Many ASC directors and staff were concerned about the federal emergency preparedness final rule after the new federal regulations were published in 2016. Then, events in this year put disaster preparation into sharper focus. A series of disasters struck North America: hurricanes, storms, and flooding in Texas and neighboring states; hurricane infrastructure damage and floods in Puerto Rico; incredibly fast fire destruction in California; and the nation’s worst gun massacre by a single gunman in Nevada kept emergency preparedness and recovery on everyone’s minds.

CMS’ new Condition for Coverage for Emergency Preparedness requires ASCs to be proactive in new ways, including coordinating emergency preparations with their communities.

The CMS regulations took effect in November 2016, and organizations had until Nov. 15, 2017, to implement them. The AAAHC’s revised standards will be implemented during surveys, as of March 1, 2018.

CMS issued a 74-page “Appendix Z” memorandum on June 2, 2017. The memorandum, sent to state survey agency directors, provided background information and interpretive guidelines for the emergency preparedness final rule.

Appendix Z suggests using these survey procedures:

• Verify the facility has created an emergency preparedness plan by asking to see a copy of the plan.

• Ask facility leadership to identify the hazards (e.g., natural disasters, man-made accidents, facility, geographic, etc.) that were identified in the facility’s risk assessment and how the risk assessment was conducted.

• Review the plan to verify it contains all the required elements.

• Verify that the plan is reviewed and updated annually by looking for documentation of the date of the review and updates that were made to the plan based on the review.

The AAAHC’s new handbook includes everything that CMS has released in the revised conditions for coverage, including the core elements, says Mary Wei, MBA, assistant director of accreditation services at AAAHC.

“In the case of a natural or man-made disaster, they have to demonstrate they’re working with the community to test and train their providers on the community emergency plan,” Wei says.

The new conditions for coverage include these five aspects of emergency preparedness, according to AAAHC:

  1. emergency plan;
  2. policies and procedures;
  3. communication plan (internal and external);
  4. training and testing;
  5. integrated healthcare systems.

When hurricanes hit a region, the surgery centers in that area often sustain damage, says Tess Poland, RN, senior vice president of accreditation services at AAAHC.

“I was in conversation with an organization that was impacted by the hurricane,” Poland says. “The ASC is a part of that community at large, and so it was meaningful to them that the community’s support system was in place.”

Although the ASC’s own natural disaster damage prevented the organization from helping with disaster recovery, the ASC’s staff benefited from disaster planning, she adds. Prior to the hurricane, the ASC had conducted disaster training. When the actual disaster happened, the staff drew on the earlier drills when reacting to the emergency.

“A critical component to any disaster planning is to evaluate that mock drill, put together a corrective action plan that looks at what worked and what didn’t, and evaluate your staff in how they react and respond to the drills,” Poland says.

CMS Offers Disaster Drill Choices

Some people commented on CMS’ proposed emergency preparedness rule that ASCs should not be required to participate in a yearly community mock disaster drill because ASCs are not designed to accommodate an influx of patients in an emergency. CMS responded by revising its standards to allow either a community disaster drill or a tabletop exercise annually, or facility-based disaster drill. A tabletop exercise features key personnel discussing simulated scenarios in an informal setting, according to CMS.

The CMS final rule also specifies the following changes for ASCs:

• In a risk assessment, ASCs should consider where they will transfer patients, including entering into an agreement with a local hospital and creating a back-up plan for when the local hospital is affected by the emergency.

• ASCs must document the name and location of any receiving facility for patients and on-duty staff who are relocated during an emergency. ASCs can close or cancel appointments in the event of an emergency.

• ASCs must establish an effective communication plan that allows for patient information to be released in the event of an evacuation.

• Base the training and testing program on the ASC’s emergency plan, risk assessment, policies and procedures, and communication plan.

Surgery centers looking for more information about emergency preparedness can find a robust library of resources through CMS, Wei says.

“There is a site that is a really good source for samples of policies and training and templates, called ASPR TRACIE,” she adds.

A technical resource site, this U.S. Department of Health and Human Services healthcare emergency preparedness information gateway website can be accessed at: This site contains mass violence resources, including information about surge capacity for terrorist bombings. The paper suggests that outpatient surgery centers might not be directly affected by a mass casualty event, but could provide supplies in an emergency situation. These resources might help an ASC create better templates and procedures for emergency planning, Wei notes.

“Rather than using templates built for a hospital that wouldn’t be applicable to an ASC, they can use these as a jumping-off point and tailor them to be their own templates,” she says. “That’s what these resources do: offer suggestions.”