TJC Issues Clarification on CMS Emergency Operations Plan Exercises

PUBLISHED: Feb 7, 2018
Relevant to: Ambulatory Care, Critical Access Hospitals, Home Health, Hospice, Hospitals, Long Term Care, Rural Health Clinics

The Joint Commission (TJC) has issued a clarification about the number of required emergency operations plan exercises that must be performed each year.

TJC states that they have “…confirmed with the Centers for Medicare and Medicaid Services (CMS) that organizations are required to have two exercises of their emergency operations plan annually…” According to TJC, this requirement is a part of the updated emergency planning standards that were effective on November 15, 2017

CMS has the following additional clarification on their Emergency Preparedness Rule website:

  • If a facility has activated their emergency plan due to a disaster, the facility is exempt from one full-scale/individual based exercise for that year. However, the secondary requirement for a table-top exercise or exercise of choice still applies.
  • Facilities must demonstrate completion of two exercises per annual year.

The TJC two emergency operations plan requirement applies to the following organizations, including those undergoing an initial survey.

  • Deemed hospitals
  • Critical access hospitals
  • Deemed home health
  • Deemed hospice
  • Deemed ambulatory surgical centers
  • Rural health clinics
  • Federally qualified health centers

Want to read the full alert and receive alert emails?

Browse Additional Alerts