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Team Newsletter

May 2022

Kelly’s Quality Corner                                 

CMS Waiver Termination QSO Highlights [QSO 22-15-NH

Per CMS, the waivers listed below have been identified as those requirements that should be restored to address the risks to resident health and safety that are not related to infection control. Furthermore, CMS believes that at this time, our facilities should be able to adjust their operations to meet these regulatory requirements, while also addressing any issues related to COVID-19. CMS notes that states and individual facilities are still able to request regulatory waivers for issues unique to their facility or location provide flexibility. See below to learn how the termination of specific waivers affects your facility.


Quality Assurance and Performance Improvement (QAPI) (effective 5-7-2022) Facilities are to develop, implement, evaluate, and maintain an effective, comprehensive, data-driven QAPI program. The scope of the QAPI program may no longer be narrowed to focus on adverse events and infection control as it has been throughout the PHE.


Physical Environment (effective 6-6-2022) Spaces or rooms not licensed for resident rooms may no longer be utilized as such (i.e., offline rooms, unlicensed rooms). Facilities are to have an outside window or outside door in every sleeping room.

Equipment Maintenance (effective 6-6-2022) Facilities and their equipment are to be maintained to ensure an acceptable level of safety and quality. CMS is no longer permitting facilities to adjust scheduled inspection, testing and maintenance (ITM) frequencies and activities for facility and medical equipment.

LSC & HCFC (effective 6-6-2022) Facilities to be in compliance with the Life Safety Code (LSC) and Health Care Facilities Code (HCFC). CMS is no longer permitting facilities to adjust scheduled ITM frequencies and activities required by the LSC and HCFC.

Fire Drills (effective 6-6-2022) The quarterly fire drill requirement is reinstated. The drills will instruct employees, including existing, new or temporary employees, on their current duties, life safety procedures and the fire protection devices in their assigned area.

Temporary Construction (effective 6-6-2022) Temporary walls and barriers between residents are no longer permitted.


Resident Groups (effective 5-7-2022) Facilities may no longer restrict residents from participating in-person in resident groups.

Physician Visits (effective 5-7-2022) Regulatory physician visits must once again be performed in-person by a physician.

Physician Delegation of Tasks (effective 5-7-2022) The physician is once again prevented from delegating a task when the regulations specify that the physician must perform it personally.

Detailed Information Sharing for Discharge Planning (effective 5-7-2022) Facilities are required to assist residents and their representatives in selecting a post-acute care provider using data, such as standardized patient assessment data, quality measures and resource use [expedited discharge process no longer permitted].


Training and Certification of Nurse Aides (effective 6-6-2022) A facility may not employ anyone for longer than four months unless they have met the training and certification requirements. This includes our temporary nurse aides (Resident Care Assistants, RCAs). RCAs must be certified by 10/6/22 (4 months post the termination of the waiver).

In-Service Training (effective 6-6-2022) Nursing assistants are to receive at least 12 hours of in-service training annually.

Paid Feeding Assistants (effective 6-6-2022) This training to be a minimum of 8 hours and contain infection control training and other elements.


Clinical Records (effective 5-7-2022) Facilities are required to provide a resident with a copy of their records within two working days when requested by the resident (no longer have a 10-day grace).


Kelly Dines
Vice President of Clinical Operations