CMS SOM App. Z, Tag E-0039

§483.73(d)(2), §483.475(d)(2), §484.102(d)(2), §485.68(d)(2), §485.625(d)(2),

§485.727(d)(2), §485.920(d)(2), §491.12(d)(2), §494.62(d)(2).

*[For RNCHIs at §403.748, ASCs at §416.54, CORFs at §485.68, OPO, “Organizations”

under §485.727, CMHCs at §485.920, RHCs/FQHCs at §491.12, and ESRD Facilities at

§494.62]:

(2) Testing. The [facility] must conduct exercises to test the emergency plan

annually. The [facility] must do all of the following:

(i) Participate in a full-scale exercise that is community-based every 2 years;

or

(A) When a community-based exercise is not accessible, conduct a

facility-based functional exercise every 2 years; or

(B) If the [facility] experiences an actual natural or man-made

emergency that requires activation of the emergency plan, the [facility]

is exempt from engaging in its next required community-based or

individual, facility-based functional exercise following the onset of the

actual event.

(ii) Conduct an additional exercise at least every 2 years, opposite the year

the full-scale or functional exercise under paragraph (d)(2)(i) of this section is

conducted, that may include, but is not limited to the following:

(A) A second full-scale exercise that is community-based or individual,

facility-based functional exercise; or

(B) A mock disaster drill; or

(C) A tabletop exercise or workshop that is led by a facilitator and

includes a group discussion using a narrated, clinically-relevant

emergency scenario, and a set of problem statements, directed messages,

or prepared questions designed to challenge an emergency plan.

(iii) Analyze the [facility's] response to and maintain documentation of all

drills, tabletop exercises, and emergency events, and revise the [facility's] emergency

plan, as needed.

*[For Hospices at 418.113(d):]

(2) Testing for hospices that provide care in the patient’s home. The hospice must

conduct exercises to test the emergency plan at least annually. The hospice must do

the following:

(i) Participate in a full-scale exercise that is community based every 2 years;

or

(A) When a community based exercise is not accessible, conduct an

individual facility based functional exercise every 2 years; or

(B) If the hospice experiences a natural or man-made emergency that

requires activation of the emergency plan, the hospital is exempt from

engaging in its next required full scale community-based exercise or

individual facility-based functional exercise following the onset of the

emergency event.

(ii) Conduct an additional exercise every 2 years, opposite the year the full-scale or functional exercise under paragraph (d)(2)(i) of this section is

conducted, that may include, but is not limited to the following:

(A) A second full-scale exercise that is community-based or a facility

based functional exercise; or

(B) A mock disaster drill; or

(C) A tabletop exercise or workshop that is led by a facilitator and

includes a group discussion using a narrated, clinically-relevant

emergency scenario, and a set of problem statements, directed

messages, or prepared questions designed to challenge an emergency

plan.

(3) Testing for hospices that provide inpatient care directly. The hospice must

conduct exercises to test the emergency plan twice per year. The hospice must do

the following:

(i) Participate in an annual full-scale exercise that is community-based; or

(A) When a community-based exercise is not accessible, conduct an

annual individual facility-based functional exercise; or

(B) If the hospice experiences a natural or man-made emergency that

requires activation of the emergency plan, the hospice is exempt from

engaging in its next required full-scale community based or facility-based functional exercise following the onset of the emergency event.

(ii) Conduct an additional annual exercise that may include, but is not

limited to the following:

(A) A second full-scale exercise that is community-based or a facility

based functional exercise; or

(B) A mock disaster drill; or

(C) A tabletop exercise or workshop led by a facilitator that includes

a group discussion using a narrated, clinically-relevant emergency

scenario, and a set of problem statements, directed messages, or

prepared questions designed to challenge an emergency plan.

(iii) Analyze the hospice’s response to and maintain documentation of all

drills, tabletop exercises, and emergency events and revise the hospice's

emergency plan, as needed.

*[For PRFTs at §441.184(d), Hospitals at §482.15(d), CAHs at §485.625(d):]

(2) Testing. The [PRTF, Hospital, CAH] must conduct exercises to test the

emergency plan twice per year. The [PRTF, Hospital, CAH] must do the following:

(i) Participate in an annual full-scale exercise that is community-based; or

(A) When a community-based exercise is not accessible, conduct an

annual individual, facility-based functional exercise; or

(B) If the [PRTF, Hospital, CAH] experiences an actual natural or

man-made emergency that requires activation of the emergency plan,

the [facility] is exempt from engaging in its next required full-scale

community based or individual, facility-based functional exercise

following the onset of the emergency event.

(ii) Conduct an [additional] annual exercise or and that may include, but is

not limited to the following:

(A) A second full-scale exercise that is community-based or

individual, a facility-based functional exercise; or

(B) A mock disaster drill; or

(C) A tabletop exercise or workshop that is led by a facilitator and

includes a group discussion, using a narrated, clinically-relevant

emergency scenario, and a set of problem statements, directed

messages, or prepared questions designed to challenge an emergency

plan.

(iii) Analyze the [facility’s] response to and maintain documentation of all

drills, tabletop exercises, and emergency events and revise the [facility’s] emergency

plan, as needed.

*[For PACE at §460.84(d):]

(2) Testing. The PACE organization must conduct exercises to test the emergency

plan at least annually. The PACE organization must do the following:

(i) Participate in an annual full-scale exercise that is community-based; or

(A) When a community-based exercise is not accessible, conduct an

annual individual, facility-based functional exercise; or

(B) If the PACE experiences an actual natural or man-made

emergency that requires activation of the emergency plan, the PACE

is exempt from engaging in its next required full-scale community

based or individual, facility-based functional exercise following the

onset of the emergency event.

(ii) Conduct an additional exercise every 2 years opposite the year the full-scale or functional exercise under paragraph (d)(2)(i) of this section is conducted

that may include, but is not limited to the following:

(A) A second full-scale exercise that is community-based or

individual, a facility based functional exercise; or

(B) A mock disaster drill; or

(C) A tabletop exercise or workshop that is led by a facilitator and

includes a group discussion, using a narrated, clinically-relevant

emergency scenario, and a set of problem statements, directed

messages, or prepared questions designed to challenge an emergency

plan.

(iii) Analyze the PACE’s response to and maintain documentation of all

drills, tabletop exercises, and emergency events and revise the PACE’s

emergency plan, as needed.

*[For LTC Facilities at §483.73(d):]

(2) The [LTC facility] must conduct exercises to test the emergency plan at least

twice per year, including unannounced staff drills using the emergency procedures.

The [LTC facility, ICF/IID] must do the following:

(i) Participate in an annual full-scale exercise that is community-based; or

(A) When a community-based exercise is not accessible, conduct an

annual individual, facility-based functional exercise.

(B) If the [LTC facility] facility experiences an actual natural or man-made emergency that requires activation of the emergency plan, the

LTC facility is exempt from engaging its next required a full-scale

community-based or individual, facility-based functional exercise

following the onset of the emergency event.

(ii) Conduct an additional annual exercise that may include, but is not

limited to the following:

(A) A second full-scale exercise that is community-based or an

individual, facility based functional exercise; or

(B) A mock disaster drill; or

(C) A tabletop exercise or workshop that is led by a facilitator

includes a group discussion, using a narrated, clinically-relevant

emergency scenario, and a set of problem statements, directed

messages, or prepared questions designed to challenge an emergency

plan.

(iii) Analyze the [LTC facility] facility's response to and maintain

documentation of all drills, tabletop exercises, and emergency events, and

revise the [LTC facility] facility's emergency plan, as needed.

*[For ICF/IIDs at §483.475(d)]:

(2) Testing. The ICF/IID must conduct exercises to test the emergency plan at least

twice per year. The ICF/IID must do the following:

(i) Participate in an annual full-scale exercise that is community-based; or

(A) When a community-based exercise is not accessible, conduct an

annual individual, facility-based functional exercise; or.

(B) If the ICF/IID experiences an actual natural or man-made

emergency that requires activation of the emergency plan, the

ICF/IID is exempt from engaging in its next required full-scale

community-based or individual, facility-based functional exercise

following the onset of the emergency event.

(ii) Conduct an additional annual exercise that may include, but is not

limited to the following:

(A) A second full-scale exercise that is community-based or an

individual, facility-based functional exercise; or

(B) A mock disaster drill; or

(C) A tabletop exercise or workshop that is led by a facilitator and

includes a group discussion, using a narrated, clinically-relevant

emergency scenario, and a set of problem statements, directed

messages, or prepared questions designed to challenge an emergency

plan.

(iii) Analyze the ICF/IID’s response to and maintain documentation of all

drills, tabletop exercises, and emergency events, and revise the ICF/IID’s

emergency plan, as needed.

*[For HHAs at §484.102]

(d)(2) Testing. The HHA must conduct exercises to test the emergency plan at

least annually. The HHA must do the following:

(i) Participate in a full-scale exercise that is community-based; or

(A) When a community-based exercise is not accessible, conduct an

annual individual, facility-based functional exercise every 2 years; or.

(B) If the HHA experiences an actual natural or man-made emergency

that requires activation of the emergency plan, the HHA is exempt from

engaging in its next required full-scale community-based or individual,

facility based functional exercise following the onset of the emergency

event.

(ii) Conduct an additional exercise every 2 years, opposite the year the full-scale

or functional exercise under paragraph (d)(2)(i) of this section is conducted,

that may include, but is not limited to the following:

(A) A second full-scale exercise that is community-based or an

individual, facility-based functional exercise; or

(B) A mock disaster drill; or

(C) A tabletop exercise or workshop that is led by a facilitator and

includes a group discussion, using a narrated, clinically-relevant

emergency scenario, and a set of problem statements, directed messages,

or prepared questions designed to challenge an emergency plan.

(iii) Analyze the HHA’s response to and maintain documentation of all drills,

tabletop exercises, and emergency events, and revise the HHA’s emergency

plan, as needed.

*[For OPOs at §486.360]

(d)(2) Testing. The OPO must conduct exercises to test the emergency plan. The

OPO must do the following:

(i) Conduct a paper-based, tabletop exercise or workshop at least annually.

A tabletop exercise is led by a facilitator and includes a group discussion,

using a narrated, clinically relevant emergency scenario, and a set of

problem statements, directed messages, or prepared questions designed to

challenge an emergency plan. If the OPO experiences an actual natural or

man-made emergency that requires activation of the emergency plan, the

OPO is exempt from engaging in its next required testing exercise following

the onset of the emergency event.

(ii) Analyze the OPO’s response to and maintain documentation of all

tabletop exercises, and emergency events, and revise the [RNHCI’s and

OPO’s] emergency plan, as needed.

Interpretive Guidelines applies to: §403.748(d)(2), §416.54(d)(2), §418.113(d)(2),

§441.184(d)(2), §460.84(d)(2), §482.15(d)(2), §483.73(d)(2), §483.475(d)(2),

§484.102(d)(2), §485.68(d)(2), §485.625(d)(2), §485.727(d)(2), §485.920(d)(2),

§486.360(d)(2)§491.12(d)(2), §494.62(d)(2)

NOTE: This does not apply to Transplant Programs.

Variability in Requirements

For inpatient providers (inpatient hospice facilities, PRTFs, hospitals, LTC facilities*,

ICFs/IID, and CAHs): The types of acceptable testing exercises are expanded. Inpatient

providers can choose one of the two annually required testing exercises to be an exercise

of their choice, which may include one community-based full-scale exercise (if available),

an individual facility-based functional exercise, a mock disaster drill, or a tabletop

exercise or workshop that includes a group discussion led by a facilitator.

*NOTE: For LTC facilities, while the types of acceptable testing exercises was

expanded, LTC facilities must continue to conduct their exercises on an annual basis.

Facilities must conduct exercises to test the emergency plan, which for LTC facilities also

includes unannounced staff drills using the emergency procedures.

For outpatient providers (ASCs, freestanding/home-based hospice, PACE, HHAs,

CORFs, Organizations (which include Clinics, Rehabilitation Agencies, and Public

Health Agencies as Providers of Outpatient Physical Therapy and Speech-Language

Pathology Services), CMHCs, OPOs, RHCs, FQHCs, and ESRD facilities): Facilities are

required to only conduct one testing exercise on an annual basis, which may be either

one community-based full-scale exercise, if available, or an individual facility-based

functional exercise. The opposite years (every other year opposite of the full-scale

exercises), these providers may choose the testing exercise of their choice, which can

include either another full-scale, individual facility-based, a mock disaster drill (using

mock patients), tabletop exercise or workshop which includes a facilitator.

For OPOs and RNCHIs, these providers must at a minimum conduct either a paper-based, tabletop exercise or workshop every year, however can elect to also participate in

full-scale, individual facility-based exercise.

Understanding Exercises and Terminology

Similar to the training expectations outlined under E-0037 or (d)(1), such as hospitals at

482.15(d)(1), a facility’s testing exercises require they be based on the individual

facility’s risk assessment, policies and procedures, and communication plan and support

the patient population it serves. Testing exercises should vary, based on the facility’s

requirements, by cycles and frequency of testing. The intent is that testing exercise

provide a comprehensive testing and training for staff, volunteers, and individuals

providing services under arrangement as well community partners. Testing exercises

must be based on the facility’s identified hazards, to include natural or man-made

disasters. This should include EID outbreaks.

Facilities are expected to test their response to emergency events as outlined within their

comprehensive emergency preparedness program. Testing exercises should not test the

same scenario year after year or the same response processes. The intent is to identify

gaps in the facility’s emergency program as it relates to responding to various

emergencies and ensure staff are knowledgeable on the facility’s program. In the event

gaps are identified, facilities should update their emergency programs as outlined within

the requirements for After-Action Review (AAR).

Full-Scale and Community Based Exercises

As the term full-scale exercise may vary by sector, facilities are not required to conduct a

full-scale exercise as defined by FEMA or DHS’s Homeland Security Exercise and

Evaluation Program (HSEEP). For the purposes of this requirement, a full scale exercise

is defined and accepted as any operations-based exercise (drill, functional, or full-scale

exercise) that assesses a facility’s functional capabilities by simulating a response to an

emergency that would impact the facility’s operations and their given community. Full-scale exercises in the industry setting are large exercises in which multiple agencies

participate and may only be available every three to five years; while functional

exercises are similar in nature, but may not involve as many participants and in which

each agency can choose its priorities to test within the confines of the exercise.

Therefore, full-scale can include what is known as a “functional” exercise or drill in the

industry and according to HSEEP. A full-scale exercise is also an operations-based

exercise that typically involves multiple agencies, jurisdictions, and disciplines

performing functional or operational elements. There is also definition for “community”

as it is subject to variation based on geographic setting, (e.g. rural, suburban, urban, etc.),

state and local agency roles and responsibilities, types of providers in a given area in

addition to other factors. In doing so, facilities have the flexibility to participate in and

conduct exercises that more realistically reflect the risks and composition of their

communities. Facilities are expected to consider their physical location, agency and other

facility responsibilities and needs of the community when planning or participating in

their exercises. The term could, however, mean entities within a state or multi-state

region.

In many areas of the country, State and local agencies (emergency management agencies

and health departments) and some regional entities, such as healthcare coalitions may

conduct an annual full-scale, community-based exercise in an effort to more broadly

assess community-wide emergency planning, potential gaps, and the integration of

response capabilities in an emergency. Facilities should actively engage these entities to

identify potential opportunities, as appropriate, as they offer the facility the opportunity to

not only assess their emergency plan but also better understand how they can contribute

to, coordinate with, and integrate into the broader community’s response during an

emergency. They also provide a collective forum for assessing their communications

plans to ensure they have the appropriate contacts and understand how best to engage and

communicate with their state and local public health and emergency management

agencies and other relevant partners, such as a local healthcare coalition, during an

emergency.

Facilities are expected to contact their local and state agencies and healthcare coalitions,

where appropriate, to determine if an opportunity exists and determine if their

participation would fulfill this requirement. It is also important to note that agencies and

or healthcare coalitions conducting these exercises will not have the resources to fulfill

individual facility requirements and thus will only serve as a conduit for broader

community engagement and coordination prior to, during and after the full-scale

community-based exercise. Facilities are responsible for resourcing their participation

and ensuring that all requisite documentation is developed and available to demonstrate

their compliance with this requirement.

Facilities are encouraged to engage with their area Health Care Coalitions (HCC)

(partnerships between healthcare, public health, EMS, and emergency management) to

explore integrated opportunities. Health Care Coalitions (HCCs) are groups of individual

health care and response organizations who collaborate to ensure each member has what

it needs to respond to emergencies and planned events. HCCs plan and conduct

coordinated exercises to assess the health care delivery systems readiness. There is value

in participating in HCCs for participating in strategic planning, information sharing and

resource coordination. HCC’s do not coordinate individual facility exercises, but rather

serve as a conduit to provide an opportunity for other provider types to participate in an

exercise. HCCs should communicate exercise plans with local and state emergency

preparedness agencies and HCCs will benefit the entire community’s preparedness. In

addition, CMS does not regulate state and local government disaster planning agencies.

It is the sole responsibility of the facility to be in compliance.

Facilities which determine that a full-scale community-based exercise will be planned for

the facility’s exercise requirement must also ensure that the exercise scenario developed

is identified within the facility’s risk assessment. While generally local and state

emergency officials plan emergency exercises which could occur within the geographic

location or community, facilities must ensure that participation in the exercise would

adequately test the facility’s emergency program (specifically its policies and procedures

and communication plan). For instance, in the event the local or state full-scale exercise

is testing the response to a major multiple car accident requiring airlift transfers of

patients, a LTC facility or ESRD facility may not be impacted by this type of disaster or

require activation of its emergency program, therefore the exercise may not be as

appropriate. In this case, the facility could document that the scenario offered in this

full-scale community based exercise and that the facility conducted an individual facility-based exercise to test its emergency program instead. However, if the state or local

exercise is testing an EID outbreak, all facilities in the community may be impacted,

therefore participation would be strongly recommended.

The intent behind full-scale and community based exercises is to ensure the facility’s

emergency program and response capabilities complement the local and state emergency

plans and support an integrated response while protecting the health and safety of

patients.

Individual Facility-Based Exercises:

Facilities that are not able to identify a full-scale community-based exercise, can instead

fulfill this part of their requirement by either conducting an individual facility-based

exercise, documenting an emergency that required them to fully activate their emergency

plan, or by conducting a smaller community-based exercise with other nearby facilities.

Facilities that elect to develop a small community-based exercise have the opportunity to

not only assess their own emergency preparedness plans but also better understand the

whole community’s needs, identify critical interdependencies and or gaps and potentially

minimize the financial impact of this requirement. For example, a LTC facility, a

hospital, an ESRD facility, and a home health agency, all within a given area, could

conduct a small community-based exercise to assess their individual facility plans and

identify interdependencies that may impact facility evacuations and or address potential

surge scenarios due to a prolonged disruption in dialysis and home health care services.

Those that elect to conduct a community-based exercise should make an effort to contact

their local/state emergency officials and healthcare coalitions, where appropriate, and

offer them the opportunity to attend as they can provide valuable insight into the broader

emergency planning and response activities in their given area. Community partners are

considered any emergency management officials (fire, police, emergency medical

services, etc.) for full-scale and community-based exercises, however can also mean

community partners that assist in an emergency, such as surrounding providers and

suppliers.

Participation

While the regulations do not specify a minimum number of staff, or the roles of staff in

the exercises, it is strongly encouraged that facility leadership and department heads

participate in exercises. If an exercise is conducted at the individual facility-based level

and is testing a particular clinical area, staff who work in this clinical area should

participate in the exercise for a clear understanding of their roles and responsibilities.

Additionally, facilities can review which members of staff participated in the previous

exercise, and include those who did not participate in the subsequent exercises to ensure

all staff members have an opportunity to participate and gain insight and knowledge.

Facilities can use a sign-in roster for the exercise to substantiate staff participation. A

sufficient number of staff should participate in the exercise to test the scenario and

thoroughly assess the risk, policy, procedure, or plan being tested.

Facilities that conduct an individual facility-based exercise will need to demonstrate how

it addresses any risk(s) identified in its risk assessment. For example, an inpatient facility

might test their policies and procedures for a flood that may require the evacuation of

patients to an external site or to an internal safe “shelter-in-place” location (e.g. foyer,

cafeteria, etc.) and include requirements for patients with access and functional needs and

potential dependencies on life-saving electricity-dependent medical equipment. An

outpatient facility, such as a home health provider, might test its policies and procedures

for a flood that may require it to rapidly locate its on-duty staff, assess the acuity of its

patients to determine those that may be able to shelter-in-place or require hospital

admission, communicate potential evacuation needs to local agencies, and provide

medical information to support the patient’s continuity of care. If the facility uses fire

drills based on their risk assessment (e.g. wild fires) as a full-scale community based

exercise in one given year (which is also a requirement for some providers/suppliers

under Life Safety Code), the facility is encouraged to choose in the following year a

different hazard in their risk assessment to conduct an exercise in order to ensure

variability in the training and testing program. The intent of the requirements under the

emergency preparedness condition for participation/condition for coverage, or

requirement for LTC, is to test the facility’s ability to respond to any emergency outlined

within their risk assessment. The purpose of testing the facility’s emergency program is

to identify gaps in response which could result in adverse events for patients and staff

and to adjust plans, policies and procedures to ensure patient and staff safety is

maintained regardless of the type of emergency which occurs.

Table-Top Exercise and Workshops

Facilities are also required to conduct an “exercise of choice” or, for some, only conduct

a table-top exercise (TTX) or workshop. Please refer back to the definition section

above. TTX’s or workshops are expected to be group discussions led by a facilitator. We

are not defining whether or not the facilitator must be a staff member or contracted

service. Some facilities may find that a specific department lead may be best suited

dependent on the scenario being tested, while other facilities may find an outside

facilitator may be more appropriate to facilitate.

The intent behind TTX’s or workshops is to test an exercise based on the facility’s risk

assessment. Some facilities may find it prudent to conduct a TTX or workshop prior to a

full-scale or individual-facility based exercise in order to identify potential gaps or

challenges and then update the policies and procedures accordingly to resolve the

potential issue. This would allow for facilities to test their adjustments during a full-scale or individual facility-based exercise to determine if the corrective action was

appropriate.

After-Action Reviews

Each facility is responsible for documenting their compliance and ensuring that this

information is available for review at any time for a period of no less than three (3) years.

Facilities should also document the lessons learned following their tabletop and full-scale

exercises and real-life emergencies and demonstrate that they have incorporated any

necessary improvements in their emergency preparedness program. Facilities may

complete an after action review process to help them develop an actionable after action

report (AAR). The process includes a roundtable discussion that includes leadership,

department leads and critical staff who can identify and document lessons learned and

necessary improvements in an official AAR. The AAR, at a minimum, should determine

1) what was supposed to happen; 2) what occurred; 3) what went well; 4) what the

facility can do differently or improve upon; and 5) a plan with timelines for incorporating

necessary improvement. Lastly, facilities that are a part of a healthcare system, can elect

to participate in their system’s integrated and unified emergency preparedness program

and exercises. However, those that do will still be responsible for documenting and

demonstrating their individual facility’s compliance with the exercise and training

requirements.

Exemption based on Actual Emergency

Finally, an actual emergency event or response of sufficient magnitude that requires

activation of the relevant emergency plans meets the full-scale exercise requirement and

exempts the facility for engaging in their next required community-based full-scale

exercise or individual, facility-based exercise for following the actual event; and facilities

must be able to demonstrate this through written documentation. With the changed

requirements as a result of the 2019 Burden Reduction final rule (81 FR 63859) for

outpatient providers required to conduct full-scale exercises only every other year,

opposite of their exercises of choice, these facilities are exempt from their next required

full-scale or individual facility-based exercise. For inpatient providers, the full-scale

exercise would be annually. The intent is to ensure that facilities conduct at least one

exercise per year.

For example, in the event an outpatient provider conducts a required full-scale

community based exercise in January 2019, and completed the optional exercise of its

choice in January 2020, and experiences an actual emergency in March 2020, the

outpatient provider is exempt from next required full-scale community based or

individual facility based exercise in January 2021. If the outpatient provider conducts a

required full-scale community based exercise in January 2020, and has the optional

exercise of its choice scheduled for January 2021, and experiences an actual emergency

in March 2020, the outpatient provider is exempt from next required full-scale

community based or individual facility based exercise in January 2022, but must still

conduct the required exercise of choice in January 2021. The exemption is based on the

facility’s required full-scale exercise, not the exercise of choice, therefore the exemption

may not be applicable until two years following the activation of the emergency plan,

dependent on the cycle the facility has determined and the actual emergency event.

For inpatient providers, the exemption would apply for the next required full-scale

exercise as well, however, it may be the same year or following year, as inpatient

providers are required to perform two exercises per year. If an inpatient provider

completed the full-scale exercise in January 2020 and is scheduled to conduct an

exercise of choice in November 2020, but experiences an actual emergency in March

2020 which required activation of its emergency plan, the inpatient provider is exempt

from the next required full-scale exercise in January 2021, but must complete the

exercise of choice. If the inpatient provider conducted an exercise of choice prior to the

actual emergency and had a full-scale exercise scheduled for November 2020, then the

inpatient provider would be exempt from that full-scale exercise as it would not be the

exercise of choice.

The exercises of choice, which allow facilities to choose one (e.g., another full-scale/individual facility based; mock disaster drill; or table top exercises) are not

considered as the required full-scale community based or individual facility based

exercises. Facilities which may have schedule full-scale exercises annually as part of

their licensure or accrediting organizations requirements, would be exempt from their

next required annual full-scale exercise. Facilities which have a full-scale exercise

scheduled as part of their exercise of choice for the opposite years would be exempt from

their next scheduled exercise following an emergency, which would still be July 2021

(using the above example).

Facilities must document that they had activated their emergency program based on an

actual emergency. Documentation may include, but is not limited to: a section 1135

waiver issued to the facility (time limited and event-specific); documentation alerting

staff of the emergency; documentation of facility closures; meeting minutes which

addressed the time and event specific information. The facility must also complete an

after action review and integrated corrective actions into their emergency preparedness

program.

Resources

For additional information and tools, please visit the CMS Quality, Safety & Oversight

Group Emergency Preparedness website at:

https://www.cms.gov/Medicare/Provider-Enrollment-and-Certification/SurveyCertEmergPrep/index.html or ASPR TRACIE.

Survey Procedures

• Ask facility leadership to explain the participation of management and staff during

scheduled exercises.

• Ask to see documentation of the exercises (which may include, but is not limited to,

the exercise plan, the AAR, and any additional documentation used by the facility to

support the exercise). Documentation must demonstrate the facility has conducted

the exercises described in the standard.

• Ask to see the documentation of the facility’s efforts to identify a full-scale

community based exercise if they did not participate in one (i.e. date and personnel

and agencies contacted and the reasons for the inability to participate in a community

based exercise).

• Request documentation of the facility’s analysis and response and how the facility

updated its emergency program based on this analysis.

NOTE: We recommend facilities to retain, at a minimum, the past 2 cycles (generally 2

years for inpatient providers and 4 years for outpatient providers of emergency testing

exercise documentation. This would allow surveyors to assess compliance on the cycle of

testing required for outpatient providers.