Keeping your hospital survey-ready in the COVID-19 pandemic has been a challenge for many organizations. New regulations and moving timelines can make it feel like the target keeps moving.
In the last quarter, I worked through two onsite Joint Commission surveys and several CMS complaint surveys and want to share some insights to help you identify opportunities to mitigate findings on your next survey.
This year, I’m writing a series of five blogs about getting survey-ready in 2022. The first blog is about 1135 blanket waivers. Stay tuned for future blogs on workplace violence, water management, resuscitation and performance improvement.
Let’s start by looking at 1135 blanket waivers.
Using blanket waivers and declaring them is very important to reduce the number of citations for an organization. When we adopt blanket waivers, we need to show proof of them. Say we start with the 1135 blanket waivers. These waivers were extended as of January 14, 2022, by Xavier Becerra, U.S. Secretary of Health and Human Services, and are good until HHS declares an end to the COVID-19 pandemic or the emergency.
You don’t have to apply to CMS to take a waiver. To take a waiver, you need to declare them internally. You will declare them in some type of internal meeting. The key is to actively capture those in committee meeting minutes so you can show proof.
There are now over 35 waivers activated by CMS that became effective since March 1, 2020. It’s important to remember they allow you to retrospectively approve these, so if you haven’t done it today, it is not too late. If you are ready for survey or are anticipating a survey soon, review these waivers and adopt them as you see fit for your organization.
Some Waivers of Note
There are some waivers that all hospitals should consider. It’s good to remember that for these waivers you can go back and cover yourself from March 1, 2020, moving forward until the expiration date and/or HHS declares an end to the COVID-19 public health emergency.
1. Patient rights and visitation.
As you know, we have really limited our visitation due to the COVID-19 isolation and quarantine processes. CMS does allow a support person to be a part of care and stay with the patient at all times. This waiver allows you to change your visitation policies and not allow that support person in the room if that’s the decision your organization makes. Your policy during this time may be different, so I would make sure you adopted this wavier so you could set your policy to whatever you feel is right for your hospital in your community.
2. Utilization plan review.
Some organizations are struggling to ensure they are compliant with utilization plan review. If your utilization review plan hasn’t been reviewed in a while, consider taking this waiver. Declare it internally in one of your meetings and capture the declaration in the meeting notes.
3. QAPI process and policy.
Some accrediting organizations have adopted CMS’s requirement to annually review the quality assurance and performance improvement (QAPI) plan. Joint Commission has recently put that requirement in their standards and elements of performance. If your organization has not completed a review of the QAPI process and policy during the pandemic, I would definitely take this wavier.
4. Nursing services and the care planning process.
The care planning process is a big focus for regulatory bodies. CMS wants to see a measurable goal and processes on interventions and resolution; they also want you to address comorbidities. So, if you know that your care planning process has not addressed comorbidities because they’re too involved with COVID-19 patients, please make sure you take this waiver and declare it internally.
5. Physical environment.
What this means is CMS will permit facilities to adjust some of your scheduled inspection, testing and maintenance (ITM) frequencies for the facility and medical equipment. I can’t say enough that is probably one of the biggest waivers that any organization should take. If you can’t find documentation of that inspection, please make sure you take advantage of this waiver in the physical environment.
6. Life safety.
The last waiver holds temporary modifying provisions to the extent necessary to permit facilities to adjust their scheduled
inspection, testing and maintenance (ITM) frequencies and activities required by life safety code. Please review, however, and note that the following provisions are not included in this waiver as they are considered critical:
- Sprinkler system monthly electric motor-driven and weekly diesel engine driven fire pump testing.
- Portable fire extinguisher monthly inspection.
- Elevators with firefighters’ emergency operations monthly testing.
- Emergency generator 30 continuous minute monthly testing and associated transfer switch monthly testing.
- Means of egress daily inspection in areas that have undergone construction, repair, alterations or additions to ensure its ability to be used instantly in case of emergency.
You will want to talk to your engineering or facilities maintenance staff to ask if the hospital has been continually meeting the mark on testing requirements for the last two years, or if adopting the waiver would be appropriate.
With more than 35 waivers activated by CMS in the last two years, I encourage your organization to review each one and discuss which ones would be appropriate to adopt. These were created to help your organization stay survey-ready and have some retrospective provision during the pandemic.
For more information about QHR Health’s regulatory readiness services, visit: https://qhr.com/solutions/clinical-support/.