CMS Final Rule for RHCs and FQHCs!  Policy and Procedure Review, Annual Evaluation, and Emergency Preparedness requirements have been changed.

Document Number:  2019-20736 “Medicare and Medicaid Programs: Regulatory Provisions to Promote Program Efficiency, Transparency, and Burden Reduction; Fire Safety Requirements for Certain Dialysis Facilities; Hospital and Critical Access Hospital Changes to Promote Innovation, Flexibility, and Improvement in Patient Care. ”

The new final rule does the following:

  • changes the Policy Review and Annual Evaluations to biennial requirements.
  • changes the requirement for facilities to review their emergency preparedness program to at least biennial.
  • eliminates the need to document outreach efforts to local emergency resources, but facilities will “still be required to include a process for cooperation and collaboration” with them.
  • requires facilities to provide training biennially or every 2 years, after facilities conduct initial training on their emergency program.
  • requires that providers of outpatient services conduct only one testing exercise per year, that either a community-based full-scale exercise (if available) or conduct an individual facility-based functional exercise every other year.
  • In the opposite years, these providers may conduct the testing exercise of their choice, which may include either a community-based full-scale exercise (if available), an individual, facility-based functional exercise, a drill, or a tabletop exercise or workshop that includes a group discussion led by a facilitator.
  • if a provider experiences an actual natural or man-made emergency that requires activation of their emergency plan, inpatient and outpatient providers will be exempt from their next required full-scale community-based exercise or individual, facility-based functional exercise following the onset of the actual event.

The following are now biennial, not annual requirements:

Review of Patient Care Policies §491.9(b)(4)

RHC and FQHC Program Evaluation – §491.11(a)

Annual Review of Emergency Preparedness Program – §491.12

Annual Emergency Preparedness Training Program §491.12(d)(1)(ii)

The requirements for the following have been eased:

Documentation of Cooperation Efforts – §491.12(a)(4) has been eliminated

Annual Emergency Preparedness Testing – §491.12(d)(2) – only one required per year


Let us know if you have any questions!