Hospitals, Psychiatric Hospitals, and CAHs
- EMTALA Enforcement: Allows hospitals, psychiatric hospitals, and CAHs to screen patients at a location offsite from the hospital’s campus to prevent the spread of COVID-19, in accordance with the state emergency preparedness or pandemic plan. - FAQ clarifying requirements, flexibilities, and considerations for hospitals and other providers during the pandemic (5/1/2020): Link here
- Verbal Orders under §482.23, §482.24, and §485.635(d)(3): Allows for additional flexibilities related to verbal orders where read-back verification is still required but authentication may occur later than 48 hours. This will allow for more efficient treatment of patients in a surge situation.
- Reporting Requirements: Waives requirement that hospitals report patients in an intensive care unit whose death is caused by their disease process but who required soft wrist restraints to prevent pulling tubes/IVs may be reported later than close of business next business day.
- Patient Rights: Waives requirements under 42 C.F.R. §482.13(d)(2) with respect to timeframes in providing a copy of a medical record, 42 C.F.R. §482.13(h) related to Patient visitation, and 42 C.F.R. §482.13(e)(1)(ii) regarding seclusion, but only for hospitals which are considered to be impacted by a widespread outbreak of COVID-19.
- Sterile Compounding: Waives requirements under 42 C.F.R. §482.25(b)(1) and §485.635(a)(3) in order to allow used face masks to be removed and retained in the compounding area to be re-donned and reused during the same work shift in the compounding area only.
- Information Sharing for Discharge Planning for Hospitals and CAHs: Waives the requirement to provide detailed information regarding discharge planning, including the requirement that hospital, psychiatric hospital, and CAH must assist patients, their families, or the patient's representative in selecting a post-acute care provider by using and sharing data; CMS is maintaining, however, the discharge planning requirements that ensure a patient is discharged to an appropriate setting with the necessary medical information and goals of care.
- Discharge Planning for Hospitals: Waives all the requirements post-acute care services, to expedite the safe discharge and movement of patients among care settings, and to be responsive to fluid situations in various areas of the country. CMS is maintaining the discharge planning requirements that ensure a patient is discharged to an appropriate setting with the necessary medical information and goals. Waives the requirement that for those patients discharged home and referred for HHA services, or for those patients transferred to a SNF for post-hospital extended care services, or transferred to an IRF or LTCH for specialized hospital services, the hospital must: (1) include in the discharge plan a list of HHAs, SNFs, IRFs, or LTCHs that are available to the patient; (2) must inform the patient or the patient's representative of their freedom to choose among participating Medicare providers and suppliers of post-discharge services and that and (3) discharge plan must identify any HHA or SNF to which the patient is referred in which the hospital has a disclosable financial interest, as specified by the Secretary, and any HHA or SNF that has a disclosable financial interest in a hospital under Medicare.
- Medical Staff: Waives 42 C.F.R. §482.22(a) and §485.627(a) to allow for physicians whose privileges will expire to continue practicing at the hospital or CAH and for new physicians to be able to practice in the hospital or CAH before full medical staff/governing body review and approval.
- Medical Records Timing: Waives 42 C.F.R. §482.24(c)(4)(viii) and §485.638(a)(4)(iii). CMS to allow flexibility in completion of medical records within 30 days following discharge and for CAHs that all medical records must be promptly completed. This may be implemented so long as they are not inconsistent with a state’s emergency preparedness or pandemic plan.
- Flexibility in Patient Self Determination Act Requirements (Advance Directives): Waives the requirements at section 1902(a)(58) and 1902(w)(1)(A) for Medicaid, 1852(i) (for Medicare Advantage); and 1866(f) and 42 CFR 489.102 for Medicare, which require hospitals and CAHs to provide information about its advance directive policies to patients
- Physical Environment: Waives certain requirements under the Medicare conditions at 42 C.F.R. §482.41 and §485.623 to allow for increased flexibilities for surge capacity and patient quarantine, such as permitting space not normally used for patient care to be used for patient care and quarantine sites, provided that the location is approved by the State (ensuring safety and comfort for patients and staff are sufficiently addressed) and so long as it is not inconsistent with a state’s emergency preparedness or pandemic plan. This allows for increased capacity and promotes appropriate cohorting of COVID-19 patients.
- Telemedicine for Hospitals and CAHs: Waives the provisions related to telemedicine at 42 CFR §482.12(a) (8)–(9) for hospitals and §485.616(c) for CAHs, making it easier for telemedicine services to be furnished to the hospital’s patients through an agreement with an off-site hospital. This allows for increased access to necessary care for hospital and CAH patients, including access to specialty care
- Physician Services: Waives requirements under 42 CFR §482.12(c)(1)–(2) and §482.12(c)(4), which requires that Medicare patients be under the care of a physician. This waiver may be implemented so long as it is not inconsistent with a state’s emergency preparedness or pandemic plan. This allows hospitals to use other practitioners to the fullest extent possible.
- Anesthesia Services: Waives requirements under 42 CFR §482.52(a)(5), §485.639(c) (2), and §416.42 (b)(2) that a certified registered nurse anesthetist (CRNA) is under the supervision of a physician in paragraphs §482.52(a)(5) and §485.639(c)(2). CRNA supervision will be at the discretion of the hospital and state law. This waiver applies to hospitals, CAHs, and Ambulatory Surgical Centers (ASCs). These waivers will allow CRNAs to function to the fullest extent of their licensure, and may be implemented so long as they are not inconsistent with a state’s emergency preparedness or pandemic plan.
- Utilization Review: Waives certain requirements under 42 CFR §482.1(a)(3) and 42 CFR §482.30 which address the statutory basis for hospitals and includes the requirement that hospitals participating in Medicare and Medicaid must have a utilization review plan that meets specified requirements.
- Written Policies and procedures for Appraisal of Emergencies at Off Campus Hospital Departments: Waives 42 CFR §482.12(f)(3), emergency services, with respect to surge facilities only, such that written policies and procedures for staff to use when evaluating emergencies are not required for surge facilities. This removes the burden on facilities to develop and establish additional policies and procedures at their surge facilities or surge sites related to the assessment, initial treatment and referral of patients. These flexibilities may be implemented so long as they are not inconsistent with a state’s emergency preparedness or pandemic plan.
- Emergency Preparedness Policies and Procedures: Waives requirement that hospital and CAH to develop and implement emergency preparedness policies and procedures, and provisions requiring that the emergency preparedness communication plans for hospitals and CAHs to contain specified elements with respect to the surge site.
- Quality Assessment and Performance Improvement Program: Waives 42 CFR §482.21(a)–(d) and (f), and §485.641(a), (b), and (d), which provide details on the scope of the program, the incorporation, and setting priorities for the program’s performance improvement activities, and integrated Quality Assurance & Performance Improvement programs (for hospitals that are part of a hospital system).
- Nursing Services: Waives 42 CFR §482.23(b)(4), which requires the nursing staff to develop and keep current a nursing care plan for each patient, and §482.23(b)(7), which requires the hospital to have policies and procedures in place establishing which outpatient departments are not required to have a registered nurse present.
- Food and Dietetic Services: Waives requirement at paragraph 42 CFR §482.28(b) (3), which requires providers to have a current therapeutic diet manual approved by the dietitian and medical staff readily available to all medical, nursing, and food service personnel.
- Respiratory Care Services: Waives requirements at 42 CFR §482.57(b)(1) that require hospitals to designate in writing the personnel qualified to perform specific respiratory care procedures and the amount of supervision required for personnel to carry out specific procedures.
- CAH Personnel Qualifications: Waives minimum personnel qualifications for clinical nurse specialists at paragraph 42 CFR §485.604(a)(2), nurse practitioners at paragraph §485.604(b)(1)–(3), and physician assistants at paragraph §485.604(c)(1)–(3), providing maximum staffing flexibility.
- CAH Staff Licensure: CMS is deferring to staff licensure, certification, or registration to state law by waiving 42 CFR §485.608(d) regarding the requirement that staff of the CAH be licensed, certified, or registered in accordance with applicable federal, state, and local laws and regulations.
- CAH Status and Location: Waives requirement at 42 CFR §485.610(b) that the CAH be located in a rural area or an area being treated as being rural, allowing the CAH flexibility in the establishment of surge site locations.
- Temporary Expansion Locations: For the duration of the PHE related to COVID-19, CMS is waiving certain requirements under the Medicare conditions of participation at 42 CFR §482.41 and §485.623 (as noted elsewhere in this waiver document) and the provider based department requirements at §413.65 to allow hospitals to establish and operate as part of the hospital any location meeting those conditions of participation for hospitals that continue to apply during the PHE. - CAH 25 Bed Limit and 96 Hour Stay Requirements: CMS is waiving the requirements that CAHs limit the number of beds to 25, and that the length of stay be limited to 96 hours under the Medicare conditions of participation for number of beds and length of stay at 42 CFR §485.620.
- Use of IRF, LTCH and IPH Units: CMS has determined it is appropriate to issue a blanket waiver to inpatient prospective payment system (IPPS) hospitals that, as a result of the emergency, need to house acute care inpatients in excluded distinct part units, where the distinct part unit’s beds are appropriate for acute care inpatient. CMS has also determined it is appropriate to issue a blanket waiver to IPPS and other acute care hospitals with excluded distinct part inpatient psychiatric units that, as a result of the emergency, need to relocate inpatients from the excluded distinct part psychiatric unit to an acute care bed and unit. Furthermore, CMS has determined it appropriate to issue a blanket waiver to IPPS and other acute care hospitals with excluded distinct part inpatient rehabilitation units that, as a result of the emergency, need to relocate inpatients from the excluded distinct part rehabilitation unit to an acute care bed and unit.
- Flexibility for Inpatient Rehabilitation Facilities Regarding the “60 Percent Rule”: IRFs may exclude patients from the hospital’s or unit’s inpatient population for purposes of calculating the applicable thresholds associated with the requirements to receive payment as an IRF (commonly referred to as the “60 percent rule”) if an IRF admits a patient solely to respond to the emergency and the patient’s medical record properly identifies the patient as such. In addition, during the applicable waiver time period, we would also apply the exception to facilities not yet classified as IRFs, but that are attempting to obtain classification as an IRF.
- Responsibilities of physicians in critical access hospitals (CAHs).;42 C.F.R. § 485.631(b)(2): Waives the requirement for CAHs that a doctor of medicine or osteopathy be physically present to provide medical direction, consultation, and supervision for the services provided in the CAH at § 485.631(b)(2). CMS is retaining the regulatory language in the second part of the requirement at § 485.631(b)(2) that a physician be available “through direct radio or telephone communication, or electronic communication for consultation, assistance with medical emergencies, or patient referral.”
- Expanded Ability for Hospitals to Offer Long-term Care Services (Swing-Beds): Waives the requirements at 42 CFR 482.58(a)(1)-(4), to allow hospitals to establish SNF swing beds payable under the SNF prospective payment system to provide additional options for hospitals with patients who no longer require acute care but are unable to find placement in SNF.
- Conditions of Participation for COVID-19 Vaccinations: Modifies § 482.23(c)(3) to allow for hospital and community administration of COVID-19 vaccines. - Hospitals Classified as Medicare-Dependent, Small Rural Hospitals (MDH): For hospitals classified as MDHs prior to the PHE, and hospitals that became newly classified as MDHs during the PHE without the application of this waiver, 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.
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