CMS Clarifies Emergency Preparedness Testing Exercise Requirements

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On September 28, 2020, the Centers for Medicare and Medicaid Services (CMS) issued a Quality, Safety and Oversight Group memorandum (QSO-20-41-ALL) (the QSO Memo) reinforcing and clarifying the testing exercises required by CMS’s emergency preparedness rule and the exemption that is available to facilities that activated their emergency plans in response to the COVID-19 national public health emergency (PHE). Healthcare facilities should ensure their ability to comply with the testing requirements once the PHE has abated.

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On September 8, 2016, CMS published the Emergency Preparedness Requirements for Medicare and Medicaid Participating Providers and Suppliers Final Rule (the Final Rule), later revised in September 2019, which establishes national emergency preparedness requirements to ensure adequate planning for natural and man-made disasters, and coordination with federal, state, tribal, regional and local emergency preparedness systems.

In part, the Final Rule requires providers and suppliers to perform annual testing exercises to prepare for natural or man-made disasters. Testing exercises required under the Final Rule are divided into two categories: 1) full-scale, functional and individual-facility-based exercises as the “Required Exercises” and 2) mock disaster drills, table-top exercises or workshops as the “Exercises of Choice.” Inpatient providers are required to conduct an Exercise of Choice annually, whereas outpatient providers are required to conduct a Required Exercise every two years with an Exercise of Choice conducted during the intervening years. However, if a provider or supplier experiences a natural or man-made emergency that requires activation of their emergency plan, inpatient and outpatient providers and suppliers will be exempt from their next required testing exercise following the beginning of the emergency event.

The recent COVID-19 PHE has led many facilities to utilize their emergency plans, which triggers the exemption to the testing exercise requirement under the Final Rule. Providers and suppliers that activated their emergency plan will need to document that they activated their program due to the emergency to utilize this option. While currently exempt from performing testing exercises, facilities must resume annual testing exercises following the COVID-19 PHE. Facilities that are due for an Exercise of Choice will be able to assess the facility’s response to the COVID-19 pandemic and revise their emergency plans accordingly.

The QSO Memo also provides suggestions as to how to best utilize the testing exercises to improve facilities’ current emergency plans, including a worksheet that illustrates relevant scenarios for providers and suppliers to utilize while conducting their testing exercises once the PHE concludes.

Key Takeaways
Providers and suppliers that activated their emergency plans in response to the COVID-19 PHE are exempt from the testing exercise requirement pursuant to the Final Rule. However, these providers will need to prepare to conduct their next required testing exercise following the conclusion of the PHE. Providers will be able to take advantage of the testing exercise to assess their facilities’ responses to the PHE and revise their emergency plans for any shortcomings found throughout this PHE and the subsequent testing exercises.