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QSO-20-41-ALL Revised 05.26.2022

The following has been sent out via IHANS.

On May 26, 2022 the Centers for Medicare and Medicaid Services (CMS) revised and published QSO-20-41-ALL Revised 05.26.2022 (PDF) to provide additional guidance and clarifications due to the ongoing COVID-19 public health emergency (PHE). Specifically, this QSO addresses preparedness training and testing program exceptions. The red font denotes revised verbiage.

Memorandum Summary:

  • For the purposes of this QSO, Inpatient providers and suppliers include long-term care (LTCs) facilities.
  • Emergency Preparedness Training and Testing Program Exemption

CMS regulations for Emergency Preparedness (EP) require facilities to conduct exercises to test the facility’s EP plan to ensure that it works and that staff are trained appropriately about their roles and the facility’s processes. During or after an actual emergency, the regulations allow for a one-year exemption from the requirement that the facility perform testing exercises.

The worksheet presents guidance for surveyors, as well as providers and suppliers, with assessing a facility’s compliance with the EP requirements, in light of many of the response activities associated with the COVID-19 Public Health Emergency (PHE).

As the PHE continues, many facilities continue to operate under their respective activated emergency plans. Therefore, CMS is providing additional guidance related to the exercise requirements (full-scale/functional drills and exercises) for inpatient and outpatient providers/suppliers.

This exemption only applies to the next required full-scale exercise (not the exercise of choice), based on the facility’s 12-month exercise cycle. The cycle is determined by the facility (e.g. calendar, fiscal or another 12-month timeframe).

Questions about this memorandum should be addressed to QSOG_EmergencyPrep@cms.hhs.gov

As a reminder, Law Chapter 114 of the Laws of 2020 created a new subdivision 12 to section 2803 of the Public Health Law. The new subdivision requires each residential health care facility in New York State to prepare a Pandemic Emergency Plan (PEP) and to review the PEP annually.

NYSHFA/NYSCAL CONTACTS:

Jackie Pappalardi, RN, BSN
Executive Director
518-462-4800 x16