Mac's Safety Space: If it ain’t over ‘til it’s over…

By Steve MacArthur, Hospital Safety Consultant

Can you get over something that’s not over?

I think this one will be relatively brief (as I always do), so we’ll see how far this takes us…

On May 1st, CMS provided guidance relative to the official expiration of the COVID-19 public health emergency (PHE). We’ve discussed some of the waivers that will be expiring, particularly those relating to hand sanitizer and certain temporary barriers, but it really wasn’t clear how the practical and operational considerations of emergency management (drills and exercises) would be returned to the mix. At any rate, the memo (which can be found here: ) covers the reintroduction of the exercising of one’s emergency response plan, but it’s not as dynamically helpful as I would have liked to see (once again, an almost pathological aversion to clarity rears its head).

So, the memo starts with the following:

“During or after an actual emergency, the emergency preparation regulations allow for a one-year exemption from the requirement that the provider/supplier perform testing exercises. The exemption only applies to the next required full-scale exercise (not the exercise of choice), based on the 12-month exercise cycle.  The cycle is determined by the provider/supplier (e.g., calendar, fiscal or another 12-month timeframe). The exemption only applies when a provider/supplier activates its emergency preparedness program for an emergency event.” 

So, I guess the clock started the last time you actually activated your response plan (I know any number of folks who have had to respond to non-pandemic-related emergencies), since it appears to be based on your own implementation as opposed to the “fact” or “reality” of the PHE. So, if you have been implementing your response plan, et al, for the duration of the pandemic, then this one’s for you:

“Providers/suppliers are expected to return to normal operating status and comply with the regulatory requirements for emergency preparedness with the conclusion of the PHE.  This includes conducting testing exercises based on the regulatory requirements for specific provider/supplier types as follows:

  • Inpatient Providers and Suppliers: The provider/supplier must conduct a full-scale exercise within its annual cycle for 2023 and an exercise of choice
  • Outpatient Providers: The provider/supplier must conduct either a full-scale exercise or an exercise of choice within its annual cycle for 2023, if scheduled to conduct the full-scale exercise within 2023. The provider/supplier must conduct the exercise of choice, if scheduled during the annual cycle for 2023 and resume the full-scale exercise requirement in 2024.

To me, the question is one of whether we have until next May (that merry merry merriest of months) to get in the two drills (inpatient; one for outpatient) or do we have to get them in by the end of calendar year 2023, which I guess is very much dependent on how you managed the pandemic. It does appear that you can self-identify the cycle and I think my best advice at this point is to do just that at your next scheduled EM or EOC meeting (depending on who would need to “bless” the new cycle in all its glory).

So, I suppose the defining clarity for all this will have to come from within (maybe that’s a new podcast Emergency Management Meditations), which I guess is all we can really ask for.

About the Author: Steve MacArthur is a safety consultant with Chartis Clinical Quality Solutions (formerly known as The Greeley Company) in Danvers, Mass. He brings more than 30 years of healthcare management and consulting experience to his work with hospitals, physician offices, and ambulatory care facilities across the country. He is the author of HCPro's Hospital Safety Director's Handbook and is contributing editor for Healthcare Safety Leader. Contact Steve at