Guidance Related to Emergency Preparedness- Exercise Exemption Based on a Facility’s Activation of Their Emergency Plan

Mary Madison, RN, RAC-CT, CDP
Clinical Consultant – Briggs Healthcare

CMS has revised QSO-20-41-ALL (same title as this blog) as of June 21, 2021.   CMS notes the Memorandum (11 pages in length) was revised to provide additional guidance and clarifications due to the continued public health emergency (PHE).

“CMS recognizes many facilities are still operating under disaster/emergency conditions during the PHE, i.e., under an activated emergency plan. We are therefore providing additional guidance for inpatient providers/suppliers, consistent with the exemption authorized by the EP regulations. 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). 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); §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.

As a reminder, all providers and suppliers must continue to analyze their facility’s response to and maintain documentation of all drills, tabletop exercises, and activation of their emergency plan. This would include documentation showing any revisions to the facility’s emergency plan as a result of the after-action review process. Further, we note, CMS released the revised State Operations Manual, Appendix Z on March 26, 2021, which is located at”

The Emergency Preparedness Surveyor Worksheet Requirements for Surveying for Testing Exercises Standard (d)(2) Exemptions begins on page 5 of the Memorandum with Requirements for Inpatient Providers beginning on page 9.

This updated QSO is a must-read for all providers.