New RHC Policy Review, Annual Evaluation, and Emergency Preparation Final Rule 0938-AT23

Effective November 30, 2019


CMS RIN 0938-AT23
Document Number: 2019-20736
Publication Date: 09/30/2019

Dear all -

CMS has issued final rule RIN 0938-AT23, which affects CAHs, RHCs, FQHCs, and other facility types. The following summary is taken in whole from the parts affecting RHC §491 in the rule:

"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"

Effective November 30, 2019:
"This final rule reforms Medicare regulations that are identified as unnecessary,
obsolete, or excessively burdensome on health care providers and suppliers. This final rule also increases the ability of health care professionals to devote resources to improving patient care by eliminating or reducing requirements that impede quality patient care or that divert resources away from furnishing high quality patient care"

Review of Patient Care Policies §491.9(b)(4) and
RHC and FQHC Program Evaluation - §491.11(a)

Changes the policy review and annual evaluation requirement to biennial.

Annual Review of Emergency Preparedness Program - §491.12
Changes emergency preparedness program review requirement to at least biennial.

Documentation of Cooperation Efforts - §491.12(a)(4)
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.

Annual Emergency Preparedness Training Program §491.12(d)(1)(ii)
Facilities are required to develop and maintain a training program that is based on the
facility's emergency plan. A well-organized effective training program must include initial training in emergency preparedness policies and procedures.

Facilities must provide training biennially or every 2 years after facilities conduct initial training on their emergency program. The plan requires additional training when the emergency plan is significantly updated.

Annual Emergency Preparedness Testing - §491.12(d)(2)
Providers of outpatient services must conduct one testing exercise per year. These providers must participate in either a community-based full-scale exercise (if available) or conduct an individual facility-based functional exercise every other year.

In the opposite years, we proposed to allow these providers to 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.

Natural and Man-Made Emergencies: 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.

Please let us know if we can help clarify these new rules for you.


Charles A. James, Jr.
President and CEO
North American Healthcare Management Services