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

Posted Jun 25, 20213 min Read

Regulatory & Clinical

On June 21, 2021, the federal Centers for Medicare & Medicaid Services (CMS) issued a revised QSO 20-41, which provides guidance on an exemption for long-term care facilities that have activated their emergency preparedness plan from conducting the next required full-scale exercise, not the exercise of choice, based on the facility’s 12-month exercise cycle.  The exercise cycle is determined by the facility (i.e., calendar year, fiscal year, or another 12- month timeframe).  A similar exemption was issued in 2020 via the original QSO 20-41.

In summary:

  • If the facility is still operating under its currently activated emergency plan, any currently-activated emergency plan will be recognized by surveyors as having met the full-scale exercise requirement for 2021 (even if the facility claimed the exemption for the 2020 full-scale exercise).  Facilities that utilize this exemption should 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.
  • If the facility claimed the full-scale exercise exemption in 2020 based on its activated emergency plan and has since resumed normal operating status, the facility is expected to complete its required full-scale exercise in 2021, unless it has reactivated its emergency plan for an actual emergency during its 12-month cycle for 2021.

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, any revisions made to their emergency preparedness plans and/or policies and procedures, and any corresponding education that is conducted.

As a general 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 (unless a facility is otherwise exempted, as outlined above); and
  • Conduct one emergency preparedness testing exercise annually that qualifies as an exercise of choice.