Center for Improvement in Healthcare Quality Newsletter
January 2022

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
December 2, 2021
Alert Subject
CMS Suspends Enforcement of Vaccine Mandate for Healthcare Workers
Source
CIHQ TJC OSHA NFPA
CMS CDC NIOSH Other:
Alert Background
In a letter to State enforcement agencies dated 12/2/21, CMS announced that it is suspending implementation and enforcement of the 11/4/21 Interim Final Rule mandating COVID vaccination of healthcare workers employed or contracted by most Medicare participating providers. The enforcement suspension is effective immediately.
On November 29 and November 30, 2021, the United States District Court for the Eastern District of Missouri and United States District Court for the Western District of Louisiana issued preliminary injunctions against the implementation and enforcement of the Interim Final Rule against Medicare-and Medicaid-certified providers and suppliers. Between the two of them, these injunctions cover all states, the District of Columbia and the US Territories.
Accordingly, while these preliminary injunctions are in effect, surveyors must not assess providers for compliance with the requirements of the Interim Final Rule (IFR). This prohibition will apply to accrediting organizations as well.
Discussion & Recommendations
To view the discussion & recommendations CIHQ Accredited Hospitals can download this alert in its entirety when logged-in/connected to your facility's CIHQ intranet site. All alerts are archived in the CIHQ intranet site for future access and reference.
Not a CIHQ Accredited Facility?
» CIHQ accredits a variety of healthcare organizations throughout the United States and abroad. Visit CIHQ.org to learn more, and to apply.

New Regulatory Alert

Alert Date
December 2, 2021
Alert Subject
CMS Ends Allowance for New Temporary Hospitals
Source
CIHQ TJC OSHA NFPA
CMS CDC NIOSH Other:
Alert Background
In a letter to State enforcement agencies dated 12/1/21, CMS announced that it will no longer accept applications from ambulatory surgery centers (ASC) and free-standing emergency centers (FSEC) to temporarily enroll has hospitals due to the COVID pandemic. This applies to new requests only and is effective immediately.
CMS indicated that those facilities that are currently temporarily enrolled as hospitals can continue providing inpatient and outpatient hospital services until:
  • They voluntarily terminate from temporary hospital enrollment; or
  • CMS initiates enforcement action for any facility that is non-compliant with applicable participation requirements, to the extent not waived; or
  • The Secretary of the Department of Health and Human Services (Secretary) determines there is no longer a public health emergency (PHE) due to COVID-19; or
  • CMS provides additional public notice that this guidance has ceased to be effective.
Discussion & Recommendations
To view the discussion & recommendations CIHQ Accredited Hospitals can download this alert in its entirety when logged-in/connected to your facility's CIHQ intranet site. All alerts are archived in the CIHQ intranet site for future access and reference.
Not a CIHQ Accredited Facility?
» CIHQ accredits a variety of healthcare organizations throughout the United States and abroad. Visit CIHQ.org to learn more, and to apply.

New Regulatory Alert

Alert Date
December 28, 2021
Alert Subject
Management of Healthcare Personnel with SARS-COV-2 Infection or Exposure
Source
CIHQ TJC OSHA NFPA
CMS CDC NIOSH Other:
Alert Background
Due to the increased transmissibility of the SARS-CoV-2 Omicron variant and concerns about potential impacts on the healthcare system, the Centers for Disease Control and Prevention (CDC) is updating recommendations to enhance protection for healthcare personnel, patients, and visitors, and ensure adequate staffing in healthcare facilities. The guidance is based on the limited information currently available about the Omicron variant and will be updated as needed as new information becomes available.
Discussion & Recommendations
To view the discussion & recommendations CIHQ Accredited Hospitals can download this alert in its entirety when logged-in/connected to your facility's CIHQ intranet site. All alerts are archived in the CIHQ intranet site for future access and reference.
Not a CIHQ Accredited Facility?
» CIHQ accredits a variety of healthcare organizations throughout the United States and abroad. Visit CIHQ.org to learn more, and to apply.

New Regulatory Alert

Alert Date
December 29, 2021
Alert Subject
CMS to Enforce COVID-19 Vaccine Mandate in Selected States
Source
CIHQ TJC OSHA NFPA
CMS CDC NIOSH Other:
Alert Background
In a memorandum dated 12/28/21, CMS instructed State Agencies (SA’) and accrediting organizations (AO’) to begin enforcing the COVID-19 vaccine mandate for healthcare workers in Medicare participating facilities in selected States. Enforcement is set to begin within 30 days after the memorandum was issued.
At this time, enforcement does not apply to the following States: Alabama, Alaska, Arizona, Arkansas, Georgia, Idaho, Indiana, Iowa, Kansas, Kentucky, Louisiana, Mississippi, Missouri, Montana, Nebraska, New Hampshire, North Dakota, Ohio, Oklahoma, South Carolina, South Dakota, Texas, Utah, West Virginia, and Wyoming.
In order to avoid being cited by an SA or AO, healthcare facilities must demonstrate by January 27, 2022 that policies and procedures have been developed and implemented for ensuring all facility staff, regardless of clinical responsibility or patient or resident contact are vaccinated for COVID-19; and 100% of staff have received at least one dose of COVID-19 vaccine, or have a pending request for, or have been granted qualifying exemption, or identified as having a temporary delay as recommended by the CDC.
CMS has instructed SA’ and AO’ to review facility policies addressing vaccine requirements (see CIHQ-ARS alert issued on 11/5/21) and determine implementation. Facilities will also be asked to provide a list of all staff and their vaccine status:
  • Including the percentage of unvaccinated staff, excluding those staff that have approved exemptions. If any concerns are identified with the staff vaccine status list, surveyors will verify the percentage of vaccinated staff.
  • The facility must identify any staff member remaining unvaccinated because it is medically contraindicated or has a religious exemption.
  • The facility must also identify newly hired staff (hired in the last 60 days).
  • The facility must indicate the position or role of each staff member
The SA or AO will select a sample of staff records from the list and review vaccination / exemption documentation. In addition, staff will be observed providing care to determine compliance with current standards of practice with infection control and prevention.
If a healthcare facility fails to meet the above requirement it will be considered non-compliant to § 482.42(g); the new standard regarding COVID-19 vaccination under the Medicare Condition of Participation for Infection Prevention and Control and Antibiotic Stewardship Programs. CMS has developed a decision-tree for use by SA’ and AO’ to determine the severity of non-compliance (i.e., standard, condition, or immediate jeopardy deficiency) based on the percentage of applicable unvaccinated staff and failure to implement required policies over time.
Discussion & Recommendations
To view the discussion & recommendations CIHQ Accredited Hospitals can download this alert in its entirety when logged-in/connected to your facility's CIHQ intranet site. All alerts are archived in the CIHQ intranet site for future access and reference.
Not a CIHQ Accredited Facility?
» CIHQ accredits a variety of healthcare organizations throughout the United States and abroad. Visit CIHQ.org to learn more, and to apply.