CMS requires outpatient providers, including ASCs, to conduct one testing exercise annually, and at least every two years, that exercise must be a full-scale exercise. The first exercise should also be a community-based drill, if possible, but must be a full-scale exercise. For the purposes of this requirement, a “full-scale exercise is defined and accepted as any operations-based exercise (drill, functional, or full-scale exercise) that assesses a facility’s functional capabilities by simulating a response to an emergency that would impact the facility’s operations and their given community.”
For the years when a full-scale exercise is not required, an ASC must conduct either a facility-based drill or a tabletop exercise (TTX) or workshop that includes a group discussion led by a facilitator. According to 42 CFR 416.54(d)(2)(ii)(C), a table-top exercise (TTX) or workshop is a “group discussion led by a facilitator, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan.” It involves key personnel discussing simulated scenarios, including computer-simulated exercises, in an informal setting. TTXs can be used to assess plans, policies and procedures.
Examples of emergency scenarios that ASCs may consider for either of the required exercises include earthquakes, tornados, hurricanes, flooding, fires, cybersecurity attacks, single-facility disasters (power-outages), medical surges (i.e., community disasters leading to influx of patients), infectious disease outbreaks or active shooters. ASCs should assess which emergencies are most appropriate to them.
If the facility had an actual emergency, that could count as the test for the year, but it must be documented. Documentation may include, but is not limited to, a section 1135 waiver issued to the facility, time limited and event-specific; documentation alerting staff of the emergency; documentation of facility closures; meeting minutes that address time- and event-specific information. The facility also must complete an after-action review and integrate corrective actions into its emergency preparedness program.