On May 26, 2022 CMS issued another revision to QSO-20-41-ALL. This update clarifies that providers are exempt from the 2021 and 2022 Full Scale Exercise (FSE) as long as the facility is still operating under an activated emergency plan or has reactivated its plan due to COVID-19.

If you choose to use the exemption, you should ensure you document your organization’s COVID-19 response in a formal After Action Report (AAR). If you have already completed a COVID-19 AAR in a previous year, you should consider updating the AAR to reflect on-going response, lessons learned and opportunities for improvement. AHCA/NCAL members can access a COVID-19 AAR Template to assist with documentation.

One key component to a comprehensive AAR is an Improvement Plan (IP). The IP should serve as roadmap for future plan enhancements and training focus.

Don’t forget that documenting your organization’s COVID-19 response will only address one of the two required annual exercises.  To comply with CMS requirements, facilities must still conduct one of the following:

• another full-scale exercise
• individual-facility-based functional exercise
• mock disaster drill
• atabletop exercise or workshop. 

Read the memo in its entirety.​​

Background on Emergency Preparedness Requirements

In September 2016 CMS published its final rule on Emergency Preparedness Requirements for Medicare and Medicaid Providers and Suppliers. That action commenced a new focus and priority around disaster preparedness for all healthcare occupancies, including nursing homes. Program “testing” was one Emergency Preparedness Program (EPP) component with very detailed and prescriptive requirements.

In September of 2019, CMS published some revisions to the original rule that were intended to reduce the burden on healthcare organizations. Additional testing options were outlined, and new language clarified that an actual emergency could be used in place of one of the required exercises. According to CMS, “If a provider experiences an actual natural or man-made emergency that requires activation of their emergency plan, inpatient and outpatient providers 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.”

Come September of 2020, as most healthcare providers found themselves dealing with the greatest health emergency in modern times, CMS developed QSO-20-41 that provided specific guidance around exercises. The original memo clarified that an organization’s COVID-19 response could serve as its FSE for 2020. The first revision to the memo issued on June 21, 2021 extended the FSE exemption through 2021 if the organization continued to “operate under their activated emergency plans for COVID-19 response.”