CMS Memo Addresses Emergency Preparedness Exercises

Under CMS emergency preparedness regulations, nursing facilities are required to conduct two emergency preparedness testing exercises annually.

If a facility experiences an actual natural or man-made emergency that requires activation of its emergency plan, the provider will be exempt from their next required full-scale community-based exercise or individual, facility-based functional exercise following the onset of the actual event. In light of the COVID-19 Public Health Emergency, CMS has issued memorandum QSO-20-41-All clarifying the testing exercise requirements to ensure that surveyors, as well as providers, are aware of the exemption available based on activation of their emergency plans.

To be eligible for the exemption, a provider must have activated its emergency plan. Among other guidance, CMS states that documentation of the activation of an emergency plan may include but is not limited to, the following:

  • Notice of activation to staff via electronic systems (alerts);
  • Proof of patient transfers and changes in daily operations based on the emergency;
  • Initiation of additional safety protocols, for example, mandate for use of personal protective equipment (PPE) for staff, visitors and patients as applicable;
  • Coordination with state and local emergency officials;
  • Minutes of board/facility meetings;
  • 1135 Waiver (individual or use of blanket flexibilities); or
  • Incident command system related reports, such as situation reports or incident action plans.

See the complete QSO-20-41-All for additional information and examples.

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