CMS provides details on emergency plan exercise exemptions

On May 26th the Centers for Medicare and Medicaid Services (CMS) provided expanded guidance on exercise exemption based on a facility’s activation of their emergency plan. The additional guidance clarifies that the exemption only applies to the next required full-scale exercise (not the exercise of choice), based on the facility’s 12-month exercise cycle which is determined by the facility (e.g. calendar, fiscal or another 12-month timeframe). For specific examples on the application of the exemption see CMS S&C Letter QSO-20-41-ALL REVISED 05.26.2022.

State survey agencies and AOs receive guidance on staff vaccination requirements 

The Centers for Medicare and Medicaid Services (CMS) announced on the 14th of June that state survey agencies and accrediting organizations will now only be expected to perform compliance reviews of the staff vaccination requirement during initial and recertification surveys and in response to specific complaint allegations that allege non-compliance with the staff vaccination requirement. In S&C Letter QSO-22-17-ALL CMS also noted that S&C Letter QSO 22-11 will be revised to ensure deficiency determinations reflect good faith efforts implemented by providers and suppliers and incorporate harm or potential harm to patients and residents resulting from any non-compliance. For additional information see S&C Letter QSO-22-17-ALL.

Conditions for Coverage amended for ambulatory surgical centers

The Centers for Medicare and Medicaid Services (CMS) published several final rules which amended the Ambulatory Surgical Center (ASC) Conditions for Coverage (CfCs) on the 3rd of June. While the many of the changes are minor, non-substantive edits; clarification on the following issues are provided:

  • Distinct entity.
  • Separation of ASC’s when located in a building that is shared with other entities are provided.
  • Applicability of ventilation standards for operating rooms within ASC’s.
  • The applicability of the Ambulatory Health Care Occupancy chapters of the 2012 edition of NFPA 101, Life Safety Code, including tentative interim amendments 12-1 through 12-4 and NFPA 99 - Health Care Facilities Code (HCFC), and Tentative Interim Amendments TIA 12-2 through 12-6. Except Chapters 7, 8, 12, and 13 to ASC’s.
  • The use of alcohol-based hand rub (ABHR) dispensers.

For additional information see S&C Letter QSO-22-16-ASC