CMS Guidance to Surveyors re EPP Testing Exercise Requirements and COVID-19

On September 28, 2020, the Centers for Medicare & Medicaid Services (CMS) issued a QSO Memo, “Guidance related to the Emergency Preparedness Testing Exercise Requirements- Coronavirus Disease 2019 (COVID-19). The Memo reiterates the requirements for providers to conduct specific testing exercises to validate their Emergency Preparedness Plans (EPPs), but also notes that there is a potential exemption to the testing requirements due to an actual emergency occurring. This means that due to the COVID-19 Public Health Emergency, if a provider activated its Emergency Preparedness Program, that facility may qualify for an exemption for performing its next required exercise.

The QSO Memo specifically states:

“The emergency preparedness regulations allow an exemption for providers or suppliers that experience a natural or man-made event requiring activation of their emergency plan. On Friday, March 13, 2020, the President declared a national emergency due to COVID-19 and subsequently many providers and suppliers have activated their emergency plans in order to address surge and coordinate response activities. 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.”

Facilities may need to conduct an additional exercise this year after the current PHE if they had not already conducted another exercise this year. The QSO Memo states that facility may conduct a table-top exercise that could assess the facility’s response to the COVID PHE, and have discussions regarding:

  • Isolation and quarantine areas for patient screening
  • Availability of personal-protective equipment (PPE)
  • Other activities implemented during the EPP activation

Facilities are required to assess and update their emergency programs as needed, so including lessons learned and challenges identified during the table-top drill could be used to make adjustments/ enhancements to their plans.

Emergency Preparedness Surveyor Worksheet – Requirements for Surveying for Testing Exercises Standard (d)(2) Exemptions

The Memo provides guidance to surveyors for determining a provider’s compliance with the testing exemption following an actual activation of the emergency plan during an emergency event. The guidance for inpatient providers, including nursing homes, includes the following 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.”

The guidance also includes several scenarios for when facilities may need to conduct their next full-scale exercise based on whether they did or did not activate their emergency programs.

To determine whether the Exemption Clause is being used, surveyors are instructed to (among other steps):

  • Ask the facility to describe the exemption to ensure the provider understands that exemption is based on the scheduled next-required full-scale exercise, not the exercise of choice.
  • Verify there is documented evidence that the facility activated its emergency plan. Documentation may include, but is not limited to:
    • Minutes of facility/board meetings
    • 1135 Waiver (individual or use of blanket flexibilities)
    • Incident Command System-related reports, such as Incident Action Plans or Situation Reports
    • Notification of activation to staff via electronic methods, such as alerts
    • Proof of patient/resident transfers and changes to daily operations based on the emergency
    • Initiation of additional safety protocols (i.e. mandating use of PPE for staff, residents and visitors, as applicable)
    • Coordination with State and local emergency management officials

Appendix Z

An update to the State Operations Manual, Appendix Z, is expected to be released with this updated guidance. No timeframe has been provided on that update.

It is also important to recap revisions that were made to the final Emergency Preparedness Rule that was published September 30, 2019, including:

  • Removed requirement for documenting efforts to contact local/tribal/regional/State/Federal emergency preparedness officials
  • Removed requirement for facilities to document their participation in collaborative/ cooperative planning efforts with emergency preparedness officials
  • Revised cycles for reviewing and updating their EPPs – all providers except LTC facilities are allowed to review their programs biennially, but LTC providers are still required to review and update on an annual basis
  • Revised training program requirements to allow facilities to provide biennial training after conducting initial training on their Emergency Programs, with the exception of LTC providers. LTC facilities still have to provide annual training.
  • In light of the COVID-19 PHE, CMS is now clarifying the testing exercise requirements for surveyors and for providers to reference so they can ensure they are aware of the exemption that is based on activation of their EPP.

View the entire QSO Memo (Ref: QSO-20-41-ALL) on the CMS website.

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