Most Frequently Scored Emergency Management Standards

by Expert Advice

Most Frequently Scored Emergency Management Standards

by Expert Advice

by Expert Advice

EC News recently posted the most frequently scored emergency management standards and EM.02.01.01 tops the list. In fact, EP 14 and 12 in this standard rank one and two. Here are the details on these EPs and the other most frequently scored elements.

Most Frequently Scored Emergency Management Standards

First, let’s start with an overview of EP 14 and EP 12.

EP 14 requires the organization to have a procedure for requesting an 1135 waiver. You would need to establish an alternate care site, absent a CMS national or blanket waiver. Also, the EC News article includes a template letter to CMS. It summarizes the required content for a letter to CMS requesting an organizational waiver.

Next, EP 12 describes the continuity of operations plan (COOP) and delegation of authority or succession planning. This is an issue we discussed previously in this newsletter.

In fact, many organizations did not prepare a COOP thinking it only applied to the scenario of a plane crash or some disaster befalling the C Suite staff. But, in actuality, this continuity of operations plan handles many simpler issues. For example, this includes senior staff being on vacation, unable to report to work due to sickness or quarantine, or other reason for non-availability.

EM Top 10 Frequently Scored

In addition to these two EPs, here is the complete list of the top 10 most frequently scored standards from May of 2020.

  1. EM.02.01.01, EP 14: 1135 waiver request procedure
  2. EM.02.01.01, EP 12: Continuity of Operations Plan
  3. EM.03.01.03, EP 1: Twice a year drills or activations of the EOP
  4. EM.02.01.01, EP 3: What you plan to do if the community can no longer support your operations
  5. EM.03.01.01, EP 3: Your documented review of the adequacy of the emergency inventory. Here’s our advice on this issue. Ensure that there is some mathematical use or burn rate analysis in support of your inventory, and your determination of its adequacy.
  6. EM.01.01.01, EP 8: Details what should be in the documented emergency inventory. This include PPE, water, fuel, medical/surgical supplies, and medication. Please note, other elements of performance reference food, medical equipment, linens, and beds
  7. EM.03.01.01, EP 2: Annual review of the scope and objectives of the EOP. Using good performance improvement techniques, analyze each drill and actual activation of the EOP. Then conduct a thorough review of the EOP and make necessary, incremental improvements
  8. EM.01.01.01, EP 2: Conduct a hazard vulnerability analysis. Remember CMS and TJC had added a requirement. It’s not just the weather related disasters. It now includes an infectious outbreak due to the high consequence of infectious disease in the HVA.
  9. EM.02.02.13, EP 2: The medical staff bylaws must identify those individuals responsible for granting disaster privileges
  10. EM.03.01.03, EP 2: At least one of your drills should include a potential influx of simulated patients

Patton Healthcare Consulting

Patton Healthcare Consulting can help you navigate the new normal. Our new remote consultation “Comprehensive Hybrid Readiness Review” is a hybrid remote/onsite support program. It is designed to assist with assessment and education to meet your needs going forward after this national emergency.

In addition, we understand the need for assistance without disrupting your organization or extensive costs. That’s the specific purpose of this program.  Contact us at (888) PHC-INC1 for more information or email us at


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