • Live operations-based exercise to allow students to demonstrate knowledge. This can count as your “full-scale exercise” for CMS compliance

On-Site Training

Specifically designed for Long-term care and Intermediate Care facilities

Helps meet CMS training and exercise requirements

Follow-up review of elopement plans is conducted two weeks after training

Select the CMS compliance service that’s right for your healthcare facility

ServicesBasicPremiumUltra
Risk Assessment trainingaccess to pre-recorded training videolive interactive online traininglive interactive online training
Review Emergency Preparedness plancms service includedcms service includedcms service included
Collaboration with local/regional preparedness officialscms service includedcms service includedcms service included
Policies and Procedures reviewcms service includedcms service includedcms service included
Emergency Communications Plan developmentcms service includedcms service includedcms service included
Emergency Preparedness Trainingreview recordsreview recordsreview records and 3 one-hour web-based sessions
Remote Tabletop Exercise with AAR/IPcms service includedcms service included
Tabletop Exercise - in personAdditional
Full-Scale Exercise - in personAdditional
After-Action Report for Real-World Eventcms service included
Review plan against appropriate state agency emergency preparedness requirementscms service included
Emergency and standby power systemsAdditionalAdditional
Integrated Healthcare System preparednessAdditional
Custom-printed CMS compliance binder cms service includedcms service included
1st-year priceget-free-quote on cms services for healthcare providersget-free-quote on cms services for healthcare providersget-free-quote on cms services for healthcare providers
Continuing Work: (years 2+)
Annual Risk Assessment reviewcms service includedcms service included
Review Plans, Policies, Procedures2 sessions2 sessions
Annual Emergency Preparedness trainingreview recordsreview records and 3 one-hour web-based sessions
Annual Remote Tabletop Exercise with AAR/IPcms service includedcms service included
Compile AAR for real-world eventcms service included
CMS Survey follow-upcms service includedcms service included
State regulations follow-upcms service included
Annual price (year 2 and subsequent years)get-free-quote on cms services for healthcare providersget-free-quote on cms services for healthcare providers

What does a project engagement with Your Crisis Team look like?

Our proven process and methodologies ensure a smooth and productive project.

RECON

Just like any incident, it’s important to first determine the initial facts and objectives. What’s the current situation with your emergency plans, training, and/or exercises? What are your mission objectives?

We will ask you the hard questions that help you draw a clear picture of where you are or need to be, and what obstacles exist between here and there.

ACTION PLAN

We will work with you to develop a step-by-step plan to help you achieve your objective. We will define operational periods – often two-week or monthly periods – which each contain clear steps to be taken. We will update you each period with an Incident Action Plan that reflects what has happened so far, and what is expected of each of us in the coming period. (If this sounds a lot like the NIMS you’re used to, that’s a good thing!)

OPERATIONS

We will work with your staff and/or independently, as dictated by the Action Plan, to achieve the tangible deliverables promised – plans, training guides, exercise elements – that reflect your organization’s culture and our professionalism.

You will have the opportunity to review and revise each, so the final version exceeds your expectations.

AFTER-ACTION

No significant project is complete until you and we have had the chance to weigh in on how well we did, and how this project has improved your preparedness.

We thrive on feedback. We can’t get better unless we get honest feedback from you.

Clients & Testimonials

Thank you for your assessment of our Emergency Preparedness Plan! Working with you has helped us understand how to prepare in an emergency and increase communication between our staff and patients.

Marian

Home Health Agency, Massachusetts

Healthcare Leadership Team

Rick Christ, MEP, CHEC

Rick Christ, MEP, CHEC

President & CEO

Read Rick’s Bio >
Rachel Arthur, NREMT, WEMT

Rachel Arthur, NREMT, WEMT

Vice President and COO

Read Rachel’s Bio >

FREE Phone Consultation

Answer a few quick questions and we’ll follow up to schedule a FREE phone consultation.

Blog Posts Related to Healthcare

Annual Review of Emergency Preparedness Plan

    by Rick Christ Current CMS Emergency Preparedness Conditions of Participation require an annual review of your emergency preparedness plan. Under the proposed rule, the plan “must be evaluated and updated at least every 2 years.” Not in the rule, but in the...

read more

Why We Support More Detailed Exercise Standards

    by Rick Christ Currently, almost every provider type is required to participate in two exercises per year. One “should be” a “community full-scale exercise” while the other can be a tabletop. The original version of the current exercise standards was clearly...

read more