CMS Releases Guidance On Emergency Preparedness Testing Exercises For Inpatient And Outpatient Facilities

October 2, 2020


In a memo, dated September 28, 2020, the Director of the Quality, Safety & Oversight Group in CMS’ Center for Clinical Standards and Quality clarified that facilities that activated their emergency plans due to the COVID-19 Public Health Emergency (PHE) are exempt from their next required full-scale community-based or individual, facility-based functional exercise. Affected facilities, however, must be able to demonstrate, through written documentation, that they activated their emergency plan due to the PHE.

Under the emergency preparedness testing regulations, revised effective November 29, 2019, CMS requires inpatient facilities to conduct exercises to test their emergency plan at least twice per year, including an annual full-scale community based exercise (or, if not accessible, a facility-based functional exercise) AND an additional “exercise of choice.” Outpatient facilities must also conduct exercises at least annually, but need only conduct a full-scale community based exercise (or if not accessible, an individual facility-based exercise) every two years. In years opposite the year of the full-scale or facility-based functional exercise, outpatient facilities must conduct an “exercise of choice.” The memo clarifies that both inpatient and outpatient facilities may need to conduct an exercise of choice following the current PHE if they were required to conduct such an exercise this year and did not already do so. An “exercise of choice” must be one of the following:

  • Another full-scale exercise;
  • Individual-facility-based functional exercise;
  • Mock disaster drill; or
  • A tabletop exercise or workshop.

CMS suggests that facilities may choose to conduct a table-top exercise, which could assess the facility’s response to COVID-19. This may include, but is not limited to:

  • discussions surrounding availability of personal protective equipment (PPE);
  • isolation and quarantine areas for screening patients; or
  • any other activities implemented during the activation of the emergency plan.

Attached to the memo is a work sheet for state surveyors, as well as facilities, to assist in determining whether they qualify for the testing exemption following activation of their emergency plans during the PHE. Facilities should review both the memo and the work sheet (available at: ) to ascertain if they meet the exemption requirements related to community-based or individual, facility-based functional exercises and for the types of documentation that surveyors will be looking for to support that an emergency plan was activated.

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