Emergency Preparedness: Exempt or Not Exempt? That is the Question

Emergency Preparedness: Exempt or Not Exempt? That is the Question

By Jennifer Kennedy, Vice President Quality & Standards

We are more than three weeks into 2022’s peak hurricane season months and things have been scarily quiet. I knock on wood as these words are written. In May, the National Oceanic and Atmospheric Administration (NOAA) forecasted an above-normal Atlantic hurricane season before the start of the in June. In early August, they revised their forecast stating that the likelihood of near-normal activity has risen to 30% and the chances remain at 10% for a below-normal season (NOAA, 2022).

For healthcare providers in hurricane susceptible states, it is another potential crisis to plan for and manage on top of the continuing COVID-19 pandemic, staffing shortages, and a newly declared Monkeypox public health emergency. Many providers have already faced down tornados, floods, and wildfires, this year which makes this the third year in a row where the healthcare workforce has been multi-managing more than one emergency event at the same time. Even with this added stress, the federal regulatory requirements for emergency preparedness remain the same and have not been included in any Centers for Medicare and Medicaid Services (CMS) 1135 blanket waivers. CMS expects providers to remain ready to test and utilize their emergency plans for whatever may happen while the COVID-19 public health emergency continues.

Emergency Preparedness Exercise Update CMS posted Memo QSO-20-41-ALL on May 26, 2022, titled Guidance related to Emergency Preparedness- Exercise Exemption based on A Facility’s Activation of their Emergency Plan. The memo gives healthcare organizations revised guidance related to exercise requirements (full-scale/functional drills and exercises) for inpatient and outpatient providers/suppliers during the ongoing COVID-19 public health emergency (PHE). This PHE has been extended through October 13, 2022, by the U.S. Department of Health and Human Services (HHS) Secretary Becarra. The updated guidance in this memo only applies if a provider is still operating under its activated emergency plan or reactivated its emergency plan for COVID-19 in 2021 or 2022. Providers that resumed normal operating status must conduct testing exercises based on regulatory requirements for their specific provider or supplier type.

The federal emergency preparedness regulations allow an exemption for natural or man-made events that require activation of a healthcare provider’s emergency plan. If an emergency plan is activated, the provider is exempt from the next required full-scale community-based or individual, facility-based functional exercise. Providers must evidence activation of their plan via documentation. The regulations also require completion of an annual exercise of choice for inpatient providers and every

two years for outpatient providers (opposite the year of the full-scale or facility-based functional exercise). The “exercise of choice must be another full-scale exercise; an individual-facility-based functional exercise; a mock disaster drill; or a table-top exercise or workshop. As a reminder, testing exemptions apply only for the next-full scale exercises, not exercises of choice.

Claiming an exemption for activation of an emergency plan due to an actual disaster can only happen once in a 12-month period or cycle. If a provider activated their plan to respond to two emergencies at the same time, it counts as one activation in that period; there is no carryover. The provider establishes the parameters of their 12-month period in their policy and procedure (i.e., calendar year, fiscal year, etc.).

CMS acknowledges that providers may have activated additional plans or procedures while still operating under an activated emergency plan for COVID-19 response and will claim an exemption. Even in that scenario, they urge providers to think about completing full-scale or individual facility-based exercises, if possible, to ensure they are fully prepared to respond to all emergencies and locates gaps in your emergency plan.

Lessons Learned
There are always opportunities for improvement following an actual emergency event. Emergency preparedness regulations require providers to evaluate their response of plan activation, so a debrief or after-action review should be conducted within a short time after the conclusion of the emergency to assess provider response to the incident. In the case of an ongoing event like COVID-19, consistent periodic review of plan activation and outcomes is recommended. Lessons learned from activation of an emergency plan and actual staff performance can identify needs for preparedness program changes. The After-Action Report (AAR) summarizes observations and key takeaways following an exercise or an actual emergency event experienced by the provider and the patients and families in their care. The key questions in an after-action discussion are what was expected to occur, what really happened, what went wrong and why it went wrong, what went well and why went well. It is critical to include key staff in the after-action discussion to ensure the full scope of the key questions are addressed and all perspectives about performance are captured. Performance improvement targets should cycle through an organization’s quality assessment performance improvement (QAPI) program and performance improvement projects.

It is important to know that an organization’s emergency plan is always evolving whether through testing or actual activation of the plan for an emergency event. The healthcare community has recognized the importance of emergency preparedness and management in the past two years with the advent and continuation of the COVID-19 PHE. Being prepared for any situation is just not a checkbox compliance item for an organization, comprehensive preparedness benefits staff, patients, families, and the community at large.