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CMS Updates Emergency Preparedness Guidance: QSO-20-41

On June 21, 2021 CMS released revisions to QSO-20-41 Guidance related to Emergency Preparedness- Exercise Exemption based on a Facility's Activation of their Emergency Plan. CMS regulations for Emergency Preparedness (EP) require facilities to conduct exercises to test the facility's EP plan to ensure that it works and that staff are trained appropriately about their roles and the facility's processes. During or after an actual emergency, the regulations allow for a one-year exemption from the requirement that the facility perform testing exercises (next required full-scale exercise-not the exercise of choice, based on the facility's 12-month exercise cycle).Within this most recent revision CMS has provided guidance to state survey agencies on the exemption due to continued public health emergency  (PHE) status.

As the PHE continues, many facilities continue to operate under their respective activated emergency plans. Therefore, CMS is providing additional guidance related to the exercise requirements (full-scale/functional drills and exercises) for inpatient providers/suppliers. The updated guidance only applies if a facility is still currently operating under its activated emergency plan. Facilities which have resumed normal operating status (not under their activated emergency plans) and were exempted from a full-scale exercise for its 2020 cycle, must conduct a full-scale exercise or an individual facility-based exercise for its next cycle.

For Inpatient Providers and Suppliers (§418.113(d)(2)(inpatient hospice); §441.184(d) (PRTFs), §482.15(d)(2) (hospitals); §483.73(d)(2)(LTC facilities); §483.475(d)(2)(ICFs/IID); and §485.625(d)(2)(CAHs): 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 it claimed the exemption for the 2020 full-scale exercise).
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 inpatient provider/supplier 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.

In addition, CMS released the revised State Operations Manual, Appendix Z on March 26, 2021.

CMS did provide an example timeline for consideration to clarify this requirement and exemption. See below for example:

Requirement & Guidance: Inpatient providers must conduct a full-scale exercise (or individual facility-based exercise when a full-scale is not available) annually pursuant to standard (d)(2) of their respective “Emergency Preparedness” regulation, and also conduct any one exercise of the “exercises of choice” which include another full-scale or individual facility-based exercise, table top exercise, workshop or mock drill annually.

The Exemption Clause: In the event a facility activates its emergency program due to an actual emergency, the inpatient provider would be exempt from engaging in its next required community based full-scale exercise or individual facility-based exercise following the onset of the emergency event. Facilities must be able to demonstrate through written documentation, that they activated their program due to the emergency.
Example Scenario(s):

Scenario #1. Facility Y conducted a table-top exercise in January 2020 as the exercise of choice and was exempt from its scheduled full-scale exercise in November 2020 due to the COVID-19 PHE (that began in March 2020) and activation of its emergency plan. The facility continues to operate under activation of its emergency plan during its 2021 exercise cycle (due to continued surge of COVID-19 in their local area). When must the facility conduct its next required full-scale exercise?

Answer: If the facility is still operating under its activated emergency plan, any currently activated emergency plan will be recognized by surveyors as having met the full-scale exercise requirement for 2021.

Scenario #2. Facility Y conducted a table-top exercise in January 2020 as the exercise of choice and was exempt from its scheduled full-scale exercise in November 2020 due to the COVID-19 PHE (that began in March 2020) and activation of its emergency plan. The facility in March 2021 resumed normal operations and is no longer operating under activation of its emergency plan. When must the facility conduct its next required full-scale exercise?

Answer: Since the facility is no longer under its activated emergency plan, the facility is required to conduct its full-scale exercise or individual facility-based exercise.

Staff Contact: dwatford@mehca.org

 

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