September 9, 2026
Alternating years is an outpatient rule, not a hospital one
The most-repeated summary of the CMS exercise cadence describes outpatient providers. Hospitals, critical access hospitals and PRTFs test twice a year, every year.
Somewhere between the regulation and the summary of it, the CMS exercise cadence picked up a rule that is not in the regulation.
The familiar version: a participating provider runs an annual exercise, and a tabletop counts as the exercise in alternating years. It turns up in readiness checklists, in conference decks, and in a good many survey-prep templates.
It describes outpatient providers. It does not describe a hospital.
Inpatient providers — hospitals, critical access hospitals, psychiatric residential treatment facilities — test twice per year, every year. An annual full-scale community-based exercise, or a facility-based functional exercise where a community-based one is not accessible, plus an additional annual exercise.¹ Nothing alternates. Both happen, every year.
Outpatient providers — ambulatory surgical centers, rural health clinics and FQHCs, CORFs, community mental health centers, ESRD facilities, OPOs, RNHCIs — test annually, with the full-scale exercise every two years and the additional exercise in the opposite year.¹ That is where the alternating pattern lives, and that is the sentence the summaries flattened.
The error travels well because Appendix Z is genuinely broad: seventeen provider and supplier types, each with its own Condition of Participation. Stating one cadence for all of them is the obvious simplification, and it is the wrong one. Breadth of scope is not uniformity of requirement.
If a program was built on the summary rather than the rule, the gap is not cosmetic. A hospital exercising once a year is running half the required cadence, and the surveyor is the one who finds out.
One more thing the summaries add that the rule does not: the tabletop is not anointed. The additional exercise "may include, but is not limited to" a second full-scale or facility-based functional exercise, a mock disaster drill, or a tabletop exercise or workshop.¹ A tabletop qualifies on its own terms. It is not the designated alternate.
The rest of it — the citations by provider type, what a surveyor actually asks to see, what the rule means by a tabletop, and the four places it is deliberately silent — is in one place: The CMS Emergency Preparedness Rule exercise requirement, explained.
Regulatory references current as of September 2026. This piece is scheduled for re-verification by March 2027.
¹ Centers for Medicare & Medicaid Services, State Operations Manual, Appendix Z — Emergency Preparedness for All Provider and Certified Supplier Types, Interpretive Guidance (Rev. 204, issued 2021-04-16). Appendix Z reproduces the Conditions of Participation text for each provider type alongside CMS's interpretive and survey guidance; all regulatory language quoted above is taken from it.