CMS finalizes guidelines on hospital co-location | Robinson + Cole Diagnosis in Health Law

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[co-author: Erin Howard]*

On November 12, 2021, the Centers for Medicare & Medicaid Services (CMS) issued finalized orientation (“Guidelines”) clarifying that hospitals may share spaces, services, or staff with another hospital or health care provider as long as they demonstrate independent compliance with Medicare Terms of Participation (CoPs). This guide, which finalizes the orientation project published on May 3, 2019, explains how CMS and state agency surveyors will assess a hospital’s space sharing or contract staff arrangements when assessing the hospital’s compliance with Medicare CoPs. The Guide entered into force upon publication on November 12, 2021.

As relayed by CMS, hospitals are increasingly collocated with other hospitals or other healthcare entities as they seek efficiencies and develop different systems of healthcare delivery. Co-location occurs when two Medicare-certified hospitals or one Medicare-certified hospital and another healthcare entity are located on the same campus or in the same building and share space, staff, or departments. CMS provides the following common colocation examples:

  • A hospital located entirely on the campus of another hospital or in the same building as another hospital;
  • Part of a hospital’s inpatient services (for example, in a remote or satellite location) is in the building of another hospital or on the campus of another hospital; and
  • A hospital’s outpatient department is located on the same campus or in the same building as another hospital or a separate Medicare certified provider / provider, such as an outpatient surgery center (ASC), medical clinic. rural health (RHC), a federally accredited health service. (FQHC), an imaging center, etc.

All co-located hospitals are required to demonstrate independent compliance with the hospital’s CoPs. The CMS Guide clarifies how hospitals can organize shared spaces, departments, staff and emergency services to meet specific regulatory requirements. Ultimately, when hospitals choose to co-locate, they must consider the risk of compliance across any shared space or shared service arrangement. Annex A of the CMS State Operations Manual will be revised to include these co-location guidelines as a component of the hospital survey process. Hospitals should keep this updated guide in mind with regards to shared space provisions, as licensure controllers will be required to use the guide in the future to assess compliance. a hospital with the CoPs.

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A hospital participating in Medicare is assessed as a whole for compliance with CoPs and must at all times meet the definition of a hospital in Section 1861 (e) of the Social Security Act and to have operating spaces consistent with the CoPs to 42 CFR part 482. CMS specifically calls for the following areas of consideration when sharing space: (i) patient rights (including privacy and confidentiality of patient records), (ii) infection prevention and control, ( iii) the governing body, and (iv) the physical environment (including patients receiving care in a safe environment).

The hospital should determine whether hospital spaces that are used by another co-located provider may not meet these requirements. For example, a complaint may be raised against a co-located hospital for a shared space-related disability that is cited during a hospital investigation.

(b) Contractual services

Co-located hospitals are each responsible for providing their services in accordance with the hospital’s CoPs and under the supervision of the governing body of the respective hospital (see 42 CFR §482.12 (e)) as if it were provided directly by the hospital. Services that may be provided under contract or arrangement in a co-located hospital include laboratory, dietary, pharmacy, housekeeping, housekeeping, security, prep and delivery services; and utilities such as fire detection and suppression, medical gases, vacuuming, compressed air, and alarm systems, such as oxygen alarms.

(c) Staffing

A hospital is responsible for meeting the staffing requirements of the CoP and all the services it provides, including personnel provided under an agreement or contract with a co-located hospital. When hospital staff are recruited within the framework of another entity, hospital staff must meet the needs of the patients they treat and meet the legal and regulatory requirements of the activity. All persons providing services to an inpatient under a contract or arrangement should receive appropriate education and training on all relevant hospital policies and procedures, the same as that would be provided to employees of the hospital. hospital so that the quality of care and services provided is the same. .

When using staffing contracts, under the standard of contractual services at the 42 CFR §482.12 (e), the governing body is responsible for ensuring: the adequacy of the workforce; adequate monitoring and periodic evaluation of contract staff; adequate training and education of contract staff; that contracted staff know and adhere to the standards for improving the quality and performance of each hospital; and that there is accountability of contract staff for the requirements of clinical practice.

With respect to medical personnel, each co-located hospital would be responsible for meeting the applicable medical personnel requirements at the 42 CFR §482.22. With regard to nursing staff, each co-located hospital would be responsible for ensuring a nursing service organized in accordance with the 42 CFR §482.23.

(d) Emergency services

While hospitals are required to provide patient care in an emergency, hospitals are not required to have an emergency department (ER). As part of the CoP at 45 CFR §482.12 (f) (2), hospitals that do not have emergency services and are not identified as providing emergency services should have appropriate policies and procedures in place to meet the emergency care needs of individuals at all times. Hospitals should have policies and procedures to deal with potential emergency scenarios typical of the patient population they regularly care for and ensure that they are staffed to provide safe and adequate initial treatment in the event of an emergency. Policies and procedures should include: (1) identifying when a patient is in distress, (2) how to initiate an emergency response, (3) how to begin treatment, and (4) recognizing when the patient needs to be transferred to another facility for appropriate treatment.

The initial assessment and treatment performed in a hospital (eg, rehabilitation center) may require appropriate transfer of the patient to another provider such as a co-located hospital (eg, an acute care hospital with an emergency department). emergency), for the continuation of care. If the co-located hospital under investigation is identified as providing emergency services or has an emergency department, the hospital would be subject to the requirements for emergency services (see 45 CFR §482.55) and must meet EMTALA’s requirements. See Article 1867 of the Social Security Act; 45 CFR §489.20-21; and 45 CFR §489.22-24.

See page six of the Advice to read related surveyor procedures.

Comparison with drafts of the guidelines

After the comment period, several changes were made to the old orientation project which was published on May 3, 2019. Notably, in this final version of the guide, CMS removed certain personnel requirements requiring contracted personnel to be immediately available to provide contracted services and prohibiting personnel from “floating Between facilities or performing the same works simultaneously in co-located facilities. Likewise, CMS removed from this final version the requirement that when contracting with another hospital or entity for the assessment and initial treatment of patients facing an emergency, contract staff should not work / duty simultaneously in another hospital or health entity. These omissions provide flexibility and imply that certain provisions may be permitted as long as patient needs are met and all legal and regulatory requirements are met. The final guide also clarifies the procedures related to identifying gaps between co-located facilities.

* This article was co-authored by Erin Howard, Legal Intern at Robinson + Cole. Erin is not yet licensed to practice law.

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