CMS Survey and Certification Material
The links below lead to ASHE Issue briefs, memoranda, and guidance the Centers for Medicare & Medicaid Services (CMS) has issued to communicate and clarify its policies for state survey agencies and CMS regional offices. ASHE has compiled all of the guidance published that would be of most interest to ASHE members. For a complete listing of the guidance from CMS, click here.
- General Information
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QSO: 18-21-All Hospitals: CMS Clarification of Psychiatric Environmental Risks - S&C 18-06: Clarification of ligature risk policy
- S&C 17-44-Hosp – 6 Sept 17 - Appendix A Revisions
- S&C 17-38-LSC – 28 July 17 – Fire and Smoke Door Testing
- S&C 17-29-All – 2 June 17 – Appendix Z Em Prep Interpretive Guidance
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S&C-17-22-ALL: Save the Date: Medicare Learning Network Conference Call for Emergency Preparedness Requirements for Medicare & Medicaid Participating Providers and Suppliers Final Rule -
S&C-17-21-ALL: Information to Assist Providers and Suppliers in Meeting the Training and Testing Requirements of the New Emergency Preparedness Final Rule - S&C 17-17-All – 13 Jan 17 – Recs. Regarding Cyber Security
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S&C: 17-15: Use of the Fire Safety Evaluation System -
S&C: 17-14: Clarification of Automatic Fire Sprinkler System Installation Requirements in Attic Spaces in Long-Term Care Facilities - S&C: 17-05-ALL: Information on the Implementation Plans for the Emergency Preparedness Regulation
- S&C: 16-38-ALL: Notification of Final Rule Published- Emergency Preparedness
- S&C: 16-29-LSC: Adoption of the 2012 edition of the National Fire Protection Association (NFPA) 101 - Life Safety Code (LSC) and 2012 edition of the NFPA 99 - Health Care Facilities Code (HCFC)
- S&C: 16-22-LSC: Notification of Final Rule Published: Adoption of 2012 Life Safety and Health Care Facilities Code
- S&C: 16-11-ALL: Exit Conferences-Sharing Specific Regulatory References or Tags
- S&C: 16-08-CAH: Critical Access Hospital (CAH) Recertification Checklist for Evaluation of Compliance with the Location and Distance Requirements
- S&C: 16-01-Hospital: Revised Hospital Guidance for Pharmaceutical Services and Expanded Guidance Related to Compounding of Medications
- S&C: 14-46 Categorical Waiver for Power Strip Use in Patient Care Areas
- S&C: 14-07 Hospital Equipment Maintenance Requirements
- S&C: 14-03-NH/LSC: Citations at F Tag 454 – 42 CFR §483.70 Physical Environment, §483.70(a) Life Safety from Fire
- S&C: 13-58-LSC Life Safety Code Waivers
- S&C: 13-55 Installation of Automatic Sprinkler Systems in Nursing Homes
- S&C: 13-25 Waiver of Life Safety Code Regarding Operating Room Relative Humidity
- S&C: 13-22 Life Safety Code Short Form Survey for Nursing Homes
- S&C: 13-03 Pilot Phase of Revised Draft Surveyor Worksheets
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S&C 12-21 Waivers of Specific Requirements of the 2012 Edition of NFPA 101 - S&C 12-07 Clarification of Hospital Equipment Maintenance Requirements
- S&C 11-07 Interior Finish Documentation Requirements
- S&C-11-05-LSC Occupancy Classification Update
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S&C-10-20 Ambulatory Surgical Center (ASC) Waiting Area Separation Requirements - S&C-10-18 Revision of S&C-04-41 dated Aug. 12, 2004. Corridor Width 7 Corridor-Mounted Computer Touch Screens in Health Care Facilities. - Clarification Effective Immediately
- S&C-10-04 Waiver to Allow Hospitals to Use the NFPA 6-Year Damper Testing Interval
- S&C-09-56 End Stage Renal Disease - FAQs
- S&C-09-55 Flash Sterilization Clarification - Ambulatory Surgery Center
- S&C-09-51 Clarification of Ambulatory Surgical Center (ASC) Interpretive Guidelines
- S&C-09-37 Ambulatory Surgical Centers Revisions to State Operations Manual
- S&C-09-24 End Stage Renal Disease Interpretive Guidance
- S&C-09-24 End Stage Renal Disease - Life Safety Code
- S&C 09-13 Waivers and Phase-In Time Extensions for the Implementation of the New End Stage Renal Disease (ESRD) Conditions for Coverage
- S&C 09-04 All long term care facilities to be equipped with a supervised automatic sprinkler
- S&C-08-34 Compliance with State Fire and Safety Code in Lieu of Life Safety Code
- S&C-08-09 Food Prepared Off-Site
- S&C-08-04 Infection Control Guidelines
- S&C-07-29 Canopy and Overhang Sprinkler Requirements
- S&C-07-21 Generators in ASCs
- S&C-07-18 Gaps in Corridor and Smoke Barrier Doors
- S&C-07-11 Use of Alcohol-Based Skin Preparations in Anesthetizing Locations
- S&C-07-10 Medical Gas Storage and Usage Considerations
- S&C-07-05 Exit Discharge Requirements & Fire Safety Evaluation System (FSES)
- S&C-07-01 Use of ABHR
- S&C 06-33 Basic Principles of Using Photography During the Survey
- S&C-06-18 Air Movement between Corridors and Resident Rooms
- S&C 05-38 Life Safety Code - wardrobe/closet sprinkler requirements, exit discharge surfacing requirements, canopy sprinkler requirements
- S&C-05-33 Fire Safety Amendment for the Use of ABHRs
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S&C 05-25 Adoption of a New Fire Safety Requirement for Long Term Care Facilities (Battery Powered Smoke Detector Installation) - S&C-04-41 Corridor-Mounted Touch Screen and Corridor Obstructions
- S&C 04-33 Use of Waivers and NFPA 101A – Fire Safety Evaluation System (FSES)
- S&C 04-29 Life Safety Code reference materials for surveyors
- S&C 04-23 Reporting Procedures in the Event of a Fire with Patient Harm and Immediate Jeopardy
- S&C 04-22 Overnight Stay in ASCs
- S&C-04-15 Major vs. Minor Alteration and Application of the Life Safety Code Existing/New Chapters
- S&C-03-22 Clarification of CMS Payment Policies Regarding Ambulatory Surgical Centers/Independent Diagnostic Testing Facilities Conducting Business from the Same Location (added 06/10)
- S&C 03-21 Adoption and Application of Life Safety Code Effective March 10, 2003
- S&C-02-16 Separate waiting and recovery, Length of Stay, Non Sterile Procedure Rooms