Accreditation Resource Services Newsletter
June 2020

ARS Regulatory Alerts

CIHQ-ARS notifies member organizations of any new or modified accreditation standard, or CMS COP for acute care hospitals. Each alert summarizes the standard / regulation, likely impact to members, and recommends compliance strategies. Whenever possible, alerts are limited to one-page in length so that they can be quickly read and disseminated.

New Regulatory Alert

Alert Date
May, 27 2020
Alert Subject
Joint Commission Announces Resumption of Survey Activities
Alert Applicability
Acute Care Ambulatory Care Behavioral Health
Critical Access Home Health / Hospice Laboratory
Long Term Care Other: __________  
Alert Background
In an on-line posting dated 5/27/20, the Joint Commission announced that it will resume regular survey activities effective June of 2020. The Joint Commission indicated that on-site survey processes will be somewhat modified in light on the ongoing COVID-19 public health emergency. Modifications include the following:
  • Limiting the numbers of individuals in group sessions. The use of audio or video conference calls can be incorporated by the organization to safely expand the number of attendees.
  • Minimizing the number of people who accompany the surveyor on tracer activities.
  • Using masks will be a routine practice, and the Joint Commission expects the organization to provide masks and/or other personal protective equipment (PPE) to surveyors and reviewers while on-site.
  • Maximizing the use of technology to eliminate the need for a number of people to sit directly next to an individual for an extended time. For example, conducting electronic medical record reviews using screen-sharing or displaying/projecting the record. Other examples include simulating an activity if surveyors are unable to enter a high-risk space, and interviewing patients or staff by phone.
  • Driving in separate cars to off-site locations or home visits.
The Joint Commission is reviewing a variety of factors and criteria for determining where and which organizations will be surveyed, including identifying and then prioritizing low-risk areas in which a survey can safely occur.
Discussion & Recommendations
To view the discussion & recommendations ARS Organization Members can download this alert in its entirety when logged-in/connected to the ARS Members section. All alerts are archived in the member’s only section of our web site for future access and reference.
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New Regulatory Alert

Alert Date
May, 10 2020
Alert Subject
CMS Issues Additional Blanket Waivers in Response to COVID-19 Pandemic
Alert Applicability
Acute Care Ambulatory Care Behavioral Health
Critical Access Home Health / Hospice Laboratory
Long Term Care Other: __________  
Alert Background
In an update dated 5/8/20, CMS announced the following additional Section 1135 waivers in response to the COVID-19 public health emergency (PHE):
  1. Expanded Ability for Hospitals to Offer Long-term Care Services (“Swing-Beds”) for Patients Who do not Require Acute Care but do Meet the Skilled Nursing Facility (SNF) Level of Care Criteria as Set Forth at 42 CFR 409.31. (New since 4/30 Release)
    Under section 1135(b)(1) of the Act, CMS is waiving the requirements at 42 CFR 482.58, “Special Requirements for hospital providers of long-term care services (“swing-beds”)” subsections (a)(1)-(4) “Eligibility”, to allow hospitals to establish SNF swing beds payable under the SNF prospective payment system (PPS) to provide additional options for hospitals with patients who no longer require acute care but are unable to find placement in a SNF.
    In order to qualify for this waiver, hospitals must:
    • Not use SNF swing beds for acute level care.
    • Comply with all other hospital conditions of participation and those SNF provisions set out at 42 CFR 482.58(b) to the extent not waived.
    • Be consistent with the state’s emergency preparedness or pandemic plan.
    Hospitals must call the CMS Medicare Administrative Contractor (MAC) enrollment hotline to add swing bed services. The hospital must attest to CMS that:
    • They have made a good faith effort to exhaust all other options;
    • There are no skilled nursing facilities within the hospital’s catchment area that under normal circumstances would have accepted SNF transfers, but are currently not willing to accept or able to take patients because of the COVID-19 public health emergency (PHE);
    • The hospital meets all waiver eligibility requirements; and
    • They have a plan to discharge patients as soon as practicable, when a SNF bed becomes available, or when the PHE ends, whichever is earlier.
    This waiver applies to all Medicare enrolled hospitals, except psychiatric and long term care hospitals that need to provide post-hospital SNF level swing-bed services for non-acute care patients in hospitals, so long as the waiver is not inconsistent with the state’s emergency preparedness or pandemic plan. The hospital shall not bill for SNF PPS payment using swing beds when patients require acute level care or continued acute care at any time while this waiver is in effect. This waiver is permissible for swing bed admissions during the COVID-19 PHE with an understanding that the hospital must have a plan to discharge swing bed patients as soon as practicable, when a SNF bed becomes available, or when the PHE ends, whichever is earlier
  2. Hospitals Classified as Sole Community Hospitals (SCH’) (New since 4/30 Release)
    CMS is waiving certain eligibility requirements at 42 CFR § 412.92(a) for hospitals classified as SCH’ prior to the PHE. Specifically, CMS is waiving the distance requirements at paragraphs (a), (a)(1), (a)(2), and (a)(3) of 42 CFR § 412.92, and is also waiving the “market share” and bed requirements (as applicable) at 42 CFR § 412.92(a)(1)(i) and (ii). CMS is waiving these requirements for the duration of the PHE to allow these hospitals to meet the needs of the communities they serve during the PHE, such as to provide for increased capacity and promote appropriate cohorting of COVID-19 patients. MACs will resume their standard practice for evaluation of all eligibility requirements after the conclusion of the PHE period.
  3. Hospitals Classified as Medicare-Dependent, Small Rural Hospitals (MDH’) (New since 4/30 Release)
    For hospitals classified as MDHs prior to the PHE, CMS is waiving the eligibility requirement at 42 CFR § 412.108(a)(1)(ii) that the hospital has 100 or fewer beds during the cost reporting period, and the eligibility requirement at 42 CFR § 412.108(a)(1)(iv)(C) that at least 60 percent of the hospital's inpatient days or discharges were attributable to individuals entitled to Medicare Part A benefits during the specified hospital cost reporting periods. CMS is waiving these requirements for the duration of the PHE to allow these hospitals to meet the needs of the communities they serve during the PHE, such as to provide for increased capacity and promote appropriate cohorting of COVID-19 patients. MACs will resume their standard practice for evaluation of all eligibility requirements after the conclusion of the PHE period.
  4. Multiple Providers: Specific Life Safety Code (LSC) Waiver Information: (New since 4/30 Release)
    CMS is waiving and modifying particular waivers under 42 CFR §482.41(b) for hospitals; and §485.623(c) for CAH’. Specifically, CMS is modifying these requirements as follows:
    • Alcohol-based Hand-Rub (ABHR) Dispensers:
      others due to the need for the increased use of ABHR in infection control. However, ABHRs contain ethyl alcohol, which is considered a flammable liquid, and there are restrictions on the storage and location of the containers. This includes restricting access by certain patient/resident population to prevent accidental ingestion. Due to the increased fire risk for bulk containers (over five gallons) those will still need to be stored in a protected hazardous materials area. Refer to: 2012 LSC, sections 18/19.3.2.6. In addition, facilities should continue to protect ABHR dispensers against inappropriate use as required by 42 CFR §482.41(b)(7) for hospitals; and §485.623(c)(5) for CAH’.
    • Fire Drills:
      Due to the inadvisability of quarterly fire drills that move and mass staff together, CMS will instead permit a documented orientation training program related to the current fire plan, which considers current facility conditions. The training will instruct employees including existing, new or temporary employees, on their current duties, life safety procedures and the fire protection devices in their assigned area. Refer to: 2012 LSC, sections 18/19.7.1.6.
    • Temporary Construction:
      CMS is waiving requirements that would otherwise not permit temporary walls and barriers between patients. Refer to: 2012 LSC, sections 18/19.3.3.2.
Discussion & Recommendations
To view the discussion & recommendations ARS Organization Members can download this alert in its entirety when logged-in/connected to the ARS Members section. All alerts are archived in the member’s only section of our web site for future access and reference.
Not an ARS Member Organization?
» Find out how to Enroll and enjoy these as well as other benefits from ARS!