Updated 5/24/21
6
Departments. CMS is waiving 42 CFR §482.12(f)(3), emergency services, with respect to surge
facilities only, such that written policies and procedures for staff to use when evaluating
emergencies are not required for surge facilities. This removes the burden on facilities to
develop and establish additional policies and procedures at their surge facilities or surge sites
related to the assessment, initial treatment, and referral of patients. These flexibilities may be
implemented so long as they are not inconsistent with a state’s emergency preparedness or
pandemic plan.
• Emergency Preparedness Policies and Procedures. CMS is waiving 42 CFR §482.15(b) and
§485.625(b), which requires the hospital and CAH to develop and implement emergency
preparedness policies and procedures, and §482.15(c)(1)–(5) and §485.625(c)(1)–(5) which
requires that the emergency preparedness communication plans for hospitals and CAHs to
contain specified elements with respect to the surge site. The requirement under the
communication plan requires hospitals and CAHs to have specific contact information for staff,
entities providing services under arrangement, patients’ physicians, other hospitals and CAHs,
and volunteers. This would not be an expectation for the surge site. This waiver applies to both
hospitals and CAHs, and removes the burden on facilities to establish these policies and
procedures for their surge facilities or surge sites.
• Quality Assessment and Performance Improvement Program. CMS is waiving 42 CFR
§482.21(a)–(d) and (f), and §485.641(a), (b), and (d), which provide details on the scope of the
program, the incorporation, and setting priorities for the program’s performance improvement
activities, and integrated Quality Assurance & Performance Improvement programs (for
hospitals that are part of a hospital system). These flexibilities, which apply to both hospitals
and CAHs, may be implemented so long as they are not inconsistent with a state’s emergency
preparedness or pandemic plan. We expect any improvements to the plan to focus on the
Public Health Emergency (PHE). While this waiver decreases burden associated with the
development of a hospital or CAH QAPI program, the requirement that hospitals and CAHs
maintain an effective, ongoing, hospital-wide, data-driven quality assessment and performance
improvement program will remain. This waiver applies to both hospitals and CAHs.
• Nursing Services. CMS is waiving the requirements at 42 CFR §482.23(b)(4), which requires the
nursing staff to develop and keep current a nursing care plan for each patient, and
§482.23(b)(7), which requires the hospital to have policies and procedures in place establishing
which outpatient departments are not required to have a registered nurse present. These
waivers allow nurses increased time to meet the clinical care needs of each patient and allow
for the provision of nursing care to an increased number of patients. In addition, we expect that
hospitals will need relief for the provision of inpatient services and as a result, the requirement
to establish nursing-related policies and procedures for outpatient departments is likely of
lower priority. These flexibilities apply to both hospitals and CAHs §485.635(d)(4), and may be
implemented so long as they are not inconsistent with a state’s emergency preparedness or