An effective and compliant Emergency Preparedness Program (EPP) is one that is continually reviewed and improved. This is most commonly accomplished by testing the program through drills and exercises. A well-planned and executed exercise can validate plan content, staff knowledge, and overall organizational preparedness.
To ensure providers adequately test their EPP, the Centers for Medicare and Medicaid Services (CMS) established specific testing requirements when they introduced emergency preparedness regulations in 2016.
CMS requires long term care providers to test their programs twice annually. Providers must conduct at least one (1) full scale, community-based, exercise. If a community-based exercise is not accessible, an individual facility-based functional exercise is permitted.
The second annual test can be accomplished by any of the following:
- an additional full-scale exercise
- a functional facility-based exercise
- a mock disaster drill
- a tabletop exercise
- a planning meeting / exercise workshop.
Each exercise or drill should be documented via an After-Action Report (AAR). A comprehensive AAR will include an overview of the exercise, an outline of exercise objectives, an analysis of strengths and weaknesses, and a specific outline of actionable improvement recommendations. CMS offers a free online AAR template.
An organization that experiences a real-life event involving the activation of their emergency preparedness plan may use that event to satisfy one (1) of the required annual exercises. It should be documented accordingly through an AAR. A second exercise is still required and cannot be supplemented with a real-life event.
Several organizations provide useful exercise tools and resources online. The following is a list of helpful links:
In addition, the CMS Emergency Preparedness Regulations – Self Assessment and Resource Tool is available to members on the AHCA website. This tool identifies each CMS emergency preparedness requirement applicable to long-term care providers, provides key guidance from Appendix Z, and describes surveyor validation methods. It also includes a variety of useful web links that provide access to information and tools on everything from incident command to after-action reports.
AHCA is always available to support members with emergency preparedness questions. Inquiries can be emailed to emergencyprep@ahca.org.