CMS Speaks: What Frequently Cited Emergency Preparedness Deficiencies Mean for Healthcare Organizations

The latest findings from the Centers for Medicare & Medicaid Services (CMS) serve as a clear warning to healthcare providers nationwide: emergency preparedness programs are still falling short in critical areas—and the consequences can directly impact patient safety.

Drawing from recently cited deficiencies, CMS has highlighted recurring gaps that organizations must address to remain compliant and, more importantly, ready to respond when it matters most.

Let’s break down what these findings mean—and how your organization can take action.

1.    Training & Testing: The Readiness Gap

CMS continues to identify deficiencies in staff training and exercise programs. Facilities are expected to provide both initial and ongoing training for all staff and regularly test their plans through various exercises.

Why it matters: Without hands-on training and realistic exercises, even the most well-written emergency plans will fail under pressure. Staff may lack confidence/awareness, coordination breaks down, and response times suffer.

Where organizations fall short:

• Infrequent or outdated training programs

• Lack of full-scale or functional exercises

• Failure to include all staff roles and external partners

HAPevolve Insight: Preparedness isn’t a one-time event—it’s a continuous cycle. Exercises should simulate real-world complexity, including cascading failures, staffing shortages, and communication breakdowns.

2.    All-Hazards Risk Assessments: The Foundation is Cracking

A comprehensive all-hazards risk assessment remains the backbone of any emergency preparedness program. Yet CMS findings show many organizations are not fully accounting for the range of threats they face.

Key gaps include:

• Incomplete hazard identification (e.g., cyberattacks, utility failures)

• Failure to account for emerging infectious diseases

• Lack of alignment with patient population needs

Why it matters: An incomplete risk assessment leads to incomplete planning. If you haven’t identified the risk, you haven’t planned for it.

HAPevolve Insight: Your risk assessment should be a living document—regularly updated, data-informed, and tailored to your facility’s unique vulnerabilities and patient demographics.

3.    Subsistence Needs: A Critical Patient Safety Issue

CMS emphasizes the importance of planning for subsistence needs during both shelter-in-place and evacuation scenarios.

This includes:

• Food and water supplies

• Medical and pharmaceutical resources

• Backup power and emergency lighting

• Safe storage and sanitation

Why it matters: Failure in this area can lead to immediate and severe health consequences, particularly for vulnerable populations in hospitals, long-term care, and inpatient settings.

HAPevolve Insight: Subsistence planning should go beyond minimum requirements. Consider extended-duration events, supply chain disruptions, and staff family needs, which directly impact workforce availability.

4.    Dialysis Emergency Equipment: No Room for Error

For End-Stage Renal Disease (ESRD) facilities, CMS cited ongoing issues with the availability and readiness of emergency equipment.

At-risk areas:

• Lack of consistent equipment checks

• Missing or inaccessible life-saving tools

• Inadequate processes for ensuring readiness

Why it matters: In emergencies, delays in care for dialysis patients can quickly become life-threatening, especially when EMS resources are strained or unavailable.

HAPevolve Insight: Redundancy and verification are key. Equipment readiness should be validated through routine checks and incorporated into exercise scenarios

5.    Program Review & Updates: Stagnation is a Risk

CMS requires regular review and updates to emergency preparedness programs—every two years for most providers and annually for long-term care.

Common deficiencies:

• Outdated contact lists and protocols

• Failure to incorporate lessons learned from exercises or real events

• Lack of documented review processes

Why it matters: An outdated plan is a liability. Emergencies evolve; so should your preparedness program.

  HAPevolve Insight: Program review should be more than a compliance checkbox. It’s an opportunity to strengthen your entire preparedness posture through after-action improvements and stakeholder engagement.

Final Thoughts

The CMS report is not just a regulatory reminder—it’s a call to action.

Healthcare organizations must take a proactive approach to emergency preparedness, ensuring their programs are not only compliant but also operationally sound and resilient under real-world conditions.

At HAPevolve, we partner with healthcare organizations to turn regulatory requirements into real-world readiness because when emergencies happen, preparedness is the difference between chaos and coordinated care.

Author: Charles “CJ” Sabo, MPH, CHEP, EMT-B, Manager