Healthcare Regulatory Alerts
CIHQ-ARS notifies its client organizations of any new or modified accreditation standard, or CMS COP for acute care hospitals. Alerts are also published when changes are made by CDC, OSHA, NIOSH, NFPA. Each alert summarizes the standard, regulation, recommendations, likely impact to members, and recommendations for compliance strategies. Whenever possible, alerts are limited to one-page in length so that they can be quickly read and disseminated.
New Regulatory Alert
Date: September 11, 2023
Subject: CMS Set To Resume Validation Surveys
Source: CMS
Background:
In a letter to State enforcement agencies (SA) dated 9/6/23, CMS announced that it will resume validation surveys of accrediting organizations (AO) beginning in mid-October 2023. CMS also announced that it will be adopting revisions to the survey process that were piloted in 2018 and 2019. Salient features of the revised process includes the following:
- There will no longer be two separate survey activities (one by the AO and a second survey by the SA within the following 60 days).
- There will only be the AO survey, which will be observed by CMS contractors in real time. The CMS contractors will be accompanying the AO and observing the AO’ during the survey. They will not be surveying the Medicare provider / supplier.
- SA’ will no longer participate in the validation survey process. There will be no SA presence when the AO performs its survey.
- There will be no separate SA validation survey.
- There will be no 2567 report issued to the Medicare provider / supplier. The only report of deficiencies will be that of the AO’.
- The validation surveys will be unannounced.
Discussion & Recommendations:
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.
Not a CIHQ Accredited Facility, ARS Member or hold HACP certification?
» Visit CIHQ.org to learn more, and to apply.
New Regulatory Alert
Date: September 21, 2023
Subject: CMS Reinforces Interpretive Guidance For Nurse Midwives
Source: CMS
Background:
In a letter to State enforcement agencies (SA’) dated 9/21/23, CMS reinforced existing interpretive guidance surrounding the supervision of nurse-midwives in hospitals and critical access hospitals and caring for Medicaid patients.
Hospitals
In States that permit nurse midwives to admit patients (in accordance with hospital policy and practitioner privileges), CMS requires ONLY Medicare patients of a nurse midwife be under the care of an MD/DO. CMS does not require Medicaid or other non-Medicare patients admitted by a nurse midwife to be under the care of an MD/DO.
Critical Access Hospitals
For Critical Access Hospitals, CMS does not have the authority to remove the physician oversight requirement for inpatients at 485.631(b)(1)(iv) as this is a statutory requirement and the physician oversight requirement for outpatients at 485.631(b)(1)(v) is only applicable if required by State law.
Discussion & Recommendations:
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.
Not a CIHQ Accredited Facility, ARS Member or hold HACP certification?
» Visit CIHQ.org to learn more, and to apply.