CMS Issues Guidance on Exemption from Conducting Full-Scale Emergency Preparedness Testing Exercises

On September 28, 2020, the federal Centers for Medicare & Medicaid Services (CMS) issued QSO 20-41, which provides guidance on an exemption for long-term care facilities that have activated their emergency preparedness plan from conducting their next full-scale emergency preparedness testing exercise.

As a reminder, on September 30, 2019, CMS published the “Medicare and Medicaid Programs; Regulatory Provisions To Promote Program Efficiency, Transparency, and Burden Reduction; Fire Safety Requirements for Certain Dialysis Facilities; Hospital and Critical Access Hospital Changes To Promote Innovation, Flexibility, and Improvement in Patient Care” Final Rule, which revised the requirements for emergency preparedness for a variety of inpatient and outpatient health facilities.  Under the 2019 Final Rule, CMS requires long-term care facilities to:

• Review their emergency preparedness plan annually;
• Provide emergency preparedness training annually;
• Provide emergency preparedness training when the emergency preparedness plan is significantly updated, in addition to the annual training, as applicable;
• Conduct one emergency preparedness testing exercise annually that qualifies as a full-scale community-based or individual, facility-based functional exercise; and
• Conduct one emergency preparedness testing exercise annually that qualifies as an exercise of choice.

Importantly, the 2019 Final Rule provides an exemption to the emergency preparedness requirements if a provider is experiencing an actual emergency that requires activation of its emergency preparedness plan.  Accordingly, under the newly issued QSO 20-41, those facilities that have activated their emergency preparedness plan are advised that they are exempt from their next required full-scale community-based or individual, facility-based functional exercise and are not required to  make-up that next required full-scale or functional exercise at a later date.  Facilities that utilize this exemption must be able to demonstrate, through written documentation, that they activated their emergency preparedness plan due to the COVID-19 public health emergency.  Documentation may include, but is not limited to, notice of the plan’s activation to staff, minutes of board/facility meetings, coordination with state and local emergency officials, initiation of additional safety protocols, etc.

Long-term care facilities will still need to conduct an exercise of choice if they have not already done so this year.  For example, long-term care facilities could conduct a table-top exercise that assesses the facility’s response to COVID-19, including discussions surrounding the availability of PPE, quarantining procedures, and/or any other activities implemented during the activation of the emergency plan.  The following After Action Report should be utilized to conduct such exercises, although the template may be modified depending on the exercise conducted.

After the exercise of choice is completed, best practices indicate the following next steps:

• The completed After Action Report should be submitted to the facility’s QAPI.
• The emergency preparedness plan should be updated if the lessons learned and challenges identified through the exercise of choice warrant adjustment of the plan.
• If the emergency preparedness plan is updated, corresponding policies and procedures should be updated.
• Education should be conducted related to any updates/changes.
• Facilities should maintain documentation of all exercises conducted and any revisions made to their emergency preparedness plans and/or policies and procedures.

QSO 20-41 also provides several timeline scenarios that are helpful to review, as well as steps for surveyors to utilize when reviewing facilities’ use of the exemption.