On September 2, 2020, CMS published an interim final rule (IFC), CMS-3401-IFC, that included new requirements for hospitals and CAHs to report data in accordance with a frequency and in a standardized format as specified by the Secretary during the Public Health Emergency for COVID-19. The regulatory requirements for hospitals and CAHs can be found at 42 CFR §§ 482.42(e) and 485.640(d) respectively (see 85 FR 54873). This data allows CMS to monitor whether individual hospitals and CAHs are appropriately tracking, responding to, and mitigating the spread and impact of COVID-19 on patients, the staff who care for them, and the general public.
CMS has established a multi-step approach to enforcement for non-compliance with the hospital and CAH reporting requirements implemented in the IFC. CMS wrote that hospitals or CAHs that fail to report the specified data elements on a daily basis, with certain exceptions, will receive a notification from CMS of their noncompliance with the reporting requirements and any further noncompliance with reporting requirements may result in future enforcement actions. CMS also wrote that compliance with these reporting requirements will be determined independently from health and safety surveys for all other CoPs performed by state survey agencies or accreditation organizations processes under 42 CFR Part 488.
WHA was made aware that last Wednesday, Oct. 7, 2020, CMS emailed several documents, including the first enforcement letter, to the last known hospital “Administrator” contact. WHA sent a communication to all hospital CEOs, compliance officers and quality mangers to ensure that the information was received and, if not, to provide background on the latest interim rule regarding data reporting and forthcoming penalties for non-compliance. In addition, the email announced a DHS webinar that was intended to provide information on the reporting requirements. The link to the webinar recording is here. (No password needed).
Please contact Jennifer Mueller, Vice President WHA Information Center, for more information.