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It Is an Emergency That You Be Prepared…

flashlights and a lantern

Shocking variances between private practice and Rehab Agencies

By Mary R. Daulong, PT, and Nancy J. Beckley, MS, MBA

In Part I of “It Is an Emergency That You Be Prepared,” (bit.ly/3Q1ohmf) the focus was on therapists in private practice
(TPP) and COVID-19 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-19, 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 § 485.7271: “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.2

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.

compliance table

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.4 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 November 29, 2019, and the Interpretive Guidelines (Appendix Z) updated as of April
16, 2021.5

If you are a Rehab Agency developing or updating your Emergency Plan, it is best to reference the CMS Interpretive
Guidelines (Appendix Z).6

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.” 

References:

1eCFR :: 42 CFR 485.727 — Condition of participation: Emergency preparedness

2Subsequent updates to the Rule were included in the Burden Reduction Rule. See
https://www.cms.gov/files/document/fact-sheet-cms-releases-updated-emergency-preparedness-guidance.pdf.

3Emergency Preparedness. “Kaiser HVA Tool.” Updated February 2021.
https://www.calhospitalprepare.org/hazard-vulnerability-analysis

4ASF. “Medicare Physical Therapy Documents.” https://www.aaaasf.org/documents/medicare-physical-therapy?hsLang=en

5Emergency Preparedness. “IOM 100-07, Appendix Z — Emergency Preparedness for All Provider and Certified Supplier Types
Interpretive Guidance.” https://www.cms.gov/Regulations-and Guidance/Guidance/Manuals/Downloads/som107ap_z_emergprep.pdf

6CMS. “State Operations Manual.” Published April 16, 2021.
https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/downloads/som107ap_z_emergprep.pdf.


Mary R. Daulong, PT and Nancy J. Beckley, MS, MBA

Mary R. Daulong, PT, is an APTA Private Practice member and is the CEO/president of Business & Clinical Management
Services, Inc., a compliance consulting firm. She may be reached at daulongm@bcmscomp.com.

Nancy J. Beckley, MS, MBA, is a compliance consultant located in Milwaukee, Wisconsin. She can be reached at
nancy@nancybeckley.com and @nancybeckley.