On March 30, 2020, the Centers for Medicare and Medicaid Services (CMS) updated a Quality, Safety & Oversight (QSO) memorandum addressed to state survey agencies to expand infection control and prevention guidance related to the Coronavirus (COVID-19) crisis. The updated QSO memorandum now applies to hospitals, critical access hospitals (CAHs) and psychiatric hospitals and provides expanded guidance related to visitors and transmission mitigation strategies.

In Depth

On March 30, 2020, CMS updated a Quality, Safety & Oversight (QSO) memorandum (QSO-20-13-Hospitals-CAHs REVISED) addressed to state survey agencies identifying modifications to the survey and certification process in response to the growing COVID-19 crisis in the United States. While the original memorandum issued on March 4, 2020, focused on acute care hospitals and provided detailed guidance on screening visitors and patients, and monitoring and restricting healthcare facility staff from working in case of exposure, revisions to the QSO memorandum make clear that it also applies to psychiatric and critical access hospitals.

The updated QSO memorandum addresses questions received by CMS from stakeholders and provides guidance to hospitals, psychiatric hospitals and critical access hospitals to address the COVID-19 pandemic and to provide guidance regarding infection control, visitation and patient placement. Key features of QSO-20-13-Hospitals-CAHs REVISED are described below.

Section 1135 Waivers

As has been discussed previously, CMS has waived numerous requirements applicable to all inpatient facilities. Such waivers were further expanded on March 30, 2020. If these waivers do not cover a particular need, facilities may email a request to 1135waiver@cms.hhs.gov, and the request will be reviewed on a case-by-case basis. Hospitals seeking up-to-date information and resources should contact their local health department if they have questions about patients or healthcare providers with suspected COVID-19 infections.

Visitor Screening and Limitation of Visitors

CMS recommends hospitals, psychiatric hospitals and CAHs screen all visitors and patients before or immediately upon arrival at the facility. All visitors and patients should be asked about the following:

The QSO memorandum provides that hospitals should set limitations on visitation and either establish limited entry points for all visitors or establish alternative sites for screening before visitors are allowed to enter the facility. Suggested limitations on visitation include restricting the number of visitors per patient, limiting visitors to those that provide assistance to patients or permitting only those visitors under a certain age. Hospitals should provide signage at screening points and screening should include temperature checks or questions about fever. Visitors with symptoms of COVID-19 who are not seeking treatment should not be permitted to enter hospitals.

While limits on visitation should be set, CMS cautions that patients must have adequate access to chaplains or clergy, in accordance with the Religious Freedom Restoration Act and Religious Land Use and Institutionalized Persons Act.

With respect to organ procurement, CMS asks that donor hospitals continue to permit organ procurement coordinators into hospitals to discuss organ donation with families. CMS reiterated the critical nature of ensuring continued access to donated organs.

Staff Returning to Work

Current CDC guidance has two pathways for determining when healthcare staff who are exposed or infected with COVID-19 can return to work. If testing is available, staff should be excluded from work until their fever has resolved without medication, respiratory symptoms have improved, and two consecutive negative tests from nasopharyngeal swab specimens collected more than 24 hours apart have been produced. If no testing is available, staff should be excluded from work until three days after fever and respiratory symptoms have resolved without medications and at least seven days have elapsed since symptoms first appeared. Staff should also consult with the facility’s occupational health program for continued monitoring and should seek a re-evaluation if symptoms re-emerge or worsen.

Mitigating Transmission

Inpatient hospitals are encouraged to implement several steps to mitigate the transmission of COVID-19. These include, to the extent practicable:

• Rescheduling elective surgeries, procedures, and non-critical visits.
• Shifting elective urgent inpatient diagnostic and surgical procedures to outpatient settings.
• Practicing social distancing of at least six feet in care settings.
• Limiting visitors if a patient is positive for COVID-19 or meets the persons under investigation criteria.
• Planning for a surge of critically ill patients and identifying ancillary spaces to care for such patients. This may include separate and alternate space in emergency departments, intensive care units or other patient care areas where COVID-19 patients may be cohorted away from other patients. Facilities should also consider identifying dedicated staff to care for COVID-19 patients.

Admission Exceptions

CMS authorizes hospitals to engage in several temporary solutions to expand bed capacity, many of which contemplate the Section 1135 waivers referenced in the QSO memorandum. These include:

• Providing overflow care in excluded distinct part psychiatric units.
• Relocating acute care inpatients to excluded distinct part inpatient rehabilitation units appropriate for the patient’s care needs in order to provide overflow care due to COVID-19 surge.
• Relocating and admitting inpatients of an excluded rehabilitation unit to an acute care inpatient unit to provide care for overflow due to COVID-19 patients. For this waiver to be used, the inpatient facility’s acute care beds must be appropriate for providing care to rehabilitation patients and such patients must continue receiving intensive rehabilitation services.
• Admitting excluded unit psychiatric inpatients to an acute care inpatient unit to expand bed capacity. In this situation, the acute care beds must be appropriate for psychiatric patients and the staff and environment are appropriate for providing safe care.

Considerations for Patient Discharge

With the expansion of the QSO memorandum to psychiatric hospitals, CMS notes special considerations may apply when discharging a patient with psychiatric or cognitive disabilities. When a patient diagnosed with COVID-19 is being discharged from a hospital, hospitals should pay special consideration to patients with psychiatric or cognitive disabilities to ensure the patients are able to adhere to COVID-19 discharge recommendations. This includes ensuring that patients comprehend the significance of isolation recommendations and the potential risk to household members. Alternatively, hospitals must ensure there is a family member or significant other to ensure the patient can comply with infection prevention and isolation recommendations.

Key Takeaways

CMS highlights the availability of Section 1135 waivers for hospitals and expanded the options available for hospitals to increase their bed capacity. CMS provides additional strategies to prevent the spread of COVID-19 in inpatient settings and provides guidance regarding healthcare workers returning to work after COVID-19 exposure or infection to mitigate potential healthcare worker shortages in light of community spread.

Finally, CMS expands prior guidance to hospitals regarding restricting visitation in light of infection control concerns. The QSO memorandum applies to CAHs and psychiatric hospitals, as well as general acute care hospitals, emphasizing that screening should be provided to visitors and patients to the hospital. The QSO memorandum also provides a number of suggestions for screening visitors and strategies to prevent the spread of COVID-19.

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