Healthcare Regulatory Alerts

In a letter dated June 6, 2023, CMS reminded state agencies (SAs), accrediting organizations (AOs), and hospitals of the regulatory requirements for discharges and transfers to post-acute care providers.

According to CMS, it has identified areas of concern related to missing or inaccurate patient information when a patient is discharged from a hospital. These areas of concerns include missing or inaccurate information related to:

• Patients with serious mental illness (SMI), complex behavioral needs, and/or substance use disorder (SUD). Information related to patient’s acute condition may be included, but information related to the patient’s underlying diagnoses of SMI and/or SUD is not included. Additionally, specific treatments that were implemented to help manage these conditions while in the hospital are omitted from patient information upon hospital discharge and transfer to the PAC provider, such as additional supervision that was provided throughout the patient’s hospital stay (or was provided for some of the hospital stay, but discontinued prior to discharge (e.g., 24-48 hours before discharge));
• Medications, such as an incomplete comprehensive list of all medications that have been prescribed to a patient during, and prior to, their hospital stay. Common omissions also include patient diagnoses or problem lists, clinical indications, lab results, and/or clear orders for the post-discharge medication regimen. Medication information omissions have been most commonly reported for psychotropic medications and “hard” prescriptions for narcotics (i.e., provided on paper, not electronic, as required by law);
• Skin tears, pressure ulcers, bruising, or lacerations (e.g., surgical site(s), skin conditions noted upon hospital admission and/or acquired during hospitalization), including orders or instructions for cultures, treatments, or dressings;
• Durable Medical Equipment, such as Trilogy, CPAP/BiPap or high-flow oxygen which are used for respiratory treatments and skin healing equipment for example mattresses, wound vacuum machine for treatment of a variety of wounds including surgical wounds, pressure ulcers, diabetic ulcers, etc.;
• A patient’s preferences and goals for care, such as their choices for treatment or their advance directives for end-of-life care; and
• Communication (with PAC providers and/or caregivers) about a patient’s needs at home, or how their home environment may impact their ability to maintain their health and safety after discharge from the SNF (e.g., risk of falls, family or caregiving involvement/availability, homelessness, etc.).

When conducting surveys, CMS has instructed SAs and AOs to be alert to the common issues identified above and ensure these type of discharges are occurring in a compliant and safe manner.

CIHQ Accredited Hospitals, ARS Members and Healthcare Accreditation Certified Professions: To view the discussion & recommendations portion of the alert, log in to your facilities account. All alerts are archived in the library for future access and reference.

On 6/05/23, the Centers for Medicare & Medicaid Services (CMS) published a final rule in the Federal Register which ends the requirements related to Staff Vaccination for all provider types, effective on 8/05/23. Additionally, this rule states that CMS will not be enforcing the staff vaccination provisions between 6/05/23 and 8/04/23. This means that starting on 6/05/23, surveyors will no longer assess compliance with these requirements for any providers.

CIHQ Accredited Hospitals, ARS Members and Healthcare Accreditation Certified Professions: To view the discussion & recommendations portion of the alert, log in to your facilities account. All alerts are archived in the library for future access and reference.

In a letter to State enforcement agencies (SA’) dated 6/9/23, CMS stated that the COVID-19 PHE ended on May 11, 2023, the 96-hour length of stay calculation for CAHs will be adjusted to account for the waiver period (March 1, 2020 to May 11, 2023). The evaluation of the average 96-hour patient length of stay requirements will resume with the CAH’s first full cost reporting period after May 11, 2023, which will not include any of the months covered under the COVID-19 PHE blanket waiver. This will be a one-time change to the CAH 96-hour length of stay calculation.

CIHQ Accredited Hospitals, ARS Members and Healthcare Accreditation Certified Professions: To view the discussion & recommendations portion of the alert, log in to your facilities account. All alerts are archived in the library for future access and reference.

In a letter to accrediting organizations (AO) dated 6/16/23, CMS mandated changes to AO survey processes in several areas. According to CMS, these changes are designed to assure that an AO’ survey process aligns with processes established by CMS for the State Agencies (SA). These changes must be implemented no later than July 14, 2023.

CMS has forbidden AO’ from providing any prior notification to organizations that a survey will be occurring. This includes the courtesy notification that many AO’ currently issue just prior to the start of a survey. CMS stated that no contact should occur with the facility prior to the surveyor or survey team’s entrance into the facility.

While CMS understands some administrative business practices (such as gathering relevant information on the facility’s demographics, operating hours, etc.) require AO’ to communicate with facilities prior to conducting a survey, CMS “expects that these practices shall cease at least six months prior to the end of the facility’s survey cycle and that dates and times of a pending survey are not provided to the facility as part of these administrative communications.”

CMS will no longer permit an AO to offer “black-out” dates that a facility may request not be surveyed during that time. CMS believes “this practice is also inconsistent with the policies of unannounced surveys and the expectation that a provider/supplier must be “survey-ready” at all times.”

CMS will no longer permit an AO’ to investigate complaints through correspondence with an organization. All complaints that indicate potential non-compliance to CMS / AO standards must be investigated on-site. If an AO triages a complaint and determines that it does not appear to be an immediate jeopardy or condition-level deficiency, the AO must conduct an on-site complaint survey during the next scheduled accreditation survey or earlier, if appropriate.

An AO’ closure letter to a complainant must provide information that is comparable to the SA’ written report to the complainant of the investigation findings. The closure letter must “provide the complainant with information regarding whether or not noncompliance was identified during the complaint investigation; identify where the complainant may find the Statement of Deficiencies and Plan of Correction; and describe how the complainant may request a copy of the investigation report, subject to Federal and State disclosure requirements.”

CIHQ Accredited Hospitals, ARS Members and Healthcare Accreditation Certified Professions: To view the discussion & recommendations portion of the alert, log in to your facilities account. All alerts are archived in the library for future access and reference.