CIHQ-ARS Article

The global pandemic highlighted the need for alternative methods for treating patients outside the Acute Hospital setting. Several studies have shown that providing acute care in the home setting is greatly beneficial to patients. The Centers for Medicare Medicaid Services (CMS) created the Acute Hospital Care at Home program in November of 2020 and opened the program to hospitals via a Conditions of Participation waiver process. This process waives the Condition of Participation for 24-hour nursing care but did not waive any other Conditions of Participation. The Physical Environment Conditions of Participation found in 42 CFR Part 482.41 dictates hospitals meet the requirements of NFPA 101, The Life Safety Code®, and additional specific safety regulations, which are impossible to meet in a residential situation.

In the 1990s, Dr. Bruce Leff and his colleagues with Johns Hopkins Hospital Geriatrics conducted a study based on a “Hospital at Home” concept to provide hospital level care for geriatric patients that either refused to come to the hospital or were more prone to hospital acquired infections. Additional studies were conducted and found that patients receiving hospital-at-home care had shorter length of stay; lower rates of hospital readmission, emergency department visits, and skilled nursing facility admissions; and better ratings of care all while providing equal quality and safety, at reduced cost.

In November 2020 CMS announced the Acute Hospital Care at Home Program in an effort to reduce the overcrowding of hospitals as a result of the COVID 19 global pandemic. This program waived the Condition of Participation for 24-hour nursing care found in 42 CFR 482.23(b) and (b)(1) but did not waive any other Condition of Participation. The waiver information states that any hospital taking the waiver must also contact their State Medicaid agencies as there may be state law requirements that must be met. Per the CMS Acute Hospital Care at Home Resources website, as of January 31, 2023, there are 260 Hospitals in 37 states providing this service. On December 29, 2022, President Biden signed into law the Consolidated Appropriations Act (CAA), extending the Acute Hospital Care at Home (AHCaH) individual waiver through September 30, 2023.

The Conditions of Participation are specific requirements that must be met for health care facilities to receive Medicare / Medicaid funds. Under 42 CFR 482.41 (b) and (c), the requirements for health care found in NFPA 101 and NFPA 99 would need to be met in a private residence.

Under the Frequently Asked Questions section of CMS’s Acute Hospital Care at Home website a question about the application of the hospital conditions of participation to patient’s homes was raised. The answer provided stated that there is flexibility noted in the COVID 19 Emergency Blanket waivers for Healthcare Providers, but that temporary locations must also be approved by the Hospital’s state.

The COVID-19 Emergency Declaration Blanket Waivers for Health Care Providers was created to reduce the strain resulting from the COVID-19 pandemic, permitting facilities to not meet some of the conditions of participation. Note that these blanket waivers specifically state that they will terminate at the end of the COVID-19 Public Health Emergency, and some of them have already been terminated. Nothing in the blanket waivers removes the requirement to meet some or all of NFPA 101 or NFPA 99 within a private residence.

Upon the review of both the Conditions of Participation for the Physical Environment and the blanket waivers specific to these Conditions of Participation, it is clear that:

• The blanket waivers do not cover the majority of the requirements that apply to construction, safety systems, and egress.
• It is impossible to meet the Physical Environment Conditions of Participation in the residential setting.
• Each State may have differing requirements for such a program because there is no guidance on the application of safety requirements.

Private Residences: Residential occupancies vary greatly in type of construction, methods of construction, and jurisdictional construction requirements. These factors are also impacted by socio-economic and geographical conditions. Examples of residential occupancies can range from high-rise apartments in cities, to townhomes, duplexes, and sub-division single family homes in suburbs, to single family homes in a remote rural area. These buildings can be recent construction or archaic, and requirements for the construction can vary from direct oversite to no oversite.

Patient Population: Obviously, not all patients within an acute hospital will qualify for an Acute Hospital Care at Home Program. Only patients with specific diagnoses and with specific physical capacities would be candidates for such a program. Safety Concerns for the patient must also be reviewed, such as: do they live alone, are there family dynamics that need to be considered, is the patient bed-ridden, and will medical gases be used? These factors all play into the level of safety / risk associated with each patient’s residence. State Requirements: CMS has placed most of the responsibility for safety requirements related to this program on each State and with little to no guidance on the safety concerns of an Acute Hospital Care at Home program, requirements can (and do) vary greatly. The American Hospital Association is advocating that the current administration should extend the Hospital at Home program beyond the Public Health Emergency. If that were to occur, the States will need to quickly come up with regulations that will cover the safety concerns for such a program. However, without a revision to the Conditions of Participation, there will be conflicts and varying requirements.

A spotlight on the safety issues associated with Acute Hospital Care at Home is the first step in making positive change. Next, understanding that no matter how much regulation is put into place, there will always be accidents, injury, and death. There are many conditions that cannot be controlled through regulation within a private residence. Adding regulation to someone’s private home starts an entire conversation on personal freedoms; however, while the person is under care of a hospital, there is a level of responsibility for safety on the part of that Hospital. The question is, how much responsibility?

At the very least, each candidate for Acute Hospital Care at Home should have their living spaces assessed for safety risks. This assessment can be conducted prior to the patient’s return to their home. Patients that refuse the assessment or are found to not have safe living conditions can remain in the hospital. Depending on the situation, other social services can be informed to assist the patient.

Multiple studies have documented that providing Acute Hospital Care in the residential setting is highly beneficial to the patient; as well as the hospital, by reducing patient overcrowding and costs. However, the safety regulations associated with the Acute Hospital Care at Home program have not caught up to the needs and growth of this program. The lack of guidance is plaguing the health care community and making some health systems / hospitals reluctant to start an Acute Hospital Care at Home program.

The Healthcare Community needs to act now to provide proper safety requirements and guidance for a program that will change the delivery of health care in the near future. Failure to do so will result in confusion, cost, and most importantly, injury and death.

It is impossible to apply the Physical Environment Conditions of Participation to Acute Hospital Care at Home to residential occupancies. The lack of clarity in the Physical Environment Conditions of Participation are concerning to the programs currently providing this service and are keeping other hospitals and health systems from providing this service.

The current Physical Environment Conditions of Participation need to be either re-worked to include Acute Hospital Care at Home requirements or a new Subsection of Conditions of Participation need to be created specifically for this program.

This article is a condensed version of the white paper on this subject found at: https://www.compliancevanguard.com/acutecareathome

Jennifer O’Connell is a Fire Protection Engineer and Director of Regulatory Compliance for Compliance Vanguard, a division of Vanguard Resources, Inc. She has over 23 years of experience providing Regulatory Compliance consulting to health care facilities all over the country, with an emphasis on Life Safety.