ASHE News

CMS Requirements for Health Care Facilities: Provider Types and Final Rule Application

Published:

Subject Matter: Article | Topics: Codes and standards

By Jonathan Flannery, CHFM, FASHE, MHSA, FACHE, ASHE Senior Associate Director for Advocacy

This article was developed by the author with information from the CMS website and the Final Rule Document to assist ASHE members in applying CMS’s Final Rule to their provider type. The information is paraphrased and summarized, and the full language can be found on the ASHE website.

42 CFR Part 403 - Special Programs and Projects: Religious Nonmedical Health Care Institutions

Religious Nonmedical Health Care Institutions (RNHCI) furnish only nonmedical nursing items and services to beneficiaries who choose to rely solely on a religious method of healing, and for whom the acceptance of medical services would be inconsistent with their religious beliefs. These facilities:

  • Furnish nonmedical items and services to inpatients on a 24-hour basis
  • Do not furnish, on the basis of religious beliefs, through its personnel or otherwise, medical items and services (including any medical screening, examination, diagnosis, prognosis, treatment, or administration of drugs) for its patients
  • Per the Final Rule, these facilities:
    • Must meet applicable provisions and must proceed in accordance with NFPA 101: Life Safety Code® including TIAs 12-1, 12-2, 12-3, and 12-4:
      • Corridor doors and doors to rooms containing flammable or combustible materials must be provided with positive latching hardware. Roller latches are prohibited on such doors.
      • Alcohol-based hand rubs must be placed in a manner that adequately protects against inappropriate access.
      • When sprinkler system is shut down for more than 10 hours, must
        • Evacuate building or portion of building affected until system is back in service
        • Establish a fire watch until the system is back in service
      • New buildings constructed after September 3, 2016, must have an outside door or outside window with a maximum sill height of 36 inches above the finished floor in every sleeping room.
      • Waivers are allowable at the discretion of the Secretary.
    • Must meet the applicable provisions and must proceed in accordance with NFPA 99: Health Care Facilities Code including TIAs 12-2, 12-3, 12-4, 12-5, and  12-6:
      • Chapters 7 (IT), 8 (Plumbing), 12 (Emergency Management), and 13 (Security) do not apply.
      • Waivers are allowable at the discretion of the Secretary.

42 CFR Part 416 – Ambulatory Surgical Services

Participation as an ambulatory surgical center (ASC) is limited to any distinct entity that operates exclusively for the purpose of providing surgical services to patients not requiring hospitalization and in which the expected duration of services would not exceed 24 hours following an admission. An unanticipated medical circumstance may arise that would require an ASC patient to stay in the ASC longer than 24 hours, but such situations should be rare.

  • The regulatory definition of an ASC does not allow the ASC and another entity, such as an adjacent physician's office, to mix functions and operations in a common space during concurrent or overlapping hours of operations. CMS does permit two different Medicare-participating ASC to use the same physical space, so long as they are temporally separated. That is, the two facilities must have entirely separate operations, records, and so forth, and may not be open at the same time.
  • ASCs are not permitted to share space, even when temporally separated, with a hospital or critical access hospital outpatient surgery department, or with a Medicare-participating independent diagnostic testing facility (IDTF). Certain radiology services that are reasonable and necessary and integral to covered surgical procedures may be provided by an ASC; however, it is not necessary for the ASC to also participate in Medicare as an IDTF for these services to be covered.
  • Per the Final Rule, ASCs
    • Must meet provisions applicable to ambulatory health care occupancies and must proceed in accordance with NFPA 101 including TIAs 12-1, 12-2, 12-3, and 12-4:
      • Waivers are allowable at the discretion of the Secretary.
      • Alcohol-based hand rubs must be placed in a manner that adequately protects against inappropriate access.
      • When sprinkler system is shut down for more than 10 hours, must
        • Evacuate building or portion of building affected until system is back in service
        • Establish a fire watch until the system is back in service
      • Beginning July 5, 2017, ambulatory surgical services must be in compliance with Chapter 21.3.2.1. Doors to hazardous areas shall be self-closing or automatic-closing in accordance with 21.2.2.4 and held open by an automatic release device that is initiated by the fire alarm system.
    • Must meet applicable provisions and must proceed in accordance with the 2012 Edition of NFPA 99 including TIAs 12-2, 12-3, 12-4, 12-5, and 12-6:
      • Chapters 7 (IT), 8 (Plumbing), 12 (Emergency Management), and 13 (Security) do not apply.
      • Waivers are allowable at the discretion of the Secretary.

42 CFR Part 418 – Hospice Care

Furnishes items and services provided to a terminally ill individual by a hospice program under a written plan established and periodically reviewed by the individual's attending physician and by the medical director (and by the interdisciplinary group) of the program:

  • Nursing care provided by or under the supervision of a registered professional nurse
  • Physical or occupational therapy, or speech-language pathology services
  • Medical social services under the direction of a physician
  • Services of a home health aide
  • Short-term inpatient care (including both respite care and procedures necessary for pain control and acute and chronic symptom management) in an inpatient facility meeting such conditions as the Secretary determines to be appropriate to provide such care. Such respite care may be provided only on an intermittent, nonroutine, and occasional basis and may not be provided consecutively over longer than five days.
  • Per the Final Rule, hospices that provide inpatient care directly
    • Must meet applicable provisions and must proceed in accordance with NFPA 101 including TIAs 12-1, 12-2, 12-3, and 12-4:
      • Corridor doors and doors to rooms containing flammable or combustible materials must be provided with positive latching hardware. Roller latches are prohibited on such doors.
      • Waivers are allowable at the discretion of the Secretary.
      • Alcohol-based hand rubs must be placed in a manner that adequately protects against inappropriate access.
      • When sprinkler system is shut down for more than 10 hours, must
        • Evacuate building or portion of building affected until system is back in service
        • Establish a fire watch until the system is back in service
      • New buildings constructed after September 3, 2016, must have an outside door or outside window with a maximum sill height of 36 inches above the finished floor in every sleeping room.
    • Must meet applicable provisions and must proceed in accordance with NFPA 99 including TIAs 12-2, 12-3, 12-4, 12-5, and 12-6:
      • Chapters 7 (IT), 8 (Plumbing), 12 (Emergency Management), and 13 (Security) do not apply
      • Waivers are allowable at the discretion of the Secretary.

42 CFR Part 460—Programs of All-Inclusive Care for the Elderly

The Programs of All-Inclusive Care for the Elderly (PACE) provides comprehensive medical and social services to certain frail, community-dwelling elderly individuals, most of whom are dually eligible for Medicare and Medicaid benefits. An interdisciplinary team of health professionals provides PACE participants with coordinated care. For most participants, the comprehensive service package enables them to remain in the community rather than receive care in a nursing home. A PACE organization is a not-for-profit private or public entity that is primarily engaged in providing PACE services and has the following characteristics:

  • Has a governing board that includes community representation
  • Is able to provide the complete service package regardless of frequency or duration of services
  • Has a physical site to provide adult day services
  • Has a defined service area
  • Has safeguards against conflict of interest
  • Has demonstrated fiscal soundness
  • Has a formal Participant Bill of Rights
  • Per Final Rule, a PACE center:
    • Must meet applicable provisions and must proceed in accordance with NFPA 101 including TIAs 12-1, 12-2, 12-3, and 12-4:
      • Corridor doors and doors to rooms containing flammable or combustible materials must be provided with positive latching hardware. Roller latches are prohibited on such doors.
      • Waivers are allowable at the discretion of the Secretary.
      • Alcohol-based hand rubs must be placed in a manner that adequately protects against inappropriate access.
      • When sprinkler system is shut down for more than 10 hours, must:
        • Evacuate building or portion of building affected until system is back in service
        • Establish a fire watch until the system is back in service
    • Must meet applicable provisions and must proceed in accordance with NFPA 99 including TIAs 12-2, 12-3, 12-4, 12-5, and 12-6:
      • Chapters 7 (IT), 8 (Plumbing), 12 (Emergency Management), and 13 (Security) do not apply.
      • Waivers are allowable at the discretion of the Secretary.

42 CFR Part 482—Conditions of Participation for Hospitals

A hospital is an institution primarily engaged in providing, by or under the supervision of physicians, inpatient diagnostic and therapeutic services or rehabilitation services. Under the Medicare provider-based rules, “one” hospital may have multiple inpatient campuses and outpatient locations. It is not permissible to certify only part of a participating hospital. Psychiatric hospitals that participate in Medicare as a distinct part psychiatric hospital are not required to participate in their entirety. However, the following are not considered parts of the hospital and are not to be included in the evaluation of the hospital's compliance:

  • Components appropriately certified as other kinds of providers or suppliers, that is, a distinct part skilled nursing facility and/or distinct part nursing facility, home health agency, rural health clinic, or hospice; excluded residential, custodial, and non-service units not meeting certain definitions in the Social Security Act; and,
  • Physician offices located in space owned by the hospital but not functioning as hospital outpatient services departments
  • Per Final Rule, a hospital
    • Must meet applicable provisions and must proceed in accordance with NFPA 101 including TIAs 12-1, 12-2, 12-3, and 12-4:
      • Corridor doors and doors to rooms containing flammable or combustible materials must be provided with positive latching hardware. Roller latches are prohibited on such doors.
      • Waivers are allowable at the discretion of the Secretary.
      • Alcohol-based hand rubs must be placed in a manner that adequately protects against inappropriate access.
      • When sprinkler system is shut down for more than 10 hours, must
        • Evacuate building or portion of building affected until system is back in service
        • Establish a fire watch until the system is back in service
      • New buildings constructed after September 3, 2016, must have an outside door or outside window with a maximum sill height of 36 inches above the finished floor in every sleeping room.
        • Sill height does not apply to newborn nurseries and rooms intended for occupancy for less the 24 hours.
        • The sill height in special nursing care areas of new occupancies must not exceed 60 inches.
    • Must meet applicable provisions and must proceed in accordance with NFPA 99 including TIAs 12-2, 12-3, 12-4, 12-5, and 12-6:
      • Chapters 7 (IT), 8 (Plumbing), 12 (Emergency Management), and 13 (Security) do not apply.
      • Waivers are allowable at the discretion of the Secretary.

42 CFR Part 483—Requirements for States and Long-Term Care Facilities

A long-term care facility is a skilled nursing facility (SNF) or a nursing facility (NF). A facility may include a distinct part of an institution but does not include an institution for the mentally retarded or persons with related conditions. The “facility” is always the entity that participates in the program, whether that entity is comprised of all or a distinct part of a larger institution.

  • “Skilled nursing facility” is defined as an institution (or a distinct part of an institution) that is primarily engaged in providing skilled nursing care and related services for residents who require medical or nursing care, or rehabilitation services for the rehabilitation of injured, disabled, or sick persons, and is not primarily for the care and treatment of mental diseases.
  • “Nursing facility” is defined as an institution (or a distinct part of an institution) that is primarily engaged in providing skilled nursing care and related services for residents who require medical or nursing care, rehabilitation services for the rehabilitation of injured, disabled, or sick persons, or on a regular basis, health-related care and services to individuals who because of their mental or physical condition require care and services (above the level of room and board) that can be made available to them only through institutional facilities, and is not primarily for the care and treatment of mental diseases.
  • Per Final Rule, a long-term care facility:
    • Must meet applicable provisions and must proceed in accordance with NFPA 101 including TIAs 12-1, 12-2, 12-3, and 12-4:
      • Corridor doors and doors to rooms containing flammable or combustible materials must be provided with positive latching hardware. Roller latches are prohibited on such doors.
      • Waivers are allowable at the discretion of the Secretary.
      • Alcohol-based hand rubs must be placed in a manner that adequately protects against inappropriate access.
      • When sprinkler system is shut down for more than 10 hours, must
        • Evacuate building or portion of building affected until system is back in service
        • Establish a fire watch until the system is back in service
      • New buildings constructed after September 3, 2016, must have an outside door or outside window with a maximum sill height of 36 inches above the finished floor in every sleeping room.
    • Must meet applicable provisions and must proceed in accordance with NFPA 99 including TIAs 12-2, 12-3, 12-4, 12-5, and 12-6:
      • Chapters 7 (IT), 8 (Plumbing), 12 (Emergency Management), and 13 (Security) do not apply.
      • Waivers are allowable at the discretion of the Secretary.

42 CFR Part 483 Subpart 470—Requirements for Intermediate Care Facilities for Individuals with Intellectual Disabilities

An institution for individuals with intellectual disabilities or other related conditions, according to federal regulations at 42 CFR 435.1009, is defined as an institution (or distinct part of an institution) that

  • Is primarily for the diagnosis, treatment, or rehabilitation for individuals with intellectual disabilities
  • Provides, in a protected residential setting, ongoing evaluation, planning, 24-hour supervision, coordination, and integration for health or rehabilitative services to help individuals function at their greatest ability
  • Intermediate Care Facilities for Individuals with Intellectual Disabilities (ICF/IID) services may be furnished in a distinct part of a facility other than an ICF/IID if the distinct part
  • Per Final Rule, an ICF/IID facility
    • Meets all requirements for an ICF/IID;
    • Is clearly an identifiable living unit, such as an entire ward, wing, floor, or building;
    • Consists of all beds and related services in the unit;
    • Houses all recipients for whom payment is being made for ICF/IID services; and
    • Is approved in writing by the survey agency.
    • Must meet the applicable provisions of either the health care occupancies chapters or the residential board and care occupancies chapters and must proceed in accordance with NFPA 101 including TIAs 12-1, 12-2, 12-3, and 12-4:
      • Corridor doors and doors to rooms containing flammable or combustible materials must be provided with positive latching hardware. Roller latches are prohibited on such doors.
      • Chapters 32/33.3.2.11.2 Lockups. Lockups in residential board and care occupancies, other than approved existing lockups, shall comply with the requirements of Life Safety Code 23.5.5 do not apply to a facility.
      • Beginning July 5, 2019, IDF/IIDs must be incompliance with Chapter 33.2.3.5.7.1 “Sprinklers in Attics” or Chapter 33.2.3.5.7.2 “Heat Detection Systems in Attics” of the Life Safety Code.
      • For facilities that meet the Life Safety Code definition of a health care occupancy:
        • Waivers are allowable at the discretion of the Secretary.
        • ABHRs must be placed in a manner that adequately protects against inappropriate access.
        • When sprinkler system is shut down for more than 10 hours, must
          • Evacuate building or portion of building affected until system is back in service
          • Establish a fire watch until the system is back in service
        • Beginning July 5, 2019, IDF/IIDs must be incompliance with Chapter 33.2.3.5.7.1 “Sprinklers in Attics,” or Chapter 33.2.3.5.7.2 “Heat Detection Systems in Attics” of the Life Safety Code.
    • Must meet applicable provisions and must proceed in accordance with NFPA 99 including TIAs 12-2, 12-3, 12-4, 12-5, and 12-6:
      • Chapters 7 (IT), 8 (Plumbing), 12 (Emergency Management), and 13 (Security) do not apply.
      • Waivers are allowable at the discretion of the Secretary.

42 CFR 485 Conditions of Participation: Specialized Providers: Critical Access Hospitals

Critical access hospitals (CAHs) represent a separate provider type with their own Medicare Conditions of Participation (CoP) as well as a separate payment method. CAHs must:

  • Be located in a state that has established a state Medicare rural hospital flexibility program;
  • Be designated by the state as a CAH;
  • Be located in a rural area or an area that is treated as rural;
  • Be located either more than 35 miles from the nearest hospital or CAH or more than 15 miles in areas with mountainous terrain or only secondary roads; OR, prior to January 1, 2006, were certified as a CAH based on state designation as a “necessary provider” of health care services to residents in the area;
  • Maintain no more than 25 inpatient beds that can be used for either inpatient or swing-bed services;
  • Maintain an annual average length of stay of 96 hours or less per patient for acute inpatient care (excluding swing-bed services and beds that are within distinct part units);
  • Demonstrate compliance with the CAH CoPs found at 42 CFR Part 485 subpart F; and
  • Furnish 24-hour emergency care services 7 days a week.
  • Per the Final Rule, a critical access hospital
    • Must meet applicable provisions and must proceed in accordance with NFPA 101 including TIAs 12-1, 12-2, 12-3, and 12-4:
      • Corridor doors and doors to rooms containing flammable or combustible materials must be provided with positive latching hardware. Roller latches are prohibited on such doors.
      • Waivers are allowable at the discretion of the Secretary.
      • Alcohol-based hand rubs must be placed in a manner that adequately protects against inappropriate access.
      • When sprinkler system is shut down for more than 10 hours, must
        • Evacuate building or portion of building affected until system is back in service
        • Establish a fire watch until the system is back in service
      • New buildings constructed after September 3, 2016, must have an outside door or outside window with a maximum sill height of 36 inches above the finished floor in every sleeping room.
        • Sill height does not apply to newborn nurseries and rooms intended for occupancy for less the 24 hours.
        • The sill height in special nursing care areas of new occupancies must not exceed 60 inches.
    • Must meet applicable provisions and must proceed in accordance with NFPA 99 including TIAs 12-2, 12-3, 12-4, 12-5, and 12-6:
      • Chapters 7 (IT), 8 (Plumbing), 12 (Emergency Management), and 13 (Security) do not apply.
      • Waivers are allowable at the discretion of the Secretary.