CMS Updates Guidance Related to Emergency Preparedness R/T the Ongoing PHE

From CHAP

CMS’s Quality, Safety & Oversight Group posted Revised Memo on May 26, 2022, which provides updated guidance for surveyors and providers about emergency preparedness training and testing program exemptions and assessment of compliance with the EP requirements. (Guidance related to Emergency Preparedness- Exercise Exemption based on A Facility's Activation of their Emergency Plan (Ref: QSO-20-41-ALL, Revised 5/26/2022))

This updated guidance only applies if a facility/provider is still currently operating under its activated emergency plan or reactivated its emergency plan for COVID-19 in 2021 or 2022.

If your organization has resumed normal operating status (not under their activated emergency plans), you are required to conduct testing exercises based on the regulatory requirements for their specific provider or supplier type. 

Background: 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 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.

Updated guidance key points:

• CMS recognizes many facilities are still operating under disaster/emergency conditions during the PHE, (e.g., under an activated emergency plan), so they are providing additional guidance for inpatient and outpatient providers/suppliers, consistent with the exemption authorized by the EP regulations. 
• This guidance provides clarifications on testing exemptions for those providers/suppliers who continue to operate under their activated emergency plan and those which may have reactivated their emergency plans for COVID-19. 
• This exemption applies to the next required full-scale exercise only, not the exercise of choice, based on the facility's 12-month exercise cycle. 
  • The exercise cycle is determined by the facility (e.g., calendar year, fiscal year or another 12-month timeframe).

This guidance will also apply for any subsequent 12-month cycles in the future, in the event facilities continue to operate under their activated emergency plans for COVID-19 response activities.