CMS Generator Requirements for Nursing Homes: 42 CFR 483.73 Guide

Why CMS Emergency Power Rules Matter for Nursing Homes

Nursing home residents are among the people most vulnerable to a power outage. Many cannot evacuate quickly, depend on powered medical equipment, or are at serious risk from heat or cold. That is why the Centers for Medicare & Medicaid Services (CMS) treats emergency power as part of a long-term care facility's requirements for participation. If your facility bills Medicare or Medicaid, surveyors will look at your generator program.

The rules come from two places that work together. The emergency preparedness regulation at 42 CFR 483.73 requires a risk-based plan, policies for keeping residents safe during an outage, and emergency and standby power systems that are located, tested, maintained, and fueled according to the plan and the referenced NFPA codes. Separately, the physical environment rule at 42 CFR 483.90 adopts the Life Safety Code (NFPA 101) and the Health Care Facilities Code (NFPA 99), which carry their own generator testing requirements that life safety surveyors cite using K-tags.

This guide covers what 483.73 says, how CMS interprets it in the State Operations Manual, which survey tags apply to generators, how the rules differ from hospital requirements, and what to have ready when surveyors arrive.

Who 42 CFR 483.73 Applies To

Part 483 subpart B contains the requirements a facility must meet to participate as a Skilled Nursing Facility (SNF) in Medicare and as a Nursing Facility (NF) in Medicaid. The regulation refers to both as "LTC facilities," and 483.73 is the emergency preparedness section for that group.

The emergency preparedness rule itself was published in the Federal Register on September 8, 2016, took effect in November 2016, and required providers to be in compliance by November 15, 2017, according to CMS. It covers 18 provider and supplier types; long-term care facilities, hospitals, and critical access hospitals have the most detailed emergency power language.

Assisted living and residential care facilities that are not Medicare- or Medicaid-certified nursing facilities fall outside 483.73 and are regulated by the state. Under 483.73(f), an LTC facility in a healthcare system of separately certified facilities may participate in a unified, integrated emergency preparedness program.

The Four Core Elements of the Emergency Preparedness Program

The regulation opens by requiring the LTC facility to comply with all applicable federal, state, and local emergency preparedness requirements and to establish and maintain a program that includes several elements. Emergency power sits inside a broader program, and surveyors often evaluate the generator in the context of the plan.

Appendix Z assigns survey tags (E-tags) to each of these requirements. The two that matter most for the generator program, E-0015 and E-0041, are covered below.

Subsistence Needs and Alternate Energy: 483.73(b)(1)

Paragraph (b)(1) is where emergency power first appears, even before the generator paragraph. It requires policies and procedures that address subsistence needs for staff and residents, whether they evacuate or shelter in place. At a minimum these include food, water, medical, and pharmaceutical supplies, plus alternate sources of energy to maintain:

1. Temperatures to protect resident health and safety and for the safe and sanitary storage of provisions
2. Emergency lighting
3. Fire detection, extinguishing, and alarm systems
4. Sewage and waste disposal

Surveyors evaluate this under tag E-0015 in Appendix Z of the State Operations Manual.

What CMS Says About Temperatures

The Appendix Z guidance for E-0015 gives facilities flexibility but sets clear expectations. Each facility decides, based on its risk assessment, which alternate energy sources are most appropriate. Facilities are not required to upgrade their alternate energy source or electrical systems, but CMS notes that a risk assessment may make modifications prudent.

Facilities also do not have to heat and cool the entire building evenly. They must keep safe temperatures in the areas needed to protect residents, other occupants, and stored provisions for the duration of the emergency, as determined by the risk assessment. If they cannot, the facility should have a relocation or evacuation plan (internal relocation, relocation elsewhere on campus, or full evacuation), carried out in time to avoid exposing residents to unsafe temperatures.

For nursing homes, there is an additional number to keep in mind. Under 42 CFR 483.10(i)(6), facilities initially certified after October 1, 1990 must maintain a temperature range of 71 to 81 degrees F. Appendix Z points to this requirement in the E-0015 guidance and suggests facilities list their certification date at the front of their plan.

No Federal Minimum Supply Duration

Appendix Z states directly that there are no federal requirements establishing a set amount of provisions, and gives 72 hours of supplies as an example of what is not mandated. It also notes that some state laws and accrediting organizations do set a specific amount or duration, so facilities should check with their state agency and accreditor.

Portable Generators Under E-0015

If the risk assessment concludes a portable or mobile generator is the best way to meet these loads, Appendix Z says the NFPA provisions for permanent systems generally do not apply to that unit, except NFPA 70 (the National Electrical Code). CMS is specific that portable generators must connect to the building through a power transfer system as recommended by the generator manufacturer (typically a power inlet box, generator cord, and transfer switch), and that extension cords may not be used to connect facility equipment to a portable generator.

Emergency and Standby Power Systems: 483.73(e)

Paragraph (e) is the generator paragraph. It requires the LTC facility to implement emergency and standby power systems based on the emergency plan in paragraph (a). It then has three parts, all surveyed under tag E-0041.

483.73(e)(1) -- Generator Location

The generator must be located in accordance with the location requirements of NFPA 99 (with specified Tentative Interim Amendments), NFPA 101 (with specified TIAs), and NFPA 110, "when a new structure is built or when an existing structure or building is renovated."

Appendix Z explains that this applies to new structures or renovations that occur after November 15, 2016, and that the NFPA 110 location requirements apply to permanently attached generators, not portable or mobile units. NFPA 110 requires emergency power supply system equipment to be designed and located to minimize damage, such as from flooding. For older buildings that have not been renovated, the location requirement in (e)(1) does not reach back and force a relocation, although the facility's risk assessment may still show the generator is vulnerable.

483.73(e)(2) -- Inspection, Testing, and Maintenance

The LTC facility must implement the emergency power system inspection, testing, and maintenance requirements found in the Health Care Facilities Code (NFPA 99), NFPA 110, and the Life Safety Code (NFPA 101).

Appendix Z adds that generators required by NFPA 99 and the emergency preparedness rule must be maintained and tested per NFPA 110, based on manufacturer recommendations, instruction manuals, and the minimum requirements of NFPA 110 Chapter 8. The editions CMS incorporated by reference are the 2012 editions of NFPA 99 and NFPA 101 and the 2010 edition of NFPA 110. Our NFPA 110 compliance guide covers the Chapter 8 program in detail.

483.73(e)(3) -- Fuel

LTC facilities that maintain an onsite fuel source to power emergency generators must have a plan for how they will keep emergency power systems operational during the emergency, unless they evacuate.

The regulation does not set a number of hours or days of fuel. Appendix Z explains the intent:

• The plan should keep the essential electrical system running for the duration of emergencies as defined by the facility's own emergency plan, policies, and procedures.
• The plan can rely on onsite storage, on arrangements for fuel delivery during an emergency, or both.
• If delivery is part of the plan, it should account for delays during an event and for competing community demand for the same fuel.
• A facility that plans to evacuate should still keep enough onsite fuel to run the system until the building is evacuated.

Appendix Z also notes that generators required by NFPA 99 for hospitals, CAHs, and LTC facilities are designated Class X under NFPA 110, meaning the minimum run time is "other time, in hours, as required by application, code or user."

For storage, fuel quality, and environmental rules that apply to the tank itself, see our guide to generator fuel management and EPA compliance.

When Paragraph (e) Does Not Fully Apply

Appendix Z notes that if an LTC facility's risk assessment determines a permanent generator is not required to meet the emergency preparedness requirements, then 483.73(e)(1) and (e)(2) would not apply. The facility must still meet the emergency power requirements of the physical environment regulations and the Life Safety Code, which Appendix Z says typically require an emergency power system or generator in LTC facilities.

The Separate Emergency Power Rule at 483.90

Under 42 CFR 483.90(a), LTC facilities must meet the Life Safety Code (NFPA 101, 2012 edition, with specified TIAs), and under 483.90(b) they must meet the Health Care Facilities Code (NFPA 99, with specified TIAs).

Paragraph 483.90(c) adds a direct emergency power standard:

• (c)(1) An emergency electrical power system must supply power adequate at least for lighting all entrances and exits; equipment to maintain the fire detection, alarm, and extinguishing systems; and life support systems, if the normal supply is interrupted.
• (c)(2) When life support systems are used, the facility must provide emergency electrical power with an emergency generator, as defined in NFPA 99, located on the premises.

Appendix Z's E-0041 guidance explains how these fit together. NFPA 99 requires certain LTC facilities to maintain an essential electrical system (EES), typically with a generator as the alternate source, but it does not cover all the subsistence loads in 483.73(b)(1). CMS therefore says EES design should consider the additional loads the emergency plan requires, unless the plan calls for internal relocation or evacuation. Its example: an LTC facility relocating residents to a dining or activity room where temperature can be maintained.

Life Safety Code K-Tags Surveyors Cite for Generators

Generator findings are usually written by the life safety code (LSC) surveyor using the K-tags on Form CMS-2786R, the Fire Safety Survey Report for health care occupancies under the 2012 Life Safety Code. HFM Magazine counts 89 LSC-based and 34 Health Care Facilities Code-based K-tags on the form. Appendix Z notes that E-0041 should generally be reviewed by an LSC surveyor as well.

K-918 -- Essential Electric System Maintenance and Testing

K-918 is the tag most often associated with generators. Paraphrasing the current form (revision 07/2018), K-918 checks that:

• The generator or other alternate power source and associated equipment can supply service within 10 seconds. If the 10-second criterion is not met during the monthly test, a process must be in place to confirm this capability annually for the life safety and critical branches.
• Maintenance and testing of the generator and transfer switches follow NFPA 110.
• Generator sets are inspected weekly, exercised under load for 30 minutes 12 times a year at intervals of 20 to 40 days, and exercised once every 36 months for 4 continuous hours.
• Scheduled load tests include a complete simulated cold start and transfer of all EES loads, conducted by competent personnel.
• Main and feeder circuit breakers are inspected annually, with a periodic exercise program based on manufacturer requirements.
• Written records of maintenance and testing are maintained and readily available.
• EES panels and circuits are marked, readily identifiable, and separate from normal power circuits.

K-918 cites NFPA 99 sections 6.4.4, 6.5.4, and 6.6.4, along with NFPA 110, NFPA 111, and NFPA 70 section 700.10. For the long-duration test, see our 36-month 4-hour generator load test guide.

Related Electrical K-Tags

E-Tags in Appendix Z That Touch Emergency Power

Appendix Z contains the interpretive guidance and survey procedures for emergency preparedness. Two tags matter most for generators.

E-0015 -- Subsistence needs and alternate energy sources. Surveyors verify the policies described above. Appendix Z notes that for LTC facilities only, this policy must be reviewed and updated annually.

E-0041 -- Emergency and standby power systems. The survey procedures in Appendix Z direct surveyors to:

• Verify the facility has the power systems its emergency plan requires, including to maintain safe operations while sheltering in place.
• For facilities under construction or renovating existing buildings, verify there is a written plan to relocate the emergency power supply system by the time construction is completed.
• For permanently attached generators, verify location and installation per NFPA 110 and NFPA 99 for new, altered, renovated, or modified generator locations.
• Verify that facilities with an onsite fuel source maintain it per NFPA 110 and have a plan to keep the generator operational during an emergency, unless they plan to evacuate.

The version of Appendix Z we reviewed is Revision 204, issued April 16, 2021. CMS updates the manual periodically, so check the current version on CMS.gov before relying on specific wording.

Training, Exercises, and the 2019 Burden Reduction Rule

On September 30, 2019, CMS published a burden reduction final rule (84 FR 51732) that changed several emergency preparedness requirements. The rule took effect November 29, 2019. Its effect on LTC facilities was narrower than on other providers.

What changed for most providers. CMS moved most providers and suppliers, including hospitals, from annual to biennial (every two years) review of the emergency program and from annual to biennial training after initial training. CMS also removed the requirements to document efforts to contact emergency preparedness officials and to document participation in collaborative planning.

What stayed the same for LTC facilities. The Federal Register notice and CMS memo QSO-20-41-ALL both state that LTC facilities will still review their emergency program annually and will still provide training annually. The current text of 483.73 reflects this, and also requires initial training for new and existing staff, individuals providing services under arrangement, and volunteers.

Exercises. LTC facilities must conduct exercises to test the emergency plan at least twice per year, including unannounced staff drills. Each year, one exercise must be a full-scale, community-based exercise, or an individual, facility-based functional exercise when a community-based exercise is not accessible. The second exercise can be another full-scale or functional exercise, a mock disaster drill, or a tabletop exercise or workshop. The 2019 rule added the workshop option for inpatient providers, but QSO-20-41-ALL confirms those providers still must conduct two exercises annually.

Real-event exemption. If the facility activates its emergency plan for an actual natural or man-made emergency, it is exempt from its next required full-scale or facility-based functional exercise. CMS guidance makes clear that the exemption applies to the required exercise, not the exercise of choice, and that the facility must be able to show written documentation that it activated its plan.

An extended outage scenario makes a useful exercise: who calls the fuel vendor, which areas stay conditioned, and where residents go if temperatures cannot be held. The facility must analyze its response and revise the plan as needed.

How Nursing Home Rules Differ From Hospital Rules

Hospitals follow a parallel regulation at 42 CFR 482.15. The emergency power language in paragraph (e) is nearly identical, and Appendix Z uses the same tag, E-0041, for hospitals, CAHs, and LTC facilities. The main differences are in the review cycle and in what the power system must be based on.

Many hospitals are also accredited by The Joint Commission, which adds its own Environment of Care standards. For how accreditation and CMS requirements overlap, see our guide to Joint Commission and CMS emergency power compliance.

State Rules Can Go Further

Federal rules set the floor, and some states and localities add their own requirements. Appendix Z itself tells facilities to check state and accrediting organization requirements for set durations of supplies.

Texas is one example of a state with its own rules layered on top of the federal floor. Our guide to Texas and Harris County backup power for nursing homes and assisted living covers those rules, deadlines, and sizing considerations. If you operate in another state, check with your state survey agency and your local authority having jurisdiction for the generator installation.

A Practical Compliance Checklist

Use this list before a survey. Items are drawn from 483.73, 483.90, Appendix Z, and K-918.

Plan and policies

• Risk assessment and policies that address extended outages during extreme heat or cold
• Your Medicare/Medicaid certification date noted in the plan, with a strategy for holding 71 to 81 degrees F where that rule applies
• Written fuel plan: onsite storage, expected run time, delivery contracts, and backup suppliers
• Plan reviewed and updated within the last 12 months, with the review documented

Generator and electrical system

• Complete K-918 records: weekly inspections, monthly load tests, 10-second transfer confirmation, the 36-month 4-hour test, and annual breaker inspection
• Remote alarm annunciator and EES markings in place
• Portable generator connection (if used) through an inlet and transfer switch, not extension cords

Training and exercises

• Initial and annual emergency preparedness training documented for staff, contractors, and volunteers
• Two exercises in the past 12 months, including one full-scale or functional exercise, with after-action analysis
• Documentation of any real plan activation used to claim the exercise exemption

Conclusion

CMS generator requirements for nursing homes come from two linked rules. 42 CFR 483.73 requires a risk-based emergency plan reviewed annually, subsistence policies covering temperatures, lighting, and fire systems, and a generator located, tested, maintained, and fueled according to NFPA 99, NFPA 110, and the Life Safety Code. 42 CFR 483.90 separately requires emergency power for exits, fire systems, and life support, and life safety surveyors check generator testing under K-918.

The federal rule does not set a fixed fuel duration. It requires a plan, and that plan has to hold up under the conditions your risk assessment identifies. Build the plan around the outages your facility is likely to face, keep testing records complete, and check your state rules, which are often more specific than the federal floor.

Sources and References

• 42 CFR 483.73 -- Emergency preparedness (LTC facilities) -- Electronic Code of Federal Regulations. https://www.ecfr.gov/current/title-42/chapter-IV/subchapter-G/part-483/subpart-B/section-483.73
• 42 CFR 483.73 -- Emergency preparedness -- Legal Information Institute, Cornell Law School. https://www.law.cornell.edu/cfr/text/42/483.73
• 42 CFR 483.90 -- Physical environment -- Electronic Code of Federal Regulations. https://www.ecfr.gov/current/title-42/chapter-IV/subchapter-G/part-483/subpart-B/section-483.90
• 42 CFR 483.10 -- Resident rights -- Electronic Code of Federal Regulations. https://www.ecfr.gov/current/title-42/chapter-IV/subchapter-G/part-483/subpart-B/section-483.10
• 42 CFR 483.1 -- Basis and scope -- Electronic Code of Federal Regulations. https://www.ecfr.gov/current/title-42/chapter-IV/subchapter-G/part-483/subpart-B/section-483.1
• 42 CFR 482.15 -- Condition of participation: Emergency preparedness (hospitals) -- Electronic Code of Federal Regulations. https://www.ecfr.gov/current/title-42/chapter-IV/subchapter-G/part-482/subpart-B/section-482.15
• State Operations Manual Appendix Z -- Emergency Preparedness for All Provider and Certified Supplier Types -- Centers for Medicare & Medicaid Services. https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/downloads/som107ap_z_emergprep.pdf
• QSO-20-41-ALL: Guidance Related to the Emergency Preparedness Testing Exercise Requirements -- Centers for Medicare & Medicaid Services. https://www.cms.gov/files/document/qso-20-41-all.pdf
• Medicare and Medicaid Programs; Regulatory Provisions To Promote Program Efficiency, Transparency, and Burden Reduction (84 FR 51732) -- Federal Register, September 30, 2019. https://www.govinfo.gov/content/pkg/FR-2019-09-30/html/2019-20736.htm
• Emergency Preparedness Rule -- Centers for Medicare & Medicaid Services. https://www.cms.gov/medicare/health-safety-standards/quality-safety-oversight-emergency-preparedness/emergency-preparedness-rule
• Form CMS-2786R: Fire Safety Survey Report -- Health Care, 2012 Life Safety Code -- Centers for Medicare & Medicaid Services. https://www.cms.gov/medicare/cms-forms/cms-forms/downloads/cms2786r.pdf
• CMS 2786R Form Page -- Centers for Medicare & Medicaid Services. https://www.cms.gov/medicare/cms-forms/cms-forms/cms-forms-items/cms009335
• Life Safety Code and Health Care Facilities Code Requirements -- Centers for Medicare & Medicaid Services. https://www.cms.gov/medicare/health-safety-standards/certification-compliance/life-safety-code-health-care-facilities-code-requirements
• A Look at CMS K-Tag Requirements -- Health Facilities Management (HFM) Magazine. https://www.hfmmagazine.com/articles/3112-a-look-at-cms-k-tag-requirements
• K-918 Essential Electric System Maintenance and Testing -- Generator Help Online. https://generatorhelponline.com/k918-essential-electric-system-maintenance-and-testing/