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Shocking Variances Between Private Practice and Rehab Agencies

Part Two of this Two-Part Series:  Mary R. Daulong, PT, CHC, CHP

In Part I of It Is an Emergency That You Be Prepared the focus was on Therapists (TPP) in Private Practice and COVID Emergency Preparedness Plan requirements generated by the Department of Health and Human Services and the Department of Labor (OSHA). While TPPs have and must continue to deal with ever-changing guidelines and obligations related to COVID, they are dwarfed compared to the regulations mandated for Rehabilitation Agencies (Rehab Agencies).

Nancy J. Beckley, MS, MBA, CHC generously provided the following information related to Emergency Preparation for Rehab Agencies. Nancy is a nationally renowned Rehab Agency expert who recently retired but continues to share her wealth of knowledge with our members.

According to Nancy, the Emergency Preparedness Condition of Participation (CoP) for Rehab Agencies is not optional; it is a Federal requirement! She further quotes the following: Physical therapy practices that are certified by Medicare as a “Rehabilitation Agency” must comply with 42 CFR § 485.727[i]: The Clinics (not outpatient therapy clinics), Rehabilitation Agencies, and Public Health Agencies as Providers of Outpatient Physical Therapy and Speech-Language Pathology Services (“Organizations”) must comply with all applicable Federal, State, and local emergency preparedness requirements. The Organizations must establish and maintain an emergency preparedness program that meets the requirements of this section.

In various CMS documents and regulations, a Rehab Agency may also be referred to as an “OPT” or an “ORF.” Most are familiar with the term “Rehab Agency,” so that’s what we will use moving forward. There are twelve Conditions of Participation (CoP) for a Rehab Agency that must be met for initial and continued enrollment in the Medicare Program. Compliance with these CoPs is mandated by law and is subject to initial and ongoing site surveys.

On September 8, 2016, CMS published the Emergency Preparedness Requirements for Medicare and Medicaid Participating Providers and Suppliers (not applicable to TPP) Final Rule, with an effective date of November 16, 2016. Those affected by this rule, including Rehab Agencies, were to comply and implement all regulations on or before November 15, 2017. The Rehab Agency Disaster Condition of Participation was replaced at 42 CFR 485.727 with four required standards under the Emergency Preparedness CoP. [ii]

The chart below provides a quick reference summary for required elements of each Standard under the CoP and recommendations for developing and implementing specific to your Rehab Agency. This article is not a substitute for reviewing the Final Rule, updates, and the Interpretive Guidance by CMS.


Standards Required Elements of the Standard Recommended, Activities, Policies, Activities & Documents
Emergency Plan All-hazards facility & community risk assessment Conduct an All-Hazards Facility Risk Assessment to assess and document risks specific to your program. Complete for each extension location, as risks may differ.[iii]
  Strategies for addressing each risk identified For each risk area, identify training and mitigation. Tornado risk is different from the risk of an active shooter.
  Address patient population, continuity of operations, the delegation of authority & success plans Identify how your plan relates to your patients and your ability to continue operations. Identify the incident commander (who is in charge).
  Location of alarm systems, signals, methods of containing fire This Standard is retained from the old “Disaster Preparedness” CoP, focusing on drills containing a fire, egress routes, and situations requiring an integrated alarm system.
  The process to collaborate with local, tribal, regional, State & Federal E.P. officials Develop a contact list of officials, including medical and emergency management. Establish contact in advance of an emergency.
  Developed & maintained with assistance from fire, safety & other appropriate experts Document interaction and input with emergency officials, e.g., Fire Marshall or County Emergency Authority. Seek written response and input on your Emergency Plan.
Policies & Procedures Implement policies & procedures based on Emergency Plan, reviewed & updated at least every two years to include at a minimum:
  Policy on safe evacuation to include staff responsibilities and needs of the patients. Staff must be able to identify their roles in a situation-specific disaster.
  Policy means to shelter in place for patients, staff, and volunteers who remain in the facility. Shelter in place may not be feasible in a small facility but may be necessitated by urgent unusual circumstances, such as active shooter. Identify your capabilities for routine vs. emergent shelter.
  Policy on the system of medical documentation. How do you preserve patient information, protect confidentiality, and secure/maintain availability? Identify system for EMR storage and physical records.
  Policy on the use of volunteers in an emergency or other emergency staffing strategies. Typically rehab agency operations cease in an emergency. Address the use of volunteers at your facility and the capability to volunteer at other facilities in a community event.
Communication Plan Develop and maintain an emergency preparedness communication plan which must include all of the following: that complies with Federal, State, and local laws and must be reviewed and updated at least every two years.
  Provide names and contact information. Create method/list of contact info for the staff, patient physicians, other organizations, volunteers.
  Contact information for the following: Provide a list of your contact info for Federal, state, tribal & local E.P. staff.
  Primary and alternate means for communicating. List primary and secondary means for contacting staff. Identify a method for those w/only a single phone number.
  Policy on a method for sharing information and medical documentation. Develop a process for sharing info and medical records for patients. Tip: HHS has provided HIPAA guidance for use in emergencies.
  A means of providing information about your facility needs, ability to provide assistance to jurisdictional authority or Incident Command Center. Determine what and how you will communicate needs to outside authorities.
Training & Testing Develop and maintain an emergency preparedness training and testing program.
  Training Program: Initial training in emergency preparedness policies & procedures to all new & existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles. Training is required at least every two years.


Staff must demonstrate knowledge of emergency procedures, and training must include a “testing” of knowledge. Tip: develop a short quiz of the key point of your E.P. Program and maintain records.


If your Emergency Plan is significantly updated, you must conduct training on the updated policies & procedures.

  Testing Program: Participate in a full-scale exercise that is community-based every two years; or when a community-based exercise is not accessible, conduct a facility-based functional exercise every two years.



If you experience an actual natural or man-made emergency that requires activation of the emergency plan, you are exempt from engaging in your next testing activity. Hint: Your E.P. plan should have been activated for the “pandemic” Public Health Emergency. Document your activation, response, and findings.


Facility-based exercises can include a mock disaster drill or a tabletop exercise.


Tip: Be sure to maintain documentation of all drills, tabletop exercises, and an “after-action report.”

NOTE: This Table is provided for reference. Please reference the current CMS Guidance.

State agencies, prior to 2011, were the sole accrediting bodies for Rehab Agencies and other entities. In 2011, CMS approved the American Association for Accreditation of Ambulatory Surgery Facilities (AAAASF) to be a deemed authority to certify Rehab Agencies and others to assist in relieving the workload of many state agencies.

Both the state agency and AAAASF must enforce the same standards as published in the Federal Register, but they do not have to follow the same format or standard order.[iv] State agencies and AAAASF are enforcing the following updated standards and guidelines: The Emergency Preparedness Final Rule (F.R.) published on September 8, 2016, The Burden Reduction Final Rule was effective 11/29/2019, and the Interpretive Guidelines (Appendix Z) updated as of 4/16/2021[v].

If you are a Rehab Agency developing or updating your Emergency Plan, it is best to reference the  CMS Interpretive Guidelines (Appendix Z).[vi]

It is not difficult to see the additional administrative burden placed on Rehab Agencies; prudent owners will not only do their math when choosing an enrollment classification. They should also evaluate the long-range demands that accompany certified agencies as they continue to be grouped with institutions (hospitals, etc.) that often have standards based on some aspect of short or long-term in-house care.

So, to reiterate our Part I closing line by Sean Connery, we believe you might find the differences, “Shocking, simply shocking.”


[i] eCFR :: 42 CFR 485.727 — Condition of participation: Emergency preparedness

[ii] Subsequent updates to the Rule were included in the Burden Reduction Rule. See

[iii] Consider using the Kaiser HVA Tool:

[iv] See:

[v] IOM 100-07, Appendix Z “Emergency Preparedness for All Provider and Certified Supplier Types Interpretive Guidance”.

[vi] See: (4-16-2021).