CMS Updates Health and Safety Expectations

With all the news about the Hacienda Healthcare facility I thought I’d give an update about how facilities like Hacienda are regulated.  Hacienda was a special case because it was exempt from the state licensing requirements and wasn’t required to have a state license.  It did, however, need to be certified as meeting the federal standards of care.  CMS has an interest in ensuring quality care because they are the payers for many of the patients in skilled nursing facilities and the like.

In general, skilled nursing facilities are required to have a state license (and meet state licensing standards).  However, if the facility is accredited by a 3rd party like the Joint Commission or the Council on Accreditation, they can submit that certification to the ADHS and receive a license without an on-site inspection.  The Agency still has the authority to conduct complaint investigations, but will, in general not do annual surprise inspections not related to a complaint.

In addition to the state licensing standards, CMS requires that facilities that treat Medicare and Medicaid patients also be Certified as meeting their standards.  That compliance work is also done by the ADHS – under a contract between CMS and the ADHS.  CMS asks states to use what's called the States Operations Manual when they do the certification inspections. 

So, a typical skilled nursing facility for example, would need to meet the state standards as well as the CMS expectations (in order to get paid for Medicare and Medicaid patient services).  When we (ADHS) re-wrote the healthcare institution Rules back in 2013, we did our best to synchronize the ADHS rules and CMS certification expectations.

CMS certification guidance addresses violations of health and safety regulations that cause serious harm or death to a patient and require immediate action to prevent further serious harm.  Their guidance also provides inspectors with guidance on quickly identifying and handling these urgent situations. 

This week, CMS announced that they've updated their guidance to states with information clarifies what information is needed to identify immediate jeopardy cases across all healthcare provider types.  The new guidance is in Appendix Q of the State Operations Manual that federal and state inspectors use.  CMS also released some new administrative tools to help inspectors make sure they have the evidence needed to meet criteria for immediate jeopardy.

Because these changes affect all Medicare- and Medicaid-certified healthcare providers, suppliers, and laboratories, CMS is providing online training on this new guidance at and are the revised guidance and administrative tools.

This was CMS’ final statement about their new guidance: “Investigators will now have a clear framework to identify serious patient health and safety problems. Today’s guidance is just the beginning of upcoming efforts to strengthen oversight of healthcare settings. Expect to hear more from us on this issue. This is part of the agency’s broader initiative of ensuring safety and quality, and we look forward to continuing to work on this priority across all our programs.”