Ambulatory surgery centers occupy a particular position in the healthcare landscape that makes emergency preparedness both more critical and more complicated than it is for many other facility types.
ASCs perform surgical procedures on patients who are sedated, immobilized, or in active recovery. They typically operate with leaner staffing than hospital-based surgical suites. They don’t have rapid response teams or code teams on standby. And in most cases, if something goes wrong, the nearest backup resources are wherever the local fire department and EMS system happen to be at that moment.
Research on ASC emergency preparedness notes this directly: ASCs and office-based surgical practices are unique environments that require specific emergency planning precisely because they typically lack the on-site response capacity of larger health systems. The stakes of a poorly executed emergency response in an ASC aren’t abstract — they involve patients who cannot move themselves, staff who may be operating with their full attention on a procedure, and a facility that may have only minutes to respond before outside help arrives.
The regulatory framework that governs ASC emergency preparedness reflects this reality. ASCs operating under Medicare or Medicaid certification face requirements from two separate regulatory bodies, and understanding what each requires — and where the two overlap — is the starting point for building a program that actually holds up under scrutiny.
The two regulatory frameworks that apply
OSHA 29 CFR 1910.38 — Emergency Action Plan
OSHA’s emergency action plan standard applies to virtually all employers, including ASCs. It requires a written emergency action plan covering six minimum elements: procedures for reporting emergencies, evacuation procedures and exit route assignments, procedures for employees who remain to operate critical equipment before evacuating, procedures to account for all employees after evacuation, duties for employees performing rescue or medical duties, and the name or job title of the designated emergency contact.
This is the baseline requirement for the facility as a workplace. It focuses on protecting employees. It does not specifically address the additional complexity of having sedated patients on tables when an emergency occurs.
As of January 2025, OSHA serious violations carry a maximum penalty of $16,550 per violation, with willful or repeated violations reaching $165,514 per violation.
CMS 42 CFR 416.54 — ASC Emergency Preparedness
The CMS Emergency Preparedness Rule imposes significantly broader requirements for Medicare- and Medicaid-certified ASCs. These requirements are organized around four core elements — risk assessment and emergency planning, policies and procedures, communication plan, and training and testing program — and they go well beyond what OSHA requires.
Key requirements specific to ASCs under the CMS rule include:
Risk assessment using an all-hazards approach. ASCs must conduct a documented risk assessment that considers hazards specific to their geographic location, patient population, and facility operations. This means looking beyond fire and medical emergencies to include severe weather, utility failures, communication system failures, and community-level events that could affect operations or patient care.
Policies and procedures for patient tracking. ASCs must have a documented system for tracking the location of on-duty staff and patients during an emergency. When a facility is in the middle of a surgical case and an emergency requires evacuation or shelter-in-place, there must be a clear procedure for where patients go, how they get there, and how staff account for everyone — including patients who cannot move independently.
Communication plan. The CMS rule requires a documented communication plan that includes contact information for staff and key personnel, a method for sharing patient information with other providers if patients need to be transferred, and a way to communicate the facility’s status to local authorities during a declared emergency.
Training and testing. ASCs must provide initial emergency preparedness training to all new staff and at least annual training thereafter. They must also conduct exercises — at minimum, one full-scale or functional drill and one tabletop exercise annually — and document both the exercises and the after-action analysis that follows.
What makes ASC emergency preparedness different in practice
The regulatory requirements tell you what you need to have. The operational reality of an ASC tells you why those requirements are harder to meet than they look on paper.
Patients in active procedures. An evacuation scenario for a general office is relatively straightforward — most people can stand up and walk out. An ASC evacuation scenario must account for patients who may be under general anesthesia, patients in post-anesthesia recovery who are not yet stable enough to move safely, and patients who are mid-procedure when the emergency occurs. Each of those situations requires a different response sequence, a different set of responsible staff, and a different communication protocol with incoming emergency responders.
Lean staffing ratios. ASCs operate with small teams. During a busy case schedule, most staff are actively engaged in patient care. There may not be a dedicated person to make the 911 call, conduct the employee headcount, meet the fire department at the entrance, and manage a patient in recovery — all at once. The emergency plan needs to account for this reality explicitly, not assume staff can simply add emergency response to their existing duties without preparation.
No code team. In a hospital, a code call activates a dedicated response team. In an ASC, the staff in the building are the response. If a patient codes during a case and the fire alarm activates simultaneously, the people responding to both situations are the same people. Your plan needs to address what happens when your facility is managing multiple concurrent emergencies with a small team.
Equipment and supply continuity. Surgical equipment may need to be secured, powered down in a specific sequence, or maintained in a sterile state despite an emergency. An all-hazards risk assessment should include scenarios involving power failure, water interruption, and HVAC failure — not just fire and weather events — because the consequences of uncontrolled equipment failure during a procedure are immediate and severe.
Where most ASCs fall short
In my experience working with healthcare-adjacent organizations, ASCs most commonly have gaps in three areas.
The plan doesn’t reflect the actual building and actual patient scenarios. A generic emergency action plan template with the facility’s name inserted isn’t an ASC emergency preparedness program. A plan built for an ASC accounts for procedure room locations, recovery bay layouts, patient load at peak capacity, and the specific staff roles that exist in that facility. The difference between a plan written for your facility and a plan written for any facility is the difference between a tool and a document.
Exercises don’t test ASC-specific scenarios. An annual fire drill tells you whether staff can evacuate the building. It doesn’t tell you what happens when the fire alarm activates during an active case. A tabletop exercise that specifically walks your team through patient-in-procedure scenarios — who secures the airway, who communicates with incoming EMS, who manages the recovery patients, who accounts for everyone — builds the procedural memory that the drill alone can’t provide.
Training doesn’t reach everyone who needs it. ASCs use contracted staff, per-diem employees, anesthesia providers who may work across multiple facilities, and vendors who are regularly on-site. The CMS rule covers “individuals providing on-site services under arrangement.” That includes people who aren’t your direct employees but who would be in your building when something goes wrong. Your training program needs to reach them.
Building a program that holds up
An ASC that has a written plan, conducts its required exercises, trains its staff, and reviews the program annually is meeting its regulatory obligations. An ASC that has done that work thoughtfully — with scenarios built for its actual patient population and staffing model, exercises designed to find the gaps in the plan rather than confirm that the plan exists, and training structured so that staff actually retain what they’re taught — is genuinely prepared.
The difference shows up not when the surveyor walks in, but when something goes wrong on a Tuesday afternoon.
Adams Operations Group works with ambulatory surgery centers and other healthcare-adjacent facilities in the Dallas-Fort Worth area to develop emergency action plans built for the specific environment, facilitate tabletop exercises designed around ASC-specific scenarios, and train staff in a way that prepares them for the situations your facility actually faces.
If you want to talk through where your program stands, schedule a consultation call at adamsopsgroup.com.
Sources: “Emergency Preparedness in Ambulatory Surgery Centers and Office-Based Anesthesia Practices,” PMC/NCBI (pmc.ncbi.nlm.nih.gov/articles/PMC7123946); CMS Emergency Preparedness Rule (cms.gov); 29 CFR 1910.38, Electronic Code of Federal Regulations (ecfr.gov); OSHA Penalties, U.S. Department of Labor (osha.gov/penalties).