Updated 5/4/20, 4/17/20, 4/13/20, 4/9/20, 4/7/20 Created 3 ...Updated 5/4/20, 4/17/20, 4/13/20, 4/9/20, 4/7/20 Created 3/31/20 COVID-Related CMS, Indiana Code/Hospital Licensure Rule

Updated 5/4/20, 4/17/20, 4/13/20, 4/9/20, 4/7/20

Created 3/31/20

COVID-Related CMS, Indiana Code/Hospital Licensure Rule Waiver Table, Sorted by Topic This is an internally created document that will continue to be updated as Regulatory bodies grant new waivers. To the extent a waiver has been granted by federal authorities but is still precluded by state regulation, or vice versa, it has been left off this table. All federal and TJC waivers listed in this table are retroactive to March 1, 2020. All state waivers are retroactive to March 6, 2020 and are currently set to expire on June 4, 2020.

1

Code Language, A Tag, TJC Standard Source/Date of Waiver

Waiver Allowance Additional Instructions, if applicable

Advanced Directives

1866(f) and 42 CFR § 489.102 for Medicare; 1902(a)(58) and 1902(w)(1)(A) for Medicaid; 1852(i) for Medicare Advantage RI.01.05.01 EP 1 (Hospital and Critical Access Hospital)

Governor Holcomb Executive Order 20-13, TJC CMS 1135 Waiver Document 4.7.2020

Waives requirements which require hospitals and CAHs to provide information about their advance directive policies to patients to allow staff to more efficiently deliver care to a larger number of patients.

Does not waive hospital or CAH requirements at 482.13(a) to receive information about patient rights.

Ambulance Transportation Coverage

42 CFR 410.40(e)(1) CMS Interim Final Rule with Comment Period §II.AA, 85 Fed. Reg. 19230-19276 (4/6/20) Retroactively applicable to 3/1/20

Expands Medicare coverage of ambulance transportation to include all destinations that are equipped to treat the condition of the patient consistent with EMS protocols established by state and/or local laws.

For example, transport to an alternate hospital site, an urgent care center, or home (in the case of COVID-19 patient who is discharged from the hospital to home to be under quarantine). Medical necessity of ground ambulance transport must still be met.

Ambulatory Surgery Centers (ASCs)

ASCs Temporarily Converted to Hospitals

410 IAC 15-2.1 through 410 IAC 15-2.7410 QSO-20-24-ASC

4.14.20 ISDH Temporary Blanket Waivers for ASCs

Waives all ISDH ASC licensure rules if an ASC is converted to a hospital.

ACC EO #5 [ASC

Blanket Waivers] 20200414 Final Signed.pdf

CMS Memo related

to ASCs Temporarily Enrolling as Hospitals 20200403.pdf

Updated 5/4/20, 4/17/20, 4/13/20, 4/9/20, 4/7/20

Created 3/31/20


2



ASCs Not Converting to Hospitals

410 IAC 15-2.4-1(c)(5)(B) 4.14.20 ISDH Temporary Blanket Waivers for ASCs

Waives requirements that staff do cannot provide services in an adjacent office, clinic, hospital or other facility.

(see attachment as above for converted ASCs)

410 IAC 15-2.5-1(f)(2)(D) 4.14.20 ISDH Temporary Blanket Waivers for ASCs

Waives requirements for infection control committee to maintain written reports of quarterly meetings.

410 IAC 15-2.5-1(f)(2)(E)(v) 4.14.20 ISDH Temporary Blanket Waivers for ASCs

Waives requirements for reuse policies and allows ASCs to implement alternative infection standards consistent with CMS and CDC guidance.

Does require documentation of alternate standards and adherence to those standards.

410 IAC 15-2.5-1(f)(2)(E)(vi) 4.14.20 ISDH Temporary Blanket Waivers for ASCs

Allows ASC to implement alternate patient isolation standards consistent with CMS and CDC guidance.


410 IAC 15-2.5-1(g) 4.14.20 ISDH Temporary Blanket Waivers for ASCs

Waives existing requirements for sterilization of equipment and supplies and allows ASC to implement and follow alternate sterilization standards consistent with CMS and CDC guidance


Updated 5/4/20, 4/17/20, 4/13/20, 4/9/20, 4/7/20

Created 3/31/20


3



410 IAC 15-2.5-3(e)(2) 4.14.20 ISDH Temporary Blanket Waivers for ASCs

Waives existing requirements for those authorized to document in the medical record be noted in medical staff policy.

Does require that those who document is authorized by the ASC.

410 IAC 2.5-4(a) 4.14.20 ISDH Temporary Blanket Waivers for ASCs

First three sentences are waived and instead requires the medical staff and other physicians to be accountable to the governing body of the ASC.

Physicians are accountable to the governing body for the quality of medical care and surgical services they provide to patients.

410 IAC 2.5-4(a)(3) 42 CFR § 416.45(b)

4.14.20 ISDH Temporary Blanket Waivers for ASCs; CMS COVID-19 Emergency Declaration Blanket Waivers for Health Care Providers (4.29.20 update)

Waives requirements that medical staff reappointment not exceed two years.

Billing/Reimbursement

IC 12-15-10 and 12-15-10 Governor Holcomb Executive Order 20-13

Suspends requirements to allow reimbursement of services provided at a temporary facility

Further, Indiana Department of Insurance (IDOH) shall request health insurers to provide coverage for services provided at a temporary health care facility established for this public health emergency.

Updated 5/4/20, 4/17/20, 4/13/20, 4/9/20, 4/7/20

Created 3/31/20


4



410 IAC § 15-1.5-2(f)(3)(B) Infection Control Committee

3.27.20 ISDH Temporary Blanket Waivers for Hospitals

Suspends infection control committee’s duty to document work on corrective actions

Provider-based Billing CMS Interim Final Rule with Comment Period, __ Fed. Reg. ______ (5/__/20)

On-campus departments that relocate on or after March 1, 2020 through the remainder of the PHE for the purposes of addressing the COVID-19 pandemic may also seek an extraordinary circumstances relocation exception so that they may bill at the OPPS rate, as long as their relocation is not inconsistent with the state’s emergency preparedness or pandemic plan.

Hospitals that choose to permanently relocate these PBDs off-campus would be considered new off-campus PBDs billing after November 2, 2015, and therefore, would be required to bill using the PN modifier for hospital outpatient services furnished from that PBD location and would be paid the PFS-equivalent rate following the end of the COVID-19 PHE. Application for COVID-19 extraordinary circumstance is through notification to CMS RO.

Body Holding

410 IAC § 15-1.5-3(f)(3)(e) Ability to revise processes


Waives requirement for body holding and length of holding policies to be approved by the medical staff

ISDH act rapidly on requests to waive other parts of the rule on a case-by-case basis

Critical Access Hospitals

42 CFR § 485.620 Condition of participation: Number of beds and length of stay LD.04.01.01 EPs 6, 7 (Critical Access Hospital)

CMS COVID-19 Emergency Declaration Blanket Waivers for Health Care Providers

The limit of 25 inpatient beds and the 96-hour length of stay limitation is waived.

Patients to a critical access hospital operating under such waiver would not be counted toward the determination of the 25-bed limit or considered for the 96-hour average length of stay

Updated 5/4/20, 4/17/20, 4/13/20, 4/9/20, 4/7/20

Created 3/31/20


5



limit if this result is clearly identified as relating to the emergency.

42 CFR § 485.604(a)(2); 42 CFR § 485.604(b)(1)-(3); 42 CFR § 485.604(c)(1)-(3); 42 CFR § 485.608(d): Personnel Qualifications and Staff Licensure


Waives federal minimum personnel qualifications for clinical nurse specialists, nurse practitioners, and physician assistants and federal licensure, certification and registration requirements for staff.

CAH/Providers must still meet any State requirements.

42 CFR § 485.610(b); 42 CFR § 485.610(e) CAH Status and Location


Allows a Critical Access Hospital to establish a new temporary provider-based off campus location even if it is not 35 miles away from another hospital.

42 CFR § 485.63(b)(2) CAH Responsibilities of MD or DO

CMS COVID-19 Emergency Declaration Blanket Waivers for Health Care Providers (4.10.20 update)

Waives the requirement that critical access hospitals (CAHs) have a physician physically present for sufficient periods to provide medical direction, consultation and supervision.

The requirement that a physician be available “through direct radio or telephone communication, or electronic communication for consultation, assistance with medical emergencies, or patient referral” remains.

Discharge Planning

42 CFR § 482.43(c) Post-Acute Services

Governor Holcomb Executive Order 20-13, TJC CMS 1135

Waives all requirements and subparts related to post-acute services, so as to expedite the safe discharge and

Detailed Information Sharing for Discharge Planning for

Updated 5/4/20, 4/17/20, 4/13/20, 4/9/20, 4/7/20

Created 3/31/20


6



PC.04.01.01 EPs 22, 25, 31, 33 (Hospital) PC.04.01.01 EPs 31, 33 PC.04.01.01 EPs 22, 25 (Critical Access Hospital)

Waiver Document 4.7.2020

movement of patients among care settings, including the following requirements for patients discharged to home and referred for home health, those transferred to SNFs or transferred to an IRF or LTCH:

o Discharge list of HHAs, SNFs, IRFs or LTCH available to patient

o Informing patient or presentative of their freedom to choose among participating Medicare providers and suppliers and

o DC plan identifying any HHA or SNF to which patient is referred which the hospital has a disclosable financial interest

Hospitals and CAHs. CMS is waiving the requirement 42 CFR §482.43(a)(8), §482.61(e), and §485.642(a)(8) to provide detailed information regarding discharge planning, described below: • The hospital, psychiatric hospital, and CAH must assist patients, their families, or the patient’s representative in selecting a post‐acute care provider by using and sharing data that includes, but is not limited to, home health agency (HHA), skilled nursing facility (SNF), inpatient rehabilitation facility (IRF), and long‐term care hospital (LTCH) quality measures and resource use measures. The hospital must ensure that the post‐acute care data on quality measures and resource use measures is relevant and applicable to the patient’s goals of care and treatment preferences. • CMS is maintaining the discharge planning requirements

Updated 5/4/20, 4/17/20, 4/13/20, 4/9/20, 4/7/20

Created 3/31/20


7



that ensure a patient is discharged to an appropriate setting with the necessary medical information and goals of care as described in 42 CFR §482.43(a)(1)‐(7) and (b).

Distinct Part Psychiatric (Methodist) and Rehabilitation (Bloomington and Ball) Units

42 CFR § 485.647 Condition of participation: psychiatric and rehabilitation distinct part units; 410 IAC 15-1.6-6(e)

CMS COVID-19 Emergency Declaration Blanket Waivers for Health Care Providers; 3.27.20 ISDH Third Emergency Order Granting Temporary Blanket Waivers For Hospitals

Hospitals with distinct part psychiatric unit or rehab unit may: a) house acute care inpatients in

excluded distinct part units, where the distinct part unit’s beds are appropriate for acute care inpatient; and

b) relocate inpatients from the excluded distinct part psychiatric/rehab unit to an acute care bed and unit if the acute bed unit is appropriate and staffed for the relocated patient.

42 CFR § 485.647 60 Percent Rule

CMS COVID-19 Emergency Declaration Blanket

Distinct Part Rehab Unit can exclude patients from unit inpatient population for purposes of calculating 60 percent

Updated 5/4/20, 4/17/20, 4/13/20, 4/9/20, 4/7/20

Created 3/31/20


8



Waivers for Health Care Providers

rule if patient is admitted in response to COVID-19 emergency.

410 IAC § 15-1.6-6(e) Distinct Part Rehab spaces


Waives distinct part inpatient rehab requirements

This coincides with the CMS waiver on distinct part rehab units issued earlier in March 2020

Emergency Management

EM.02.01.01 EP 16 (Hospital) EM.02.01.01 EP 1 (Critical Access Hospital)

TJC CMS 1135 Waiver Document 4.7.2020

This 1135 waiver is only applicable to surge sites developed as a result of influx of COVID‐19 patients. Organizations are not required to develop an emergency operations plan for those sites.

MS.03.01.01 EP 13 (Hospital) TJC CMS 1135 Waiver Document 4.7.2020

Applies to surge facilities only: Written policies and procedures for surge facilities are not required.

MS.08.01.01 EP 1 (Hospital) The process for providing privileges in a disaster are outlined in EM.02.02.13 and required oversite. This oversite does not have to be consistent with FPPE requirements. An FAQ was also published regarding this issue.

https://www.jointcommission.org/standards/standard-faqs/hospital-and-hospital-clinics/medical-staff-ms/000002291/?p=1

MS.08.01.03 EPs 1, 2, 3 (Hospital and Critical Access Hospital)


until such time resources can be re‐allocated back to resume the process as designed. • Any modifications to the review process should allow the medical staff to detect – and address – downward trending performance. Examples may include review of incident reports, staff/patient complaints, post procedure complications, sentinel or other events resulting in negative patient outcomes, etc. • The organization should periodically reassess the availability of

Ongoing Professional Practice Evaluations (OPPE) • To the extent possible, practitioner performance data collection for OPPE should continue based on the established process. • If gaps in data occur as a result of temporary reallocation of resources, the organization should document the contributing factors leading to such gaps. • If resources are unavailable to review the data within the defined time frames, the organization may temporarily modify the review process until such time resources can be re‐allocated back to resume the process




Updated 5/4/20, 4/17/20, 4/13/20, 4/9/20, 4/7/20

Created 3/31/20


9



resources to determine when the OPPE data collection and review

as designed. • Any modifications to the review process should allow the medical staff to detect – and address – downward trending performance. Examples may include review of incident reports, staff/patient complaints, post procedure complications, sentinel or other events resulting in negative patient outcomes, etc. • The organization should periodically reassess the availability of resources to determine when the OPPE data collection and review process can resume as designed.

MS.13.01.01 1 (Hospital and Critical Access Hospital)


The process for providing (Telemedicine) privileges in a disaster are outlined in EM.02.02.13. In addition, a written contract is not required and is waived unless the services will extend beyond the declared disaster timeframe.

Updated 5/4/20, 4/17/20, 4/13/20, 4/9/20, 4/7/20

Created 3/31/20


10



PC.01.03.01 EPs 1, 5, 22, 23 (Hospital) PC.01.03.01 EPs 4, 5, 22, 23 (Critical Access Hospital)


Organizations may wish to develop care plans to assist in delivery of care but are not required at this time.

PC.02.02.03 EP 22 (Hospital) TJC CMS 1135 Waiver Document 4.7.2020

Waiver only applies to surge treatment sites. Organizations are not required to develop a diet manual for surge sites used for patient care.

Durable Medical Equipment (DME)

EQ.01.01.01 EP 12 TJC CMS 1135 Waiver Document 4.7.2020:

Waiving signature and proof of delivery requirements for DME when a signature cannot be obtained. Suppliers should document in the medical record the appropriate date of delivery and that a signature was not able to be obtained because of COVID‐19.

Applies to Respiratory Therapy Durable Medical Equipment (RTDME).

Not specified CMS COVID-19 Emergency Declaration Blanket Waivers for Health Care Providers

When DMEPOS is lost, destroyed, irreparably damaged, or otherwise rendered unusable, DME MACs may waive the replacement requirements such that a face-to-face requirement, a new physician’s order, and new medical necessity documentation are not required.

Must document that replacement relates to COVID-19 loss destruction or damage.

Updated 5/4/20, 4/17/20, 4/13/20, 4/9/20, 4/7/20

Created 3/31/20


11



EMTALA

42 CFR 489.24(b)

3.30.20 QSO-20-15 Hospital/CAH/EMTALA REVISED

Clarifies that receiving hospitals may deny a transfer of patient if they are at capacity. Further, clarifies allowances of drive-through COVID testing sites for which EMTALA requirements do not apply. Clarifies that patients presenting onsite to ED for COVID testing may be redirected as registering and triage by an RN to site away from ED for testing. Telehealth may also be used on or off campus for MSE and would not be viewed as a violation of EMTALA.

qso-20-15-hospital-c

ah-emtala-revised (002).pdf

42 CFR § 489.24(a)(1)-(2) Requirement to perform MSE

3.13.2020 Secretary Azar Waiver or Modification of Requirements under Section 1135 of the Social Security Act; CMS COVID-19 Emergency

Hospitals may screen patients at a location offsite from the hospital’s campus to prevent the spread of COVID-19, so long as it is not inconsistent with a state’s emergency preparedness plan.

The obligation to perform an MSE at the hospital is still in effect because the State has not yet identified alternate screening locations to which emergency departments should send potential COVID-19 patients. Consistent with prior guidance and existing EMTALA rules, hospitals may set up alternate MSE sites on hospital property

Updated 5/4/20, 4/17/20, 4/13/20, 4/9/20, 4/7/20

Created 3/31/20


12



Declaration Blanket Waivers for Health Care Providers

Fraud, Waste and Abuse Laws

42 U.S.C. § 1320a-7b(b); 42 U.S.C. § 1320a-7(b)(7) and 1320a7a(a)(7); 42 U.S.C. § 1320a-7a(a)(5) Anti-kickback and civil money penalties related to reduction or waivers of cost

3.12.20 OIG Policy Statement Regarding Physicians and Other Practitioners That Reduce or Waive Amounts Owed by Federal Health Care Program Beneficiaries for Telehealth Services During the 2019 Novel Coronavirus (COVID-19) Outbreak

Healthcare providers may reduce or waive cost-sharing for telehealth visits paid by federal healthcare programs.

42 CFR § 411.351 et seq. Stark Law

Blanket Waivers of Section 1877(g) of the Social Security Act Due to Declaration of COVID-19 Outbreak in

Waives penalties for remuneration from hospital and physician practices (both designated health services) to physician outside an established stark exception for certain types of

Retroactive to March 1. Please consult legal counsel prior to using any of these.

Updated 5/4/20, 4/17/20, 4/13/20, 4/9/20, 4/7/20

Created 3/31/20


13



the United States as a National Emergency

compensation provided the remuneration is solely related to COVID-19 purposes. Example: Hospitals may now pay for child care, laundry, meals etc. for physicians providing care at the hospital during COVID-19 emergency.

Home Health

42 CFR §§ 409, 424, 484.2 CMS Interim Final Rule with Comment Period §II.J, __ Fed. Reg. __, __ (5/__/20)

NPs, CNSs, and PAs are able to practice to the top of their state licensure to certify eligibility for home health services, as well as establish and periodically review the home health plan of care.

Regulation changes will become permanent and are not time limited to the period of the PHE for COVID-19

42 CFR § 484.80 (h)(1)(i) HR.01.03.01 EP 27 Onsite Aide Supervision

CMS COVID-19 Emergency Declaration Blanket Waivers for Health Care Providers ; TJC CMS 1135 Waiver Document 4.7.2020

Waiving the requirement for a registered nurse, or other appropriate skilled professional, to conduct an onsite aide supervisory visit every 14 days to evaluate if aides are providing care consistent with the care plan. Virtual supervision is encouraged, but not required, during the period of the waiver.

Updated 5/4/20, 4/17/20, 4/13/20, 4/9/20, 4/7/20

Created 3/31/20


14



42 CFR § 484.80 (h)(1)(iii) Assessment of Aides

CMS COVID-19 Emergency Declaration Blanket Waivers for Health Care Providers (added 4.29.20)

Postponing the requirement that a registered nurse or other appropriate skilled professional (PT/OT/SLT) make an annual onsite supervisory visit (direct observation) for each aide that provides services on behalf of the agency.

All postponed onsite assessments must be completed by these professionals no later than 60 days after the expiration of the PHE.

42 CFR § 484.55(a) PC.01.02.05 EP 2 PC.01.02.05 EP 3

CMS COVID-19 Emergency Declaration Blanket Waivers for Health Care Providers ; TJC CMS 1135 Waiver Document 4.7.2020

Allows Home Health Agencies to perform Medicare covered initial assessments and determine patients' homebound status remotely or by record review.

42 CFR § 484.55; § 484.250 OASIS Data Requirements IM.02.02.03 EP9 PC.01.02.03 EP 12

CMS COVID-19 Emergency Declaration Blanket Waivers for Health Care Providers TJC CMS 1135 Waiver Document 4.7.2020

Waives the following timeframes for OASIS transmission:

Extension of the 5-day completion requirement for the comprehensive assessment

Waives the 30-day OASIS submission requirement

Updated 5/4/20, 4/17/20, 4/13/20, 4/9/20, 4/7/20

Created 3/31/20


15



Not Specified CMS COVID-19 Emergency Declaration Blanket Waivers for Health Care Providers

To ensure the correct processing of home health emergency related claims, Medicare Administrative Contractors (MACs) are allowed to extend the auto-cancellation date of Requests for Anticipated Payment (RAPs)

42 CFR § 484.55(a) Initial Assessments


Home health agencies can perform initial assessments and determine patients’ homebound status remotely or by record review.

This will allow patients to be cared for in the best environment while supporting infection control and reducing impact on acute care and long-term care facilities. This will allow for maximizing coverage by already scarce physician and advanced practice clinicians and allow those clinicians to focus on caring for patients with the greatest acuity.

IC § 16-27-1-16 Acceptance of Written Orders for Home Health Services 42 CFR § 440.70

CMS Interim Final Rule with Comment Period §II.AA, 85 Fed. Reg. 19230, 19275 (4/6/20) Retroactively applicable to 3/1/20. Governor Holcomb Executive Order 20-19

Home health agencies may accept written orders from home health services from any licensed physician, NP, CNS, or PA acting within his or her scope of practice.

Previously limited to physician, dentist, chiropractor or optometrist.

Updated 5/4/20, 4/17/20, 4/13/20, 4/9/20, 4/7/20

Created 3/31/20


16



42 CFR § 484.55(a)(2) and 484.55(b)(3) Comprehensive Assessment of Patients


OTs may perform the initial and comprehensive assessment for all patients receiving therapy services as part of the plan of care, to the extent permitted under state law, regardless of whether occupational therapy is the service that establishes eligibility

OTs and other therapists are not permitted to perform assessments in nursing only cases.

42 CFR § 484.80(d) 12 hour annual service requirement for home health aides


Postponing the deadline for completing the requirement that each home health aide receives 12 hours of in-service training in a 12-month period until the end of the first full quarter after the declaration of the PHE concludes.

42 CFR § §484.110(e) Clinical Records


Extends the deadline to provide a patient a copy of their medical record at no cost from 4 to 10 business days.

42 CFR § 484.58(a) Detailed Information Sharing for discharge Planning for HHA

CMS COVID-19 Emergency Declaration Blanket Waivers for Health

Waives the requirements to provide detailed information regarding discharge planning, to patients and their caregivers, or the patient’s

Updated 5/4/20, 4/17/20, 4/13/20, 4/9/20, 4/7/20

Created 3/31/20


17



Care Providers (added 4.29.20)

representative in selecting a post-acute care provider by using and sharing data that includes, but is not limited to, (another) home health agency (HHA), skilled nursing facility (SNF), inpatient rehabilitation facility (IRF), and long-term care hospital (LTCH) quality measures and resource use measures.

42 CFR § 484.65. CMS COVID-19 Emergency Declaration Blanket Waivers for Health Care Providers (added 4.29.20)

Narrows the scope of required QAPI program to concentrate on infection control issues, while retaining the requirement that remaining activities should continue to focus on adverse events.

The requirement that HHAs maintain an effective, ongoing, agency-wide, data-driven quality assessment and performance improvement program will remain.

Hospice

42 CFR § 418.22(a)(4) Face to face visit for recertification

CMS Interim Final Rule with Comment Period §II.AA, 85 Fed. Reg. 19230, 19251 (4/6/20) Retroactively applicable to 3/1/20.

Allows the use of telecommunications technology by the hospice physician or NP for the face-to-face visit when such visit is solely for the purpose of recertifying a patient for hospice services during the PHE for the COVID-19 pandemic

Updated 5/4/20, 4/17/20, 4/13/20, 4/9/20, 4/7/20

Created 3/31/20


18



Governor Holcomb Executive Order 20-19

42 CFR § 418.78(e) Use of Volunteers


CMS is waiving the requirement that hospices are required to use volunteers (including at least 5% of patient care hours).

42 CFR § 418.54(d) Comprehensive Assessments


CMS extends the timeframe requirements for Hospice related to update of the comprehensive assessments of patients from 15 to 21 days.

42 CFR § 418.72 Non-core services


CMS is waiving the requirement for hospices to provide certain non-core hospice services during the national emergency, including the requirements at §418.72 for physical therapy, occupational therapy, and speech-language pathology.

42 CFR §418.76(h)(2) CMS COVID-19 Emergency Declaration Blanket Waivers for Health

Postponing the requirement that a registered nurse make an annual onsite supervisory visit (direct observation) for

All postponed onsite assessments must be completed by these professionals no later than 60 days after the expiration of the PHE.

Updated 5/4/20, 4/17/20, 4/13/20, 4/9/20, 4/7/20

Created 3/31/20


19



Care Providers (added 4.29.20)

each aide that provides services on behalf of the agency.

42 CFR § 418.76(h) Onsite Visits and Aide Supervision


CMS waives the requirement for a nurse to conduct an onsite visit every two weeks. This would include waiving the requirements for a nurse or other professional to conduct an onsite visit every two weeks to evaluate if aides are providing care consistent with the care plan.

42 CFR § 418.76(c)(1) Competency Evaluation


Hospice aides may be evaluated by utilizing “pseudo patients,” such as a computer-based mannequin device, instead of actual patients.

Role-play situation or a computer-based mannequin device may be used instead of actual patients, in the competency testing for tasks that must be observed on a patient.

42 CFR 418.76(d) In service training


Waives the requirement that hospices must assure that each hospice aide receives 12 hours of in-service training in a 12-month period.

Updated 5/4/20, 4/17/20, 4/13/20, 4/9/20, 4/7/20

Created 3/31/20


20



42 CFR § 418.100(g)(3) CMS COVID-19 Emergency Declaration Blanket Waivers for Health Care Providers (added 4.29.20)

Postpones the deadline to annually assess the skills and competence of all individuals furnishing care and provide in-service training and education programs throughout the COVID-19 PHE until the end of the first full quarter after the declaration of the PHE concludes

This does not alter the minimum personnel requirements at 42 CFR §418.114. Selected hospice staff must complete training and have their competency evaluated in accordance with unwaived provisions of 42 CFR Part 418.

42 CFR § 418.58 CMS COVID-19 Emergency Declaration Blanket Waivers for Health Care Providers (added 4.29.20)

Narrows the scope of required QAPI program to concentrate on infection control issues, while retaining the requirement that remaining activities should continue to focus on adverse events.

The requirement that hospices maintain an effective, ongoing, agency-wide, data-driven quality assessment and performance improvement program will remain.

Human Resources

Updated 5/4/20, 4/17/20, 4/13/20, 4/9/20, 4/7/20

Created 3/31/20


21



HR.01.01.01 EP 1 (Hospital and Critical Access Hospital) and Home Care HR.01.05.03 EP 14 (Hospital and Critical Access Hospital) HR.01.05.03 EP 25 (Hospital)


Regarding CPR, ACLS, BLS: The Joint Commission released an FAQ supporting the extension of expiration dates for certifications by 120 days, in accordance with published guidance by the American Heart Association.

Hospital: Regarding respiratory treatments: This waiver only applies to who is authorized to administer respiratory care treatments. The waiving of the requirements at 42 CFR §482.57(b)(1) that require hospitals to designate in writing the personnel qualified to perform specific respiratory care procedures and the amount of supervision required for personnel to carry out specific procedures. These flexibilities may be implemented so long as they are not inconsistent with a state’s emergency preparedness or

Updated 5/4/20, 4/17/20, 4/13/20, 4/9/20, 4/7/20

Created 3/31/20


22



pandemic plan. Not being required to designate these professionals in writing will allow qualified professionals to operate to the fullest extent of their licensure and training in providing patient care.

Lab

42 CFR § $410.32(a)(3) Interim Final Rule __ Fed, Reg. __ (05/__.20)

The order of a physician or NPP is not required for otherwise covered diagnostic lab tests for COVID-19 and for otherwise covered diagnostic lab tests for influenza virus or similar respiratory condition needed to obtain final COVID-19 diagnosis.

Flu test must be performed in conjunction with COVID-19 diagnostic test in order to discount flu virus or related diagnosis. FDA authorized COVID-19 serology tests are included as covered tests for beneficiaries with known/suspected current/prior COVID-19 infection.

Not specified Interim Final Rule __ Fed, Reg. __ (05/__.20)

Creating a new E/M code solely to support COVID-19 testing for the PHE, HCPCS code C9803 (Hospital outpatient clinic visit specimen collection for severe acute respiratory syndrome coronavirus 2 (sars-cov-2) (coronavirus disease [covid-19]), any specimen source).

Medical Records

Updated 5/4/20, 4/17/20, 4/13/20, 4/9/20, 4/7/20

Created 3/31/20


23



MS.05.01.03 EP 3 RC.01.03.01 EPs 1, 2 IM.02.02.03 EP 3 (Hospital)


Time frames may be extended beyond current hospital requirements for timely medical records completion. No maximum time was provided. Records completion time frames may be waived to extend beyond the 30 days following discharge.

CMS 42 CFR § 482.24(c)(4)(viii) and 485.638(a)(4)(iii) 410 IAC § 15-1.5-4(c)(3) Medical Record Authentication


Waives the requirement for prompt authentication and permit post hoc authentication with no stated time requirement.

Updated 5/4/20, 4/17/20, 4/13/20, 4/9/20, 4/7/20

Created 3/31/20


24



410 IAC § 15-1.5-4(f)(2) Documentation of History & Physical


Patient H & Ps must be documented as quickly as practical under the circumstances with no stated time frame.

410 IAC § 15-1.5-4(f)(13) Discharge Summary Authentication


Allows that the discharge summary may be authenticated by the physician or by the other advanced practice providers who are credentialed to do so by the medical staff

410 IAC § 15-1.5-4(g) Short Stay Record Authentication


Allows that the short stay record form maybe authenticated by the physician or a non-physician advanced practice providers who are credentialed to do so by the medical staff and other responsible personnel in attendance.

RC.01.01.01 EPs 1, 5 RC.02.01.01 EP 2 (Hospital)


The organization must define what minimal components of the medical record must be completed during the declared disaster time period. Minimal components must be present to reflect the care, treatment and services the patient received, ensure proper transmission of information

Updated 5/4/20, 4/17/20, 4/13/20, 4/9/20, 4/7/20

Created 3/31/20


25



for the next care team provider(s) and responses to treatment. Organizations may extend reassessments built into their policy to accommodate patient care needs. All required elements should be captured as part of the emergency operations plan.

Personal Protective Equipment (PPE)

Not specified Governor Holcomb Executive Order 20-13

Beginning 4/1, all health care providers (including hospital, ASC, dental facilities, plastic surgery centers, dermatology centers and abortion clinics) are to cancel or postpone elective and non-urgent surgical or invasive procedures (any procedure which can be delayed without undue risk to the current or future health of the patient as determined by the patient’s treating physician, dentist or health care provider). Doesn’t apply to any procedure that, if performed in

Updated 5/4/20, 4/17/20, 4/13/20, 4/9/20, 4/7/20

Created 3/31/20


26



accordance with commonly accepted standards of clinical practice, would not deplete the hospital capacity needed and available to cope with COVID-19 or utilize in any way PPE (exempting gloves). Supersedes EX 20-04 paragraph 7.

Pharmacy

IC § 25-26-13.5 Primary hospital pharmacy


Allows primary hospital pharmacy to supply a temporary facility without need of a remote facility license.

IC § 25-26-13-18 Stand-alone Pharmacy


Suspends requirement for a stand-alone pharmacy to have a license at a temporary facility.

410 IAC § 15-1.5-2(f)(3)(D)Policy on Reuse of Disposables


42 CFR § 482.25(b)(1) & 485.635(a)(3) Sterile Compounding PPE


Waives requirements to allow for used face mask to be removed, retained in the compounding area and redonned

White USP797 also outlines this, CMS will not be reviewing the use and storage of facemasks under these requirements.

Updated 5/4/20, 4/17/20, 4/13/20, 4/9/20, 4/7/20

Created 3/31/20


27



and reused during the same work shift in the compounding area only.

IC § 25-26-13-18.5 Governor Holcomb Executive Order 20-12

Authorizing a ratio of 1:8 pharmacist to pharmacy technician

Prior requirement was 1:6

IC § 25-26-19-2 Governor Holcomb Executive Order 20-12

Direct Supervision of pharmacist technician by pharmacist suspended for the limited purpose of remote data entry, insurance processing, and other ministerial and non-dispensing tasks only

IC § 25-26-13-25(d)(8) Governor Holcomb Executive Order 20-12

One-time emergency 90-day refill for non-controlled substances prescribed as maintenance medications by pharmacist without the written, electronically transmitted, or oral authorization of a licensed practitioner.

All other requirements of IC § 25-26-13-25(d) should still be met.

410 IAC § 15-1.5-7(d)(2) Monthly inspections for areas where drugs and biologics are stored

3.27.20 ISDH Third Emergency Order Granting Temporary Blanket Waivers For Hospitals

Requirement of monthly inspections is waived for the first ninety (90) days after the hospital declares a facility emergency or until the emergency ends, whichever is sooner. If the emergency extends beyond ninety (90)

Updated 5/4/20, 4/17/20, 4/13/20, 4/9/20, 4/7/20

Created 3/31/20


28



days, inspections then must occur at least every sixty (60) days until the emergency ends.

IC § 25-26-19-2 Governor Holcomb Executive Order 20-12

Direct Supervision of pharmacist technician by pharmacist suspended for the limited purpose of remote data entry, insurance processing, and other ministerial and non-dispensing tasks only

IC § 25-26-13-25(d)(8) Governor Holcomb Executive Order 20-12

One-time emergency 90-day refill for non-controlled substances prescribed as maintenance medications by pharmacist without the written, electronically transmitted, or oral authorization of a licensed practitioner.

All other requirements of IC § 25-26-13-25(d) should still be met.

42 CFR § 410.26(a)(1) Auxiliary Personnel

CMS Interim Final Rule with Comment Period, __ Fed. Reg. ______ (5/__/20)

Pharmacists fall within the regulatory definition of auxiliary personnel under our regulations at § 410.26. As such, pharmacists may provide services incident to the services, and under the appropriate level of supervision, of the billing physician or NPP, if payment for

Updated 5/4/20, 4/17/20, 4/13/20, 4/9/20, 4/7/20

Created 3/31/20


29



the services is not made under the Medicare Part D benefit.

410 IAC § 15-1.5-7(d)(2) Monthly inspections for areas where drugs and biologics are stored

3.27.20 ISDH Third Emergency Order Granting Temporary Blanket Waivers For Hospitals

Requirement of monthly inspections is waived for the first ninety (90) days after the hospital declares a facility emergency or until the emergency ends, whichever is sooner. If the emergency extends beyond ninety (90) days, inspections then must occur at least every sixty (60) days until the emergency ends.

Physical Environment/Physical Plant

EC.02.04.03 EP 20 EC.02.04.03 EP 21 EC.02.04.03 EP 22 EC.02.04.03 EP 23 EC.02.04.03 EP 24 EC.02.04.03 EP 25 (Hospital and Critical Access Hospital)


During the COVID‐19 pandemic, when a state of emergency has been declared and the organization has activated their emergency operations plan, organizations may defer completing the performance evaluations for diagnostic imaging equipment, such as Computed Tomography (CT), Magnetic

Critical Access Hospital: Time frame for completion after the end of the state of emergency not specified

Updated 5/4/20, 4/17/20, 4/13/20, 4/9/20, 4/7/20

Created 3/31/20


30



Resonance Imaging (MRI), Nuclear Medicine (NM), Positron Emission Tomography (PET), Fluoroscopy equipment and acquisition monitors for these modalities. Organizations have 60 days after the end of the state of emergency (national, federal, or local level depending upon which allows the most time to address), to complete these items.

EC.02.04.03 EP 34 (Hospital and Critical Access Hospital)


During the COVID‐19 pandemic, when a state of emergency has been declared and the organization has activated their emergency operations plan, organizations may defer completing the performance evaluations for diagnostic imaging equipment, such as Computed Tomography (CT), Magnetic Resonance Imaging (MRI), Nuclear Medicine (NM), Positron Emission Tomography (PET), Fluoroscopy equipment and acquisition monitors

Updated 5/4/20, 4/17/20, 4/13/20, 4/9/20, 4/7/20

Created 3/31/20


31



for these modalities. Organizations have 60 days after the end of the state of emergency (national, federal, or local level depending upon which allows the most time to address), to complete these items.

Isolation Room Requirements 4.8.20 ISDH Emergency Order Amending Blanket Waiver 3.22.20 ISDH Waiver Program Advisory Letter AC-2020-01-HOSP

Amends prior 3/22 waiver language to allow for intermittent negative airflow monitoring occurring at least once per day if continual measurement devices cannot be obtained. Waives state rules & FGI guidelines regarding requirements for isolation rooms allowing facilities to create negative airflow rooms, as long as the state is notified in waiver. Onsite visits by ISDH will occur to ensure compliance.

2020.03.22 ISDH

Emergency Blanket Waiver Negative Airflow.pdf

ACC EO #4 Isolation

Room Revision 20200408 Final Signed.pdf

Inpatient Room Requirements 3.24.20 ISDH Waiver Program Advisory Letter AC-2020-02-HOSP

Waives state requirement for plan review of rooms converted to patient use for duration of state and national emergency. Provides specifications of

ISDH-Emergency-Wai

ver-2-Patient-Room-2020-03-24-Final-Signed.pdf

Updated 5/4/20, 4/17/20, 4/13/20, 4/9/20, 4/7/20

Created 3/31/20


32



room requirements. Notifications to state required for any repurpose of space or use of previous non-licensed space same day as activation. ISDH onsite inspections to occur as soon as practical.

410 IAC § 15-1.5-8(a)(3) Mobile & Temporary Structures


Waives requirements for approved mobile and temporary structures on or adjacent to hospital premises.

410 IAC § 15-1.5-8(b)(3) Emergency Power Requirements


Waives requirements for emergency power and lighting according to NFPA 99 for approved mobile & temporary structures on or adjacent to hospital premises.

410 IAC § 15-1.5-8(b)(5)(A) Periodic Inspection, Preventative Maintenance & Repair


Waives these requirements during the declared facility emergency.

410 IAC § 15-1.5-8(b)(5)(B) Operational & Maintenance Control Records


Waiver requirements for analysis of operational and maintenance control records during the declared facility emergency.

Updated 5/4/20, 4/17/20, 4/13/20, 4/9/20, 4/7/20

Created 3/31/20


33



410 IAC § 15-1.5-8(c)(1) Compliance with 2001 Guidelines for Construction & Equipment of Hospital & Medical Facilities


Waives requirements for compliance with these guidelines during the facility emergency.

410 IAC § 15-1.5-8(c)(4) Proposed sites Locations & Site Survey by ISDH


To the extent possible, the requirements are waived for temporary structures on or adjacent to hospital premises.

410 IAC § 15-1.5-8(c)(10) Licensure application for temporary surge


Waives these requirements for hospitals with declared emergency.

Coincides with CMS waiving select requirements at 42 CFR § 482.41 and 485.623 to allow flexibilities during hospital, psych hospital and CAH surges. CMS will permit non-hospital buildings/spaces to be used for patient care and quarantine sites, provided that the location is approved by the State.

410 IAC § 15-1.5-8(c)(11) Compliance of temporary surge capacity with Fire safety rules


Waives rule for any hospital that has declared an emergency.

410 IAC § 15-1.5-8(c)(13) Compliance of outpatient, rehab, psychiatric, and mobile, transportable & relocatable units


Waives to the extent possible requirements for temporary structures on or adjacent to hospital premises.

Updated 5/4/20, 4/17/20, 4/13/20, 4/9/20, 4/7/20

Created 3/31/20


34



410 IAC § 15-1.5-8(d)(2)(A) Equipment inspection, testing and calibration


If the annual inspection, testing and/or calibration falls during the emergency declaration period, it can be performed within ninety (90) days after the emergency ends.

Physician Supervision

42 CFR § 410.32(b)(3)(ii) Direct supervision in the office setting; 42 CFR § 410.28(e)(i) Direct supervision hospital outpatient diagnostic services; 42 CFR § 410.27(d)(1)(iv)(D) Direct supervision cardio rehab, intensive cardio rehab and pulm rehab

CMS Interim Final Rule with Comment Period §II.AA, 85 Fed. Reg. 19230, 19245 (4/6/20) Retroactively applicable to 3/1/20

Physician may provide direct supervision through audio/video real-time communications technology when use of such technology is indicated to reduce exposure risks for the beneficiary or health care provider.

42 CFR § 410.27(d)(1)(iv)(E) Supervision requirements for Non-surgical extended duration therapeutic services (NSEDTS)

CMS Interim Final Rule with Comment Period §II.AA, 85 Fed. Reg. 19230, 19266 (4/6/20) Retroactively applicable to 3/1/20

Supervision level changed to general supervision throughout entire procedure (including initiation).

Updated 5/4/20, 4/17/20, 4/13/20, 4/9/20, 4/7/20

Created 3/31/20


35



42 CFR §410.32(b) Supervision of Diagnostic Tests by NPPS

Teaching Hospitals, Teaching Physicians and Medical Residents: CMS Flexibilities to Fight COVID-19

NP, CNS, PA, and CNM practitioners may order, furnish directly, and supervise the performance of diagnostic tests, subject to applicable state law, during the PHE. Must be furnished under the appropriate level of supervision by physician, NP, PA, CNS or CNM.

42 CFR § 410.59(a); 42 CFR § 410.60(a) Part B Therapist Established Maintenance Program


PT/OT who establishes maintenance program can delegate performance of services to TPA or OTA where clinically appropriate.

Point of Care Testing Competency

410 IAC § 15-1.5-3(f)(3)(e) WT.03.01.01 EP 6 (Hospital and Critical Access Hospital)

3.27.20 ISDH Temporary Blanket Waivers for Hospitals, TJC CMS 1135 Waiver Document 4.7.2020

If an employee’s annual POCT testing competency falls within the hospital-declared emergency, renewal can be delayed and completed within 90 days of the end of the emergency, per ISDH.

NOTE: TJC allows only 60 days beyond the end of the emergency.

Privacy/HIPAA

Updated 5/4/20, 4/17/20, 4/13/20, 4/9/20, 4/7/20

Created 3/31/20


36



HIPAA Privacy, Security and Breach Notification Rules

HHS OCR Notification of Enforcement Discretion for Telehealth Remote Communications During the COVID-19 Nationwide Public Health Emergency

Hospitals may communicate with patients in telecommunication platforms that would not normally be utilized.

Continue use of fully HIPAA-compliant platforms when possible, such as AmWell, Microsoft Teams, WebEx, and Diagnotes. If you cannot use a HIPAA-compliant application to communicate with a patient, you may use the non-public facing applications listed as approved below for telehealth remote communications with patients:

Approved Not Approved

Apple Facetime

WhatsApp

Google Duo

Google Hangouts

Microsoft Teams

IUSM Zoom Health

Doximity

Doxy.me

Facebook Live

Twitch

TikTok

YouTube

Instagram

Facebook Messenger

Snapchat

Updated 5/4/20, 4/17/20, 4/13/20, 4/9/20, 4/7/20

Created 3/31/20


37



45 CFR Parts 160 and 164 4.9.20 Notice of Enforcement Discretion Regarding COVID-19 Community-Based Testing Sites (CBTS) During the COVID-19 Nationwide Public Health Emergency

OCR will not impose penalties for HIPAA rule violations on health care provider covered entities and their business associates operating COVID-19 community-based testing sites in good faith for the duration of the current national public health emergency. Community-based sites include mobile, drive-through or walk-up sites that provide only COVID-19 specimen collection or testing services to the public.

Retroactive effect to March 13, 2020

Provider/Practitioner/Student Provisions Licensing and Credentials

42 CFR §482.12(c)(1)–(2) §482.12(c)(4) MS.03.01.03 EP 1, 3 (Hospital)


This provision allows for patients to be under the care of practitioners as allowed by the scope of practice other than a licensed independent provider. CMS is waiving requirements which requires that Medicare patients be under the care of a physician. This waiver may be implemented so long as it is not

Updated 5/4/20, 4/17/20, 4/13/20, 4/9/20, 4/7/20

Created 3/31/20


38



inconsistent with a state’s emergency preparedness or pandemic plan. This allows hospitals to use other practitioners to the fullest extent possible.

IC § 25-22.5-8-1 Unlawful practice MS.06.01.05 EP 1

CMS COVID-19 Emergency Declaration Blanket Waivers for Health Care Providers; Governor Holcomb Executive Order 20-05; TJC CMS 1135 Waiver Document 4.7.2020

Healthcare provides may practice in Indiana without an Indiana license if he or she: (1) has an equivalent license from another State, and (2) is not suspended or barred from practice in Indiana or any other state.

Physicians and Advance Practice Providers must still be credentialed by any hospital at which he or she is providing care.

Unspecified: Professional Licensing Agency: Retired Health Care Professionals


A health care professional who has retired or surrendered his or her license in any state in good standing (not revoked, suspended or relinquished) may obtain a temporary license to provide health care services without reinstatement or approval by the relevant licensing board. Temporary license is granted through registration with the Indiana

Any license issued under this these provisions shall only be effective during the public health emergency and limited to a period of 90 days which may be renewed on 30 day increments.

Updated 5/4/20, 4/17/20, 4/13/20, 4/9/20, 4/7/20

Created 3/31/20


39



Professional License Agency: www.in.gov/pla

IC § 25-22.5-5-4: Medical Students; Temporary medical permits


Medical students who have completed or are in their last semester of a 4 year accredited medical school program may be granted a limited scope temporary medical permit to practice under the indirect supervision of a licensed physician.

Any permit issued under this these provisions shall only be effective during the public health emergency and limited to a period of 90 days which may be renewed on 30 day increments. After emergency, standard application procedures apply.

IC § 25-22.5-3-1: Medical Residents; Minimum license requirements.


Contingent on an order from ISDH, residents who currently hold a Post-graduate Training Permit and are enrolled in an accredited residency program are temporarily granted authority to practice under a full medical license without supervision.

According to the PLA on 4/9/2020: Once the order is issued by ISDH and the State Health Commissioner, then post graduate training permits will act as temporary medical licenses until the end of the public health emergency. As of 4/9/2020, the order has not been issued by ISDH. Any permit issued under this these provisions shall only be effective during the public health emergency and limited to a period of 90 days which may be renewed on 30 day increments. After emergency, standard application procedures apply.

http://www.in.gov/pla

Updated 5/4/20, 4/17/20, 4/13/20, 4/9/20, 4/7/20

Created 3/31/20


40



IC § 25-27.5-4-1 Physician Assistant Students; Conditions for Licensure

Governor Holcomb Executive Order 20-13 and 20-19

Waives requirement for Physician Assistant National Certifying Exams and completion of background check for licensure by PLA. Temporary license is granted through registration with the Indiana Professional License Agency: www.in.gov/pla


IC § 25-23-1-11 Licensing of Nurses; IC 25-1-2-2.1 Duration of License


Waives requirement for NCLEX exam and background check for licensure by PLA. Temporary license is granted through registration with the Indiana Professional License Agency: www.in.gov/pla Licenses of nurses may extend beyond 2 years.


IC § 25-34.5-2-8(a)(3); IC § 25-1-1.1-4; IC 25-.5-10-1 Respiratory Care Practitioner License Requirements


Waives requirement for respiratory care practitioner licensing or certification examination and background check for licensure by PLA. Temporary license is granted through registration with the Indiana




Updated 5/4/20, 4/17/20, 4/13/20, 4/9/20, 4/7/20

Created 3/31/20


41



Professional License Agency: www.in.gov/pla

IC § 16-31-3-1; 16-31-3-2 EMS Certification Requirements


An EMS professional who has retired or surrendered his or her license in any state in good standing (not revoked, suspended or relinquished) may provide services without reinstatement or approval by the relevant licensing board as follows:

May provide supplemental emergency medical services when under the direct supervision of a certified EMS or licensed healthcare professional;

May provide unsupervised patient care as part of emergency response and transport with temporary certification from IDHS.

Temporary certifications are limited to a period of 90 days.

848 IAC § 5-1-(1)(a)(7) Advance Nurse Practitioner Prescriptive Authority


Advance Practice Registered Nurses may provide services in multiple


Updated 5/4/20, 4/17/20, 4/13/20, 4/9/20, 4/7/20

Created 3/31/20


42



locations while under a single written collaboration document.

42 CFR. §482.22(a) and §485.627(a); 410 IAC § 15-1.5-5(a)(3) Extension of hospital credentials beyond natural expiration

CMS COVID-19 Emergency Declaration Blanket Waivers for Health Care Providers; 3.27.20 ISDH Third Emergency Order Granting Temporary Blanket Waivers For Hospitals

Allows physicians whose privileges will expire to continue practicing at the hospital or CAH. If a physician’s hospital privileges are set to expire during the hospital’s declared emergency, medical staff may extend those privileges to expire ninety (90) days after the emergency ends.

Should be read to extend to Advance Practice Professionals whose appointment expires as well.

Restraints

42 CFR § 482.13(g) Reporting Deaths of Patients in Restraint PC.03.05.19 EP 2 (Hospital)

Governor Holcomb Executive Order 20-13, TJC CMS 1135 Waiver Document 4.7.2020

Requirement to report these situations within 24 hours is waived. However, reporting must still occur within standard time limits (not defined). The requirements to have hospitals report to CMS any patient whose death is caused by their disease while in restraints by the end of the next business day has been waived. This only applies to soft restraints in the

Updated 5/4/20, 4/17/20, 4/13/20, 4/9/20, 4/7/20

Created 3/31/20


43



Skilled Nursing Facilities

42 CFR § 409.30 Basic requirements of post hospital SNF care


Waiver of 3-day prior hospitalization for coverage.

This waiver enables beneficiaries to receive Part A SNF benefits who may have been discharged from a hospital early to make room for more seriously ill patients. In addition, beneficiaries who had not been in a hospital or SNF prior to being diagnosed with COVID-19, but who need SNF care as a result of the diagnosis, will be eligible for Medicare Part A

ICU setting. This does not apply to deaths where restraints were felt to be a causative factor of the death.

Rural Health Center

42 CFR § 491.8(a)(6) RHC Staffing and staff responsibilities


Waiving the requirement that a NP, PA, or certified nurse midwife be available to furnish patient care services at least 50% of the time.

CMS is not waiving the requirement that a physician, NP, PA, certified nurse-midwife, clinical social worker, or clinical psychologist to be available to furnish patient care services at all times the clinic or center operates.

42 CFR § 491.8(b)(1) RHC Staffing and staff responsibilities


Waiving the requirement that physicians must provide medical supervision of nurse practitioners at RHCs, to the extent permitted by state law.

Updated 5/4/20, 4/17/20, 4/13/20, 4/9/20, 4/7/20

Created 3/31/20


44



SNF coverage without having to meet the 3-day qualifying hospital stay requirement.

42 CFR § 409.60 Benefit Periods

Authorization of renewed SNF coverage (100 days) without having to start new benefit period

42 CFR § 483.20 and 483.315 Minimum Data Set Requirements

Removed timeframes for Minimum Data Set assessments and transmissions

42 CFR § 483.70(q) Staffing Data Submission


Waiving obligation to submit staffing data through the Payroll-Based Journal system.

42 CFR § 483.106(b)(4) PASARR

Waives Level I screening requirements related to PASARR for nursing home residents who may also have a mental illness or intellectual disability for residents when they are being transferred between NFs (inter-facility transfers) and staff cannot enter nursing facilities due to quarantine.

If NF is not certain whether a Level I evaluation had been conducted at the resident's transferring/evacuating facility, a Level I can be conducted by the admitting facility during the first few days of admission as part of intake. If there is not enough information to complete a Level I evaluation, the NF must document this in the resident’s case files. Level II evaluations and determinations are also not required preadmission when residents are being transferred between NFs. Residents who are transferred will receive a post

Updated 5/4/20, 4/17/20, 4/13/20, 4/9/20, 4/7/20

Created 3/31/20


45



admission review which must be completed as resources become available.

42 CFR § 483.30 Physician Visits in SNF/NF


In person visit requirement is waived. Physicians and non-physician practitioners can conduct visits, as appropriate, via telehealth options.

Teaching Physician

42 CFR § 415.172 Physician fee schedule payment for services of teaching physicians

Teaching Hospitals, Teaching Physicians and Medical Residents: CMS Flexibilities to Fight COVID-19

Allows teaching physician to provide supervision of resident virtually through real-time audio/visual communications technology.

Not applicable to surgical, high-risk, interventional, complex procedures, services performed through endoscope or anesthesia services.

42 CFR § 415.174 Supervision of Teaching Physician in Primary Care Exception


Teaching physician may (1) direct the care furnished by residents, and (2) review the services provided with the resident, during or immediately after the visit, remotely through virtual means via audio/video real time communications technology.

Medicare may make PFS payment to the teaching physician for the following additional services when furnished by a resident under the primary care exception: 99441, 99442, 99443, 99445, 99446, 99421, 99422, 99423, 99452, G2012, G2010

Updated 5/4/20, 4/17/20, 4/13/20, 4/9/20, 4/7/20

Created 3/31/20


46



Telemedicine

42 CFR § 410.78 Telehealth Services

3.17.2020 CMS 1135 Blanket Waiver, Medicare Telemedicine Health Care Provider Fact Sheet

Medicare will pay for office, hospital, and other visits furnished via telehealth including in patient’s places of residence starting March 6, 2020. Prior originating site requirements and rural location requirements are waived.

Newly added codes may be found here. The typical times for purposes of level selection for an office/outpatient E/M are the times listed in the CPT code descriptor.

42 CFR § 410.78(a)(3) IC § 25-1-9.5-6(b)(1) & (2); Telemedicine Definition IC § 27-8-34; IC 27-13-34(b); Telehealth Coverage

Governor Holcomb Executive Order 20-13 CMS Interim Final Rule with Comment Period, __ Fed. Reg. ______ (5/__/20)

IN Medicaid: Telemedicine visits may be provided via audio-only and will be reimbursed. CMS: Certain EM services, behavioral health counseling and educational services may be provided through audio only.

This does not apply to telemedicine visits to prescribe controlled substances or PT/OT/ST services. For CMS, the list of available audio only codes can be found here.

IC § 25-1-9.5-6(a) Telemedicine Definition 42 CFR 410.78(b)(2) Telehealth Services, allowed providers

Governor Holcomb Executive Order 20-13; CMS Physicians and Other Clinicians: CMS Flexibilities to Fight COVID-19

Physical therapist, occupational therapists and speech therapists may practice telemedicine through real-time audio-visual technology. CMS has waived the requirement that the person providing telehealth

https://www.cms.gov/files/zip/covid-19-telehealth-services-phe.zip

https://www.cms.gov/files/zip/covid-19-telehealth-services-phe.zip

Updated 5/4/20, 4/17/20, 4/13/20, 4/9/20, 4/7/20

Created 3/31/20


47



services be a specific type of provider, thereby allowing PT,OT, and SLT to provide speech therapy services.

Not specified. Requirement for established relationship for certain services.

3.17.2020 CMS 1135 Blanket Waiver, Medicare Telemedicine Health Care Provider Fact Sheet

CMS will not enforce the established relationship requirement for telehealth services.

To the extent the service previously required the patient to have a prior established relationship with a particular practitioner (e.g. incident to outpatient service provided by an APP), HHS will not conduct audits to ensure that such a prior relationship existed for claims submitted during this public health emergency.

Not specified. Face to face requirement for certain IN Medicaid services


Indiana Medicaid has suspended the telehealth restrictions and face-to-face requirements for healthcare services such as mental health services, and substance use disorder treatment and prescribing.

IC-25-1-9.5-8 Issuance of Prescription; 21 U.S.C. 829(e) Controlled substances dispensed by means of the internet

Governor Holcomb Executive Order 20-13; 3.16.20 Secretary Azar/Acting DEA Administrator, designation that the telemedicine

Telemedicine may be used for prescribing all schedule II-IV controlled substances, even without prior in person medical evaluation.

Prescription must be issued for legitimate medical purpose by a practitioner in usual scope of professional practice and the telemedicine visit must be conducted using real time audio-visual interactive communication.

Updated 5/4/20, 4/17/20, 4/13/20, 4/9/20, 4/7/20

Created 3/31/20


48



allowance under section 802(54)(D) applies to all schedule II-V controlled substances in all areas of the US.

42 CFR § 482.12(a)(8)-(9): § 485.616(c) MS.13.01.01 1 (Hospital and Critical Access Hospital) LD.04.03.09 23 (Hospital and Critical Access Hospital)

CMS COVID-19 Emergency Declaration Blanket Waivers for Health Care Providers TJC CMS 1135 Waiver Document 4.7.2020

The process for providing (Telemedicine) privileges in a disaster are outlined in EM.02.02.13. In addition, a written contract is not required and is waived unless the services will extend beyond the declared disaster timeframe.

Remote Physiologic Monitoring (“RPM”) CMS Interim Final Rule with Comment Period, 85 Fed. Reg. 19264 (4/06/20); CMS Interim Final Rule with Comment Period, __ Fed. Reg. ______ (5/__/20)

RPM may be furnished to both new and established patients. RPM monitoring services may be reported for periods of fewer than 16 days of 30 days, but not less than 2 days. Consent for services must be obtained at least once annually which may be obtained verbally and documented in the medical record..

Previously only billable for established patients for no less than 16 of 30 days. Can be used for both acute and chronic conditions.

Updated 5/4/20, 4/17/20, 4/13/20, 4/9/20, 4/7/20

Created 3/31/20


49



Verbal Orders

410 IAC § 15-1.5-5(b)(1) Verbal Orders RC.02.03.07 EP 4 (Hospital and Critical Access Hospital) MM.04.01.01 EP 6 (Hospital)

3.27.20 ISDH Temporary Blanket Waivers for Hospitals, TJC CMS 1135 Waiver Document 4.7.2020

Allows for verbal orders to be authenticated within seven (7) days, irrespective of whether medical staff bylaws or rules set a shorter period. The requirement for an order remains. However, an increased frequency of verbal orders may be necessary to meet the needs of patients. The increased frequency will not be considered out of compliance with this standard and element of performance.

Coincides with CMS waivers (482.23, 482.24, 485.653(d)(3) to allow additional flexibilities related to verbal orders (VOs):

o 482.23(c)(3)(i) – if Vos are used for the use of drugs & biologicals (except immunizations), they are to be used infrequently

o 482.24(c)(2) – all orders, including Vos must be dated, timed and authenticated promptly by the ordering practitioner or by another practitioners who is responsible for the care of the patient

o 482.24(c)(3) – Hospitals may use pre-printed and electronic standing orders, order sets, and protocols for patient orders.

Utilization Review

LD LD.04.01.01 EPs 17, 18 (Hospital) LD.04.01.01 EP 8 (Critical Access Program)


The entire utilization review (UR) program has been waived by CMS during the time of the declared disaster (pandemic).

Updated 5/4/20, 4/17/20, 4/13/20, 4/9/20, 4/7/20

Created 3/31/20


50



o 482.635(d)(3) – Although regulation requires medication administration be based on written, signed order. A practitioner responsible for care must authenticate the order asap after the fact.

Documents

Updated 5/4/20, 4/17/20, 4/13/20, 4/9/20, 4/7/20 Created 3 ...Updated 5/4/20, 4/17/20, 4/13/20, 4/9/20, 4/7/20 Created 3/31/20 COVID-Related CMS, Indiana Code/Hospital Licensure Rule