The Emergency Preparedness Act and Active Shooter Protocol

Congress passed a new set of laws on emergency preparedness and active shooter protocol that will go into effect on 11/15/2017. These laws are part of Medicare/Medicaid. The rule addresses concerns regarding the ability of healthcare facilities to plan and execute appropriate emergency response procedures for disasters, both manmade (e.g. terrorism, shooters) and natural (e.g. hurricanes, earthquakes, fires).

TMC will not be developing a procedure or policy plan for these laws as it is not part of HIPAA, OSHA or Infection Control and only a small percentage of our clients are covered by these laws. There are many resources available to aid in meeting the new requirements including federal money. You can get aid on the AMA website, your risk management company, medical society or medical board.

You have to be a Medicare/Medicaid provider or supplier in one of the following 17 categories to be covered by these regulations. All the categories deal in some way with patients that must be transferred or cared for in case of an emergency. Also, if you are already actively complying with Joint Commission rules you are well on your way to meeting the new regulations.

  • Religious Nonmedical Health Care Institutions (RNHCI)
  • Ambulatory Surgical Centers (ASC)
  • Hospices
  • Inpatient Psychiatric Services for Individuals Under Age 21 in Psychiatric Residential Treatment Facilities (PRTF)
  • Programs of All-Inclusive Care for the Elderly (PACE)
  • Hospitals
  • Transplant Centers
  • Long Term Care (LTC) Facilities
  • Intermediate Care Facilities for Individuals with Intellectual Disabilities (ICF/IID)
  • Home Health Agencies (HHA)
  • Comprehensive Outpatient Rehabilitation Facilities (CORF)
  • Critical Access Hospitals (CAH)
  • Clinics, Rehabilitation Agencies, and Public Health Agencies as Providers of Outpatient Physical Therapy and Speech-Language Pathology Services
  • Community Mental Health Centers (CMHC)
  • Organ Procurement Organizations (OPO)
  • Rural Health Clinics (RHC) or Federally Qualified Health Centers (FQHC)
  • End-Stage Renal Disease (ESRD) Facilities In the proposed rule, four core elements are included to make a more comprehensive framework of emergency preparedness for the various Medicare/Medicaid-participating providers and suppliers.
  •  Risk assessment and emergency planning
  • Policies and procedures
  • Communication plan
  • Training and testing

On a final note, to meet the new requirements you need to communicate with state and federal emergency services so that patient care and necessary transfers can be coordinated.


Given the recent rise in active shooter events across the country this year, it is prudent for medical and dental practices to add this scenario to your risk management program. Several agencies, INCLUDING Homeland Security, FBI, Law Enforcement and HHS, have worked together to address this issue and offer guidance on developing a plan and training. This is available in the Active Shooter Protocol booklet ( This is not a law but a valuable resource for how to handle the problem identified in your risk analysis.

For more information, the Emergency Preparedness Laws and Commentary is available online.