On May 26, 2022, the Centers for Medicare and Medicaid Services (CMS) issued a revision to QSO-20-41-ALL, “Guidance related to Emergency Preparedness- Exercise Exemption based on A Facility’s Activation of their Emergency Plan.” The guidance, initially dated September 28, 2020, also had a prior revision in June 2021 due to the COVID-19 Public Health Emergency (PHE). The updates to the guidance are to provide additional clarification regarding providers’ need to conduct emergency testing exercises. These requirements may vary based on whether a facility is currently operating under its activated emergency plan or if it reactivated its emergency plan in either 2021 or 2022 related to the COVID-19 PHE.
As such, CMS states in the updated guidance in the Memo that it is only applicable for providers who are in the categories just mentioned – either still operating under their emergency plan due to the PHE or may have resumed normal operations only to ultimately reactivate their emergency plan due to COVID-19 in 2021 or 2022. The guidance would continue to be applicable in the event that a facility continues to operate under its activated EPP due to COVID-19 and will continue during its specified 12-month testing exercise cycle. However, if a facility is back to “normal” operations after claiming a full-scale exercise exemption in 2020 and 2021 based on the emergency plan being activated due to COVID-19, then the facility is expected to complete the required full-scale exercise unless it reactivated its emergency plan due to an actual emergency during the 12-month cycle for 2022.
Some other key points from the Memo include:
- The testing exemptions are only allowed for the next full-scale exercise, not any exercise of choice.
- A facility operating under its activated emergency plan for COVID-19 may have to activate additional elements of the plan. Full scale exemptions due to an actual emergency/disaster are based on any activation of the plan during the facility’s 12-month cycle, and exemptions do not
“carry over” to future full-scale exercises. That means that just because a facility had two separate emergency activations does not mean one will carry over to the next cycle’s exercise.
The guidance also includes updated testing requirement scenarios. These updates include information on when exercises may be needed based on when a facility returned to normal operations or if it continues to operate under its activated plan. It would be wise to read through the scenarios and updated guidance to recognize the nuances and ensure that your facility is compliant with the testing requirements.
