Vermont Association of Hospitals & Health Systems Federal and state regulatory agencies continue to flex licensing and other requirements to help health care providers and others respond to the coronavirus pandemic.
Federal and State Regulatory Flexibility- March 29, 2020
EMTALA
- • Relocation of an individual to another location for medical screening pursuant to a state emergency preparedness plan
- • Transfer of an individual who has not been stabilized if necessary under COVID-19 pandemic
Medicare Appeals: CMS will utilize all flexibilities
VERMONT 1135 WAIVERS—NOTE: WAITING FOR WRITTEN CONFIRMATION OF APPROVAL, WHEN APPROVED, WILL APPLY TO ENTIRE STATE OF VERMONT WITHOUT FURTHER ACTION
NOTE: VAHHS has and will continue to submit multiple waivers on behalf of our hospitals and health systems, nursing homes, home health and hospice agencies, and health care providers. If you have provisions you need in the waiver, please contact [email protected].
The items below have been tentatively approved. If you previously submitted something that is not seen here, it is in a different waiver request under consideration.
Hospitals, Psychiatric Hospitals and CAHs
Physical Environment: CMS will permit non-hospital buildings/space to be used for patient care and quarantine sites, provided that the location is approved by the State (ensuring safety and comfort for patients and staff are sufficiently addressed).
EMTALA: CMS is waiving enforcement of 1867(a), allowing hospitals, psychiatric hospitals, and CAHs to screen patients at a location offsite from the hospital’s campus to prevent the spread of COVID-19, in accordance with the state emergency preparedness plan.
Verbal Orders: CMS is waiving the requirements of §482.23, §482.24 and§485.635(d)(3) to allow for additional flexibilities related to verbal orders where read-back verification is still required but authentication may occur later than 48 hours.
Reporting: for patients in ICU who required soft wrist restraints and died from disease process, report may be made later than close of business next business day.
Patient Rights: Hospitals are not required to meet the following requirements
- • timeframes for providing a copy of a medical record
- • patient visitation rights
- • seclusion
Sterile Compounding: Allows used face masks to be removed and retained in the compounding area to be re-donned and reused during the same work shift in the compounding area only.
Detailed Information Sharing for Discharge Planning for Hospitals and CAHs: CMS is waiving the requirement to provide detailed information regarding discharge planning as outlined.
Discharge Planning for Hospitals: CMS is waiving all the requirements and subparts related to post-acute care services, so as to expedite the safe discharge and movement of patients among care settings, and to be responsive to fluid situations in various areas of the country.
Medical Staff: CMS is waiving these requirements to allow for physicians whose privileges will expire to continue practicing at the hospital or CAH and for new physicians to be able to practice in the hospital or CAH before full medical staff/governing body review and approval.
Medical Records Timing. 42 C.F.R. §482.24(c)(4)(viii) and §485.638(a)(4)(iii). CMS is waiving these requirements related to medical records to allow flexibility in completion of medical records within 30 days following discharge and for CAHs that all medical records must be promptly completed.
Flexibility in Patient Self Determination Act Requirements (Advance Directives): CMS is waiving the requirements to provide information about its advance directive policies to patients.
- • This would not apply to the requirements at §482.13(a) for hospitals and at §485.608(a) for CAHs to receive information about the presence of a policy regarding the facility’s recognition of advanced directives.
Skilled Nursing Facilities
Staffing Data Submission: CMS is waiving the requirements for submitting staffing data through the Payroll-Based Journal system.
Waive Pre-Admission Screening and Annual Resident Review (PASARR): CMS is waiving the Level I and Level II evaluations when for nursing home residents who may also have a mental illness or intellectual disability and are transferred between NFs.
- • 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.
- • Residents who are transferred will receive a post admission review which must be completed as resources become available.
Physical Environment: Provided that the State has approved the location as one that sufficiently addresses safety and comfort for patients and staff, CMS is waiving requirements to allow for a non-SNF buildings to be temporarily certified as and available for use by a SNF in the event there are needs for isolation processes for COVID-19 positive residents which may not be feasible in the existing SNF structure.
Resident Groups: CMS is waiving the requirements which allow for residents to have the right to participate in-person in resident groups.
Training and Certification of Nurse Aids: CMS is waiving the requirements that a SNF and NF may not employ anyone for longer than 4 months unless they met the training and certification requirements under §483.35(d).
Home Health Agencies
Reporting: Provides relief to Home Health Agencies on the timeframes related to OASIS Transmission. (Approved on 3/13/2020- Clarified) This waiver includes:
- • Extension of the 5-day completion requirement for the comprehensive assessment
- • Waives the 30-day OASIS submission requirement
Initial Assessments and Homebound Status: Home health agencies can perform initial assessments and determine patients’ homebound status remotely or by record review.
Hospice
Volunteers: CMS is waiving the requirement that hospices are required to use volunteers (including at least 5% of patient care hours).
Timeframe for Comprehensive Assessments: Hospices must continue to complete the required assessments and updates, however, the timeframes for updating the assessment may be extended from 15 to 21 days.
Waive 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.
Home Health & Hospice:
Waive onsite visits for both HHA and Hospice & Aide Supervision: CMS is waiving requirement of 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 as this may not be physically possible for a period of time. This waiver is also temporarily suspending 2-week aide supervision requirement at 42 CFR §484.80(h)(1) by a registered nurse for home health agencies, but virtual supervision is encouraged during the period of the waiver.
WORKFORCE FLEXIBILITY
Vermont’s law responding to COVID-19 provides flexibility in licensure for out-of-state providers, students, retirees, PAs, and APRNs. For more information, go here.
Under Medicare and Medicaid, providers licensed in other states and in good standing can get reimbursed for their practice in Vermont under Medicare and Medicaid.
Medicare Provider Enrollment3
3 More information from CMS
4 OCR is not imposing penalties for noncompliance with the regulatory requirements under the HIPAA Rules against covered health care providers in connection with the good faith provision of telehealth during the COVID-19 nationwide public health emergency
- • Hotline for temporary Medicare billing privileges
- • Waive application fee, criminal background check, and site visits
- • Expedite new or pending applications
OSHA instituted a new policy regarding N95 fit testing. They are temporarily lifting the annual requirement. Fit testing will be required for the first time. The guidance can be found here: https://www.osha.gov/memos/2020-03-14/temporary-enforcement-guidance-healthcare-respiratory-protection-annual-fit
HIPAA
HIPAA4 is not enforcing the following for hospitals with disaster protocols in effect:
- • Requirement to obtain patient consent to speak with family members or friends
- • Patients right to request privacy restrictions or confidential communications
OTHER
340B audits—not flexible right now - HRSA is conducting 340B Program audits remotely (virtually). If a covered entity has specific questions regarding an audit once they have been engaged, please contact the Bizzell Group (the 340B audit contractor) at [email protected] who will coordinate with HRSA based on the specifics of the request.
Controlled substances: DEA worked in consultation with HHS to allow DEA-registered practitioners to begin issuing prescriptions for controlled substances to patients for whom they have not conducted an in-person medical evaluation. DEA-registered practitioners may continue this telemedicine practice for as long as the designation is in effect, if all required conditions are met:
- • The prescription is issued for a legitimate medical purpose by a practitioner acting in the usual course of his/her professional practice
- • The telemedicine communication is conducted using an audio-visual, real-time, two-way interactive communication system.
- • The practitioner is acting in accordance with applicable Federal and State law.
Provided the practitioner satisfies these requirements, the practitioner may issue the prescription using any of the methods of prescribing currently available adhering to DEA regulations, including issuing a prescription electronically or by calling in a prescription to the pharmacy.
Substance Abuse and Mental Health Services Administration (SAMHSA) guidance allowing states and provider to request exceptions to SAMHSA’s limits on amounts of take-home medication for treatment of opioid use disorder.
State Regulatory Flexibility
PROVIDER LICENSING INFORMATION: go here.
TELEHEALTH INFORMATION: go here for comprehensive information on the latest policies and practical advice for telehealth expansion.
HOSPITAL LICENSING EMERGENCY RULES, VDH 3/27: Go here. VDH will apply federal flexibilities at the state level.
SUSPENSION OF INSURER CREDENTIALING VERIFICATION PRACTICE, DFR 3/20: Go here. The purpose of this emergency rule is to relax provider credentialing requirements in order to facilitate the reimbursement through commercial insurance during the State of Emergency for health care services provided by physicians or other health care professionals who hold an equivalent license in another State.
SUMMARY OF H.742
For the full bill, go here. For the official summary, go here.
Financial Assistance
- • Modify or postpone hospital provider tax – this needs to be a legislative change
• Medicaid testified to the mechanisms they already have to financially support the health care system o Suspend provider tax
o Exploring payment to health care providers in absence of claims or utilization due to COVID-19
o Potential advantageous change in payment methodology to FQHCs and Rural Health Clinics, if necessary
• Medicaid-funded facilities providing 24-hour per day services, such as long-term care facilities may be reimbursed by AHS for bed-hold days.
Regulatory Flexibility
- • Variance in state regulatory standards, including:
- o Hospital licensing
- o Hospital reporting
- o Nursing home licensing and operations
- o Home health licensing and operations
- o Child care licensing regulations
- o Public assistance program regulations
- o Other rules and standards under AHS
- • Green Mountain Care Board has the authority to waive statutes or rules pertaining to o Hospital budget review
- o Certificate of Need
o Health insurance rate review
o ACO certification and budget review
- • To the extent permitted under federal law, documentation or reporting requirements for involuntary treatment is waived for voluntary and involuntary patients
- • Quarantine is not considered involuntary seclusion or restraint if the patient has been exposed to COVID-19
Workforce Flexibility
- • Relaxed provider credentialing for Medicaid and commercial insurance
- • Automatic licensure of providers licensed in other jurisdictions in good standing as well as providers who have retired in the last 3 years as long as they are working at a health care facility. Temporary licenses for those who are not with a facility.
- • Waiver of supervision, including written agreement, and scope of practice for PAs
- • Waiver of transition to practice requirements for APRNs
- • Temporary licenses to those licensed who have retired 4-10 years ago in good standing and a graduate of a program who is unable to obtain a license because exams are not reasonably available
- • All fees waived
Prescription Drugs
- • Pharmacies can re-fill maintenance medications in 30-day supplies and physicians prescribing buprenorphine for treatment of SUD can renew the prescription without an office visit, to the extent federal law requires
- • Pharmacist, with patient consent, can substitute an available prescription drug for an unavailable one
- • Health care professional can authorize renewal of an existing buprenorphine prescription without an office visit
Telehealth Expansion
- • Same reimbursement as in-person visit for a telehealth visit
- • Store and forward expansion
- • Waiver of HIPAA compliant connections if not practicable
- • Waiver of documented patient consent if not practicable
COVID-19 EXECUTIVE ORDERS: go here
Source: https://vahhs.org