This revision has guidance related to the Emergency Preparedness-Exercise Exemption, based on a facility’s activation of its emergency plan. It has additional guidance to the SSA and clarifications due to the ongoing COVID-19 PHE (3/13/2020).
A facility is still required by EP regulations (Final Rule 9/30/2019) to conduct two emergency preparedness testing exercises annually (full-scale (FSE), functional (FE), mock disaster (exercise of choice only), table-top (TTX), workshop) to test the facility’s EP plan to ensure that it works and that staff are appropriately trained about their roles and the facility’s processes. During or after an actual emergency, there is a one-year exemption form the requirement to perform testing exercises.
A worksheet has guidance for surveyors and providers to assess compliance with the EP requirements.
As the PHE continues, a facility may have continued to operate under its activated emergency plan. The exemption applies only to the next required full-scale exercise based on the facility’s 12 month exercise cycle as determined by the facility. The facility must be able to demonstrate, through written documentation, that it activated its program due to the emergency.
The updated guidance only applies if the facility is currently operating under its activated emergency plan or reactivated its emergency plan for COVID-19 in 2021 or 2022. If the facility has resumed normal operating status (not under activated emergency plan), then it is required to conduct testing exercises per the regulatory requirements.
This guidance will also apply for any subsequent 12-month cycles in the future, in the event a facility continues to operate under its activated emergency plans for COVID-19 response activities. Testing exemptions only apply for the next full-scale exercises, not any exercises of choice per Appendix Z of the SOM, to maintain a high level of preparedness based on the risks identified and to ensure resident safety in emergency events.
If a facility is required to activate additional plans or procedures based on another actual disaster or emergency and that led to the full-scale exemption, it would not carry over or accumulate to following full-scale exercises.
A facility must continue to analyze its response to and maintain documentation of all drills, table-top exercises and activation of their emergency plan. This includes documentation showing any revisions to the EP as a result of the after-action review process.
The most recent SOM Appendix Z is 3/26/2021 https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/downloads/som107ap_z_emergprep.pdf
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