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
May 11, 2022
Alert Subject
CDC Issues Updated Recommendations for Testing and Reporting of Children with Acute Hepatitis of Unknown Etiology
Source
CIHQ | TJC | OSHA | NFPA |
CMS | CDC | NIOSH | Other: |
Alert Background
The Centers for Disease Control and Prevention (CDC) is issued a Health Alert Network (HAN) update to provide clinicians and public health authorities with information about an epidemiologic investigation of pediatric cases of hepatitis of unknown etiology in the United States. This alert also provides updated recommendations for testing specimens from patients under investigation.
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
May 24, 2022
Alert Subject
COVID-19 Rebound After Paxlovid Treatment
Source
CIHQ | TJC | OSHA | NFPA |
CMS | CDC | NIOSH | Other: |
Alert Background
The Centers for Disease Control and Prevention (CDC) issued a Health Alert Network (HAN) Health Advisory to update healthcare providers,
public health departments, and the public on the potential for recurrence of COVID-19 or “COVID-19 rebound.
Recent case reports document that some patients with normal immune response who have completed a 5-day course of Paxlovid for laboratory-confirmed infection and have recovered can experience recurrent illness 2 to 8 days later, including patients who have been vaccinated and/or boosted (were up to date with COVID-19 vaccination) (2-4). These cases of COVID-19 rebound had negative test results after Paxlovid treatment and had subsequent positive viral antigen and/or reverse transcriptase polymerase chain reaction (RT-PCR) testing. Both the recurrence of illness and positive test results improved or resolved (median of 3 days) without additional anti-COVID-19 treatment.
Based on information from the case reports, COVID-19 rebound did not represent reinfection with SARS-CoV-2 or the development of resistance to Paxlovid; also, no other respiratory pathogens were identified among known cases. Possible transmission of infection during COVID-19 rebound has been described however, it remains unknown whether the likelihood of transmission during rebound differs from the likelihood of transmission during the initial infection.
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
May 26, 2022
Alert Subject
CMS Updates Guidance on COVID & Emergency Preparedness Exercise Exemptions
Source
CIHQ | TJC | OSHA | NFPA |
CMS | CDC | NIOSH | Other: |
Alert Background
In a letter to State Agency’s on 5/26/22, CMS issued updated guidance to memorandum QS-20-41-ALL outlining expectations for testing of a facility’s emergency preparedness plan during the COVID public health emergency (PHE).
On Friday, March 13, 2020, the President declared a national emergency due to COVID-19 and subsequently many providers and suppliers have activated their emergency plans in order to address surge and coordinate response activities. Facilities that activate their emergency plans are exempt from the next required full-scale community-based or individual, facility-based functional exercise. Facilities must be able to demonstrate, through written documentation, that they activated their program due to the emergency.
The updated guidance only applies if a facility is still currently operating under its activated emergency plan or reactivated its emergency plan for COVID-19 in 2021 or 2022. Facilities which have resumed normal operating status (not under their activated emergency plans) are required to conduct their testing exercises based on the regulatory requirements for their specific provider or supplier type.
For Inpatient Providers (e.g., Hospitals & Critical Access Hospitals)
If the facility is still operating under its currently activated emergency plan during its specified 12-month cycle of testing exercises, any currently activated emergency plan will be recognized by surveyors as having met the full-scale exercise requirement for that 12-month cycle.
If the facility is still operating under its currently activated emergency plan during its specified 12-month cycle of testing exercises, any currently activated emergency plan will be recognized by surveyors as having met the full-scale exercise requirement for that 12-month cycle.
If the facility claimed the full-scale exercise exemption in 2020 and 2021 based on its activated emergency plan for COVID-19 response and has since resumed normal operating status, the inpatient provider/supplier is expected to complete its required full- scale exercise, unless it has reactivated its emergency plan for an actual emergency during its 12-month cycle for 2022.
For Outpatient Providers (e.g., Ambulatory Surgery Centers, Home Health, etc.)
If the facility claimed the full-scale exercise exemption in 2020 based on its activated emergency plan for COVID-19 response and has since resumed normal operating status, the outpatient provider/supplier is expected to complete its required full-scale exercise in 2022, unless it has reactivated its emergency plan for an actual emergency during its 12-month cycle for 2022.
If the facility claimed the full-scale exercise exemption in 2020 based on its activated emergency plan for COVID-19 response and has since resumed normal operating status, the outpatient provider/supplier is expected to complete its required full-scale exercise in 2022, unless it has reactivated its emergency plan for an actual emergency during its 12-month cycle for 2022.
If the facility claimed the full-scale exercise exemption in 2021 based on its activated emergency plan for COVID-19 response and has since resumed normal operating status, the outpatient provider/supplier is expected to complete its required full-scale exercise in 2024.
Testing exemptions apply only for the next-full scale exercises, not any exercises of choice. Facilities are expected to continue to conduct all exercises of choice.
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
May 31, 2022
Alert Subject
CMS Updates COVID-19 Reporting Requirements
Source
CIHQ | TJC | OSHA | NFPA |
CMS | CDC | NIOSH | Other: |
Alert Background
On May 27, 2022, CMS updated guidance issued under the Interim Final Rule (QSO-21-03) regarding reporting of COVID-19 data elements for hospitals. This includes critical access hospitals. Under the revised guidance, psychiatric and rehabilitation hospitals will only be required to report once annually and only include data from the previous week.
CMS also updated its enforcement procedures for hospitals that fail to report data as required.
- The first enforcement action will begin following one calendar week of non-compliance. Providers will have one calendar week to demonstrate compliance.
- Providers failing to meet the reporting requirements within one calendar week following the first enforcement notification letter will receive a second enforcement notification letter. This notification will indicate that that the provider will have one calendar week to demonstrate compliance with the reporting requirements otherwise the provider will receive the third and final enforcement notification letter, as noted in step three.
- Providers that have failed to meet the reporting requirements within one week following the second enforcement notification letter will receive a third and final enforcement notification letter. This notification will include a notice of termination to become effective within 30 days from the date of the notification. Failure to meet the reporting requirements within this 30- day timeframe may result in termination of the Medicare provider agreement.
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.