Accreditation Resource Services Newsletter
October 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
September, 29 2020
Alert Subject
CMS Issues Guidance on COVID-19 & Emergency Preparedness Testing Requirements
Alert Applicability
Acute Care Ambulatory Care Behavioral Health
Critical Access Home Health / Hospice Laboratory
Long Term Care Other: __________  
Alert Background
In a letter to State Agencies dated 9/28/20, CMS issued additional guidance on testing requirements for emergency preparedness. The guidance takes effect immediately.
If a provider experiences an actual natural or man-made emergency that requires activation of their emergency plan, inpatient and outpatient providers will be exempt from their next required full-scale community-based exercise or individual, facility-based functional exercise following the onset of the actual event.
On Friday, March 13, 2020, the President declared a national emergency due to COVID-19 and subsequently many providers and suppliers have activated their emergency plans in order to address surge and coordinate response activities. Facilities that activated their emergency plans due to COVID-19 are exempt from the next required full-scale community-based or individual, facility-based functional exercise. Facilities must be able to demonstrate, through written documentation, that they activated their program due to the emergency.
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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» Find out how to Enroll and enjoy these as well as other benefits from ARS!

New Regulatory Alert

Alert Date
September, 28 2020
Alert Subject
CMS Issues Categorical Waiver on Corrugated Medical Tubing
Alert Applicability
Acute Care Ambulatory Care Behavioral Health
Critical Access Home Health / Hospice Laboratory
Long Term Care Other: __________  
Alert Background
In a letter sent to State Agencies on September 25, 2020. CMS issued a categorical waiver to hospitals and other healthcare entities permitting the use of corrugated medical tubing (CMT) in new and existing health care facilities based on provisions provided in the 2018 NFPA 99, Sections 5.1.10, 5.2.10, and 5.3.10.
Entities that want to utilize a categorical waiver must formally elect and document their decision. At the survey entrance conference, an entity that has elected to use a categorical waiver must provide the survey team with their documented decision and verification of compliance with all applicable provisions. It is not acceptable for a facility to notify surveyors of the election to use a categorical waiver after the survey team has issued a citation.
The survey team will review the documentation decision to use the categorical waiver and confirm the facility is compliant with all applicable provisions. This will confirm a minimum level of protection is afforded to protect the health and safety of patients and residents, as required by regulation. If a provider/supplier conforms to the requirements identified for the categorical waiver, it will not be required to request waiver approval from CMS nor will it need to be cited for an associated deficiency in order to implement this categorical waiver.
If the survey team determines that the provisions required for the categorical waiver are not being met, a deficiency must be cited.
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!