Ensuring Emergency Preparedness in Ambulatory Surgery Centers: A CMS Compliance Checklist

Ensuring Emergency Preparedness in ASCs: A CMS Compliance Checklist


For Ambulatory Surgery Centers (ASCs), being prepared for emergencies is not only a matter of patient safety but also a critical aspect of compliance with CMS regulations. Emergency preparedness requires meticulous planning and organization. This article provides a CMS compliance checklist to help ASCs prepare effectively for unforeseen events.

The CMS Emergency Preparedness Rule

Nurse with tablet, blue scrubs and white shirt

CMS has established an Emergency Preparedness Rule that requires healthcare providers, including ASCs, to plan comprehensively for disasters and coordinate with federal, state, and local emergency preparedness systems. Compliance with this rule is mandatory and non-negotiable.

The Emergency Preparedness Compliance Checklist

Here’s a checklist that ASCs can follow to ensure they meet CMS requirements for emergency preparedness:

  1. Risk Assessment and Planning:

    • Conduct a risk assessment to identify potential emergencies that could affect the facility.
    • Develop an emergency plan based on the risk assessment, tailored to the facility’s specific needs.
  2. Policies and Procedures:

    • Establish policies and procedures that support the execution of the emergency plan.
    • Ensure that these policies and procedures are reviewed and updated regularly.
  3. Communication Plan:

    • Create a communication plan that includes contact information for staff, local emergency managers, and other essential personnel.
    • Develop a system to share information and updates with patients and their families during an emergency.
  4. Training and Testing:

    • Train staff on emergency procedures and conduct regular drills to test the emergency plan.
    • Document all training and testing activities for CMS review.
  5. Essential Resources and Assets:

    • Maintain an inventory of supplies and equipment needed during an emergency.
    • Establish agreements with external partners for services and resources that the ASC might not have on hand.
  6. Continuity of Operations and Recovery:

    • Plan for the continuity of essential services during an emergency.
    • Develop a strategy for returning to normal operations once the emergency has passed.
  7. Review and Improvement:

    • After drills or actual emergencies, debrief and identify areas for improvement.
    • Update the emergency preparedness plan accordingly.

Implementing Your Emergency Plan

Putting this checklist into action requires dedication and organization. It’s crucial to engage all levels of the ASC staff in the planning and execution of the emergency preparedness plan.

Case Study: Emergency Preparedness in Practice

To see how an ASC can effectively implement an emergency preparedness plan, check out our tutorial on emergency preparedness planning with HUB. This resource provides step-by-step guidance on creating, activating, and refining an emergency plan.


Ensuring emergency preparedness is a dynamic and ongoing process. It requires ASCs to be proactive, vigilant, and continually seeking improvement. For more information and resources on emergency preparedness in the healthcare setting, visit ready.gov.

By following this CMS compliance checklist and taking advantage of available resources, ASCs can create a robust framework to protect their patients, staff, and operations, no matter what emergencies may arise.

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