ASC Emergency Preparedness

CMS Emergency Preparedness Rule

The CMS Emergency Preparedness Rule (effective 2017, updated 2019) applies to 17 provider types including ASCs. It requires an integrated, all-hazards approach.

Four core elements

1. Risk assessment and Emergency Operations Plan (EOP) — an all-hazards risk assessment that drives a written EOP, reviewed at least annually.
2. Policies and procedures — documenting the actions the EOP describes.
3. Communication plan — how staff, patients, families, and external partners are reached.
4. Training and testing — initial and annual training, plus required exercises.

Hazard Vulnerability Analysis (HVA)

The HVA is the structured ranking of hazards by probability, severity, mitigation, preparedness, internal response, and external response. Common ASC hazards: power outage, IT outage, fire, severe weather, active shooter, chemical spill, biological exposure, patient surge.

Emergency Operations Plan

The EOP is the playbook. It includes incident command structure, evacuation procedures, shelter-in-place, surge management, succession of authority, equipment and supply staging, and post-event recovery. The EOP must be facility-specific.

Communication plan

Required content: contact lists for staff, providers, governing body, EMS, local emergency management agency, state agency, accreditor. Methods to alert staff, share information with families, share clinical information during transfer, and coordinate with healthcare coalitions and ASPR resources.

Training and testing

Initial training on hire, then annual training. Two annual exercises: one full-scale and one tabletop or other exercise.

Drill cadence

FAQ