CMS published a new guidance memo discussing co-located hospitals. The memo, QSO 19-13 dated May 3, 2019 is in draft form and the comment period to CMS is open until July 2, 2019. This draft is especially important for two types of organizations:
- An LTACH inside a full-service acute care hospital.
- A co-located outpatient service with a unique CCN number situated in the same building as the hospital.
If you have such arrangements, share this memo with the other entity. And, discuss potential implications for your arrangement together.
One point of emphasis for CMS is that co-located hospitals should have their own designated clinical space for patient care. It is permissible to share public space as public paths of travel to the designated space. But, CMS states that certain paths are not acceptable. For example, travel through a clinical hospital department such as a nursing unit, a clinic, imaging, operating room, PACU, or ED. CMS indicates that their surveyors will ask to see floor plans. And, these plans should distinguish the functional space of each entity. So, if there is any shared space, and the CMS surveyors identify standards deficiencies in that space, they can score it against both entities.
Conversely, it remains acceptable for the smaller guest entity to obtain some services from the host hospital. For example, contracts for laboratory, dietary, pharmacy, maintenance, housekeeping, and security are permissible. But, the guest entity is responsible to evaluate the quality of those services through its own QAPI program.
Also, CMS advises it surveyors that they are responsible to survey any onsite contracted services. But, they are not responsible for offsite services. And, if CMS identifies deficiencies, they can score against both entities. Furthermore, if CMS finds flaws in the contracted service, the guest entity will receive an additional deficiency scored against their governing body. CMS advises its surveyors to call the state agency or regional office to open a complaint against the host hospital. Similarly, CMS advises accrediting organizations (AO) to treat such deficiencies as “complaints” and manage using the AO complaint process.
Staff members shared by both entities can add an extra layer of management complexity. CMS does permits staff sharing with limitations. Consider this scenario:
An individual works for both the host and guest hospitals. Their schedule assigns them to work for the host hospital on a specific day and time. They cannot “float” back and forth from the host hospital to the guest hospital to handle assignments and patients during that assigned time.
But, CMS identifies a different approach for the medical staff. If credentialed and privileged by each entity, they may float back and forth at both co-located hospitals. We are curious to see if this policy remains the same after the comment period. Historically, physicians have been non-salaried, independent practitioners with privileges, not staff of the hospital. More recently, besides having privileges, physicians are often employees of the hospital.
Lastly, the draft memo touches on emergency services. CMS requires every hospital to provide emergency services. But, an emergency room isn’t required in each co-located hospital. At a minimum, CMS advises the smaller guest hospital to have policies and procedures for identifying when a patient is in distress. The staff should know how to:
- Start an emergency response
- Start an emergency treatment including CPR and AED
- Transfer a patient to another facility to receive appropriate treatment
According to this memo, transferring a patient from the smaller guest hospital to the host hospital is permissible. But, the guest hospital must initiate the emergency treatment described above.
If you are a guest or host hospital, the time is now to review and analyze this guidance. In fact, take the opportunity to review and comment if you foresee any difficulties with compliance.
Patton Healthcare Consulting
Patton Healthcare Consulting provides CMS Survey Support for co-located hospitals and a full range of pre-survey and post survey services.