S&C: 17-15-LSC-Revised: Use of the Fire Safety Evaluation System
The Centers for Medicare & Medicaid Services (CMS) finalized new mandatory values in August 2022 for the Fire Safety Evaluation System (FSES). CMS this week released revisions to the
FSES memo, which negate the need for a waiver and now allow SNFs to once again achieve a passing score on the FSES without any impact on the fire safety of the facility.
Facilities may now use NFPA 101A, 2013 edition, of the FSES. As of October 1, 2022, existing NF/SNF certified and with a previously approved FSES prior to July 5, 2016, may now use the mandatory values in NFPA 101A, 2001 edition. Time-limited waivers previously allowed for existing NF/SNF that had an FSES on record prior to July 5, 2016, are rescinded with the adoption of the FSES mandatory values in NFPA 101A, 2001 edition. CMS will be adding these updates to Appendix I to align with this revision.
QSO-23-02-ALL: Revised Guidance for Staff Vaccination Requirements
On November 5, 2021, CMS published an interim final rule with comment period. This rule establishes requirements regarding COVID-19 vaccine immunization of staff among Medicare- and Medicaid-certified providers and suppliers.
CMS this week
revised guidance for staff vaccination requirements (for all provider-types) related to assessing and maintaining compliance with the staff vaccination regulatory requirements. The memorandum replaces and consolidates information from previous memoranda QSO 22-07-ALL Revised, QSO 22-09-ALL Revised, and QSO 22-11-ALL Revised. The guidance applies to all states.
CMS changes include:
- Directing that the levels of scope and severity when citing be lowered.
- F888 will be cited at severity level 1, with a scope of widespread, or “C.” Noncompliance is based on the failure to implement policies and procedures at 483.80(i)(3)(ii).
- Situations indicating egregious noncompliance (more than 50% of staff being unvaccinated (unless exempted, or temporarily delayed), and/or no policies or procedures as required, should be cited at severity level 2, with a scope of widespread, or “F.”
- Facilities that are noncompliant (vaccination rates under 100%) but has implemented a plan to achieve a 100% staff vaccination rate would not be subject to an enforcement action.
- Streamline the process related to additional precautions by providing facilities with the discretion to choose which additional precautions to implement that align with the intent of the regulation which is intended to mitigate the transmission and spread of COVID-19 for all staff who are not fully vaccinated.
- Removal of NHSN data review-Surveyors have the discretion to verify the accuracy of NHSN data on surveys based on a complaint report or if concerns are identified.
- Good faith effort examples added which show facilities attempt to correct noncompliance.