DHDTC DAL 17-10 CMS Emergency Preparedness (EP) Rule – Compliance Reminder

October 27, 2017

DHDTC DAL 17-10 - CMS Rule Compliance Reminder

Dear Diagnostic & Treatment Center (Clinic) Administrator:

On September 16, 2016, the final rule on Emergency Preparedness Requirements for Medicare and Medicaid Participating Providers and Suppliers was published (Federal Register Vol. 81, No. 180). This rule affects all 17 provider and supplier types eligible for participation in Medicare. The rule became effective on November 15, 2016 and implementation will begin on November 15, 2017. Department surveyors will be surveying for compliance with these requirements as part of their routine visits. Facilities can be cited for not complying with this CMS rule. This letter is being sent to the federally certified providers indicated below, which are licensed by the State as diagnostic or treatment centers (D&TCs). A separate letter is being sent to other providers impacted by this rule.

Diagnostic and Treatment Centers (D&TCs)
Ambulatory Surgery Centers (ASCs) ESRDs (End-Stage Renal Disease)
Comprehensive Outpatient Rehabilitation Facilities (CORFs) Outpatient Physical Therapy Centers
Community Mental Health Centers (CMHCs) Rural Health Centers (RHCs)
Psychiatric Rehabilitation Treatment Facilities (PTRFs) Federally Qualified Health Centers (FQHCs)

All providers/suppliers are required to establish an emergency preparedness program addressing the following four core elements:

  1. Risk Assessment and Planning: Facility-based and community-based risk assessment prior to creating a plan: all-hazards approach; identify potential vulnerabilities specific to your facility and community; develop plan that addresses the identified risks.
  2. Policies and Procedures:Facilities mustrevise and, if necessary, develop new policies and procedures to ensure they align with the risk assessment and support the new preparedness plan; review and update annually. For example, Continuity of Operations (COOP); shared resource management; collaborate with key agencies and stakeholders; patient/resident/staff tracking; shelter in place (SIP), safe evacuation, Send and Receive arrangements; vulnerable populations, transportation.
  3. Communication Plan: facilities must maintain key contacts (staff, agencies, physicians) and contact information; redundant/alternate means of communication; share key facility contacts with community partners, emergency managers; system to contact patient/residents; track staff and patients during an emergency.
  4. Training and Testing:facility must develop and maintain an emergency preparedness training and testing program for new and existing staff. Demonstrate competency via Annual exercises (2 per year): a full scale, community exercise; and a facility-based drill.

To communicate and discuss CMS' four elements above and related training materials to help providers meet their CMS rule requirements, the Department will be disseminating important information via the Health Commerce System's (HCS). All facilities licensed under Article 28, including Diagnostic and Treatment Centers, are required to use HCS (Title 10 Section 400.10). https://regs.health.ny.gov/content/section-40010-health-provider-network-access-and-reporting-requirements

If your facility does not already have access to HCS as a D&TC, please complete the attached fillable form and email as directed on the form to the DOH Program Commerce Coordinator (PCC). Once the Department receives your completed form, we will use the information to add your organization, and begin the process of generating your account. An e-mail from the Department will then be sent to the facility's HCS Director and Coordinator with additional documentation to complete. The Program Commerce Coordinator (PCC) is available to assist in facilitating your HCS organizational account. Several members of your staff are required to have active HCS accounts and there should be staff on all shifts with accounts.

If your facility already has an HCS account, please update staff contact information business and after-hour phone contacts and email addresses in the HCS Communications Directory. This can be done very easily from the HCS home page by clicking on "My Content" in the top right corner of the homepage, and scrolling down to the choice, "Change my contact information". If you need to update your password or have not been on the HCS or unsure you have an account, please call the Commerce Account Management Unit at 1-866-529-1890 to reactivate your account. Once your facility has confirmed access we recommend that staff refresh their HCS skills by navigating to "My Content – Documents by Group - Getting Started – Training" for a list of training. Click on the link below for additional training and helpful HCS material:


Finally, it is imperative that facilities (to include extension clinics) maintain the assignments of employees to the following key roles:

Administrator (Main site & ext. clinic) Medical Director (Main site & ext. clinic)
Clinical Manager (Main site only) Governing Body Chair (Main site & ext. clinic)
Director, Nursing (Main site & ext. clinic) Governing Body Member (Main site & ext. clinic)
POC Editor (Main site & ext. clinic) NYPORTS Coordinator – (Main site only)

Should you have any questions, please contact the Division of Hospitals and Diagnostic & Treatment Centers at 518-402-1004.


Ruth Leslie
Division of Hospitals and Diagnostic & Treatment Centers