CMS Clarifies Emergency Preparedness Exercise Exemption Due to Activation of Emergency Plan

 

To: Administrators and Directors   From: Greg Schlosser, Branch Chief, Health Facility Quality & Education Branch                                                                   CMS recognizes that as the COVID-19 Public Health Emergency continues, many facilities continue to operate under their respective activated emergency plans. The emergency preparedness rule states that facilities that activate their emergency plans are exempt from the next required full-scale community-based or individual, facility-based functional exercise. Facilities must be able to demonstrate, through written documentation, that they activated their program due to the emergency.   Now, CMS is providing further clarification to its September 28, 2020 guidance related to the exemption requirements:   The updated guidance only applies if a facility is still currently operating under its activated emergency plan. Facilities that 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. This exemption only applies to the next required full-scale exercise (not the exercise of choice), based on the facility’s 12-month exercise cycle. The cycle is determined by the facility (e.g. calendar, fiscal, or another 12-month timeframe).   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); §484.102 (HHAs); 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.   For Outpatient Providers (Required 1 Annual Exercise- Alternating Full-Scale & Exercise of Choice): The outpatient providers will continue to follow the guidance issued, as the facility was either exempt from the full-scale exercise in 2020 or in 2021, depending on its cycle of testing exercises.   For Organ Procurement Organizations (OPOs) at §486.360 and Religious Nonmedical Healthcare Institutions (RNHCIs) at §403.748, we expect these organizations to continue to conduct the required paper-based, tabletop exercise or workshop at least annually.   For more specifics on these updates, we encourage you to review the CMS revised guidance and worksheet surveyors will use to determine compliance. (You may also copy and paste this link to your browser’s address bar: https://drive.google.com/file/d/17OnAa0OivmR66m__MiorsMT_vd9a4eBd/view?usp=sharing.   If you have any questions, please contact Melanie.Roth-Lawson@state.co.us.