Category Archives: Facility Administration

9/15+ WA CoN Listening Sessions

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The Washington State Department of Health will hold Listening Sessions to collect information about any changes that stakeholders want to Certificate of Need rules, to be held on September 15, October 12, and November 7, 2022, and January 10, 2023. For more information, click on “Kidney Dialysis Need Forecasting Methodology and Standards” at https://doh.wa.gov/licenses-permits-and-certificates/facilities-z/certificate-need/rule-making-activities. Register for the September 15 session at https://us02web.zoom.us/webinar/register/WN_PoX97gk4Rr-aRphWgWzEtg. Links to future sessions will be posted at the doh website above.

9/8+ EQRS Town Hall, New User Training, Newsletter

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EQRS will hold a September 8, 2022 Town Hall webinar featuring EQRS Data Submission Deadlines, New EQRS Features including Vaccination Module, Admission in Support of Transplant feature, Parathyroid Hormone Reporting Fields, and EQRS FAQs. Register at https://mycrownweb.org/pcw_community_events/september-2022-town-hall-2/.

The September EQRS New User Training will be held on September 20, 2022. For more information and registration see https://mycrownweb.org/2022/09/nut-september-2022-announce/.

The September issue of the EQRS Quarterly Newsletter is also available, at https://mycrownweb.org/2022/09/september-2022-newsletter/. It includes notes on the CY2023 ESRD QIP, and all of the usual news on EQRS operations.

9/2+ CMS Email Down

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CMS email is transitioning from HHS to CMS itself over the holiday weekend, and the process will take several days. All CMS email accounts will close down late on Friday September 2, 2022, until early on Tuesday, September 6. Any email sent to CMS accounts will receive a notice saying that the address does not exist. Please hold all emails for CMS until Tuesday. There is a notice but no details at https://www.medicaid.gov/.

8/28+ WA Only: FAQ re End of COVID CofN Waivers

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Certificates of Need and Construction Reviews for ESRD facilities in Washington State were waived to allow a faster response to the COVID-19 pandemic. On August 1, 2022, Washington DOH announced that those waivers would end, and provided a timeline for that process, as described at https://nwrnbulletins.wordpress.com/2022/08/03/8-4-wa-only-covid-cofn-waivers-to-end/. Washington DOH has added a web page of Frequently Asked Questions about the process, at https://doh.wa.gov/sites/default/files/2022-08/FAQ-COVID-19WaiverOffboarding.pdf. The timeline includes August 28 deadlines.

8/4+ WA only COVID CofN Waivers to End

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Urgent information about COVID waivers: Early in the COVID-19 pandemic, Governor Inslee issued Proclamation 20-36 which waived certain certificate of need (CN), construction review (CR), and facility licensing requirements to allow health care facilities to rapidly adapt and expand to meet the demands for surge capacity. The Governor has announced his intent to rescind Proclamation 20-36 on October 27, 2022. Facilities that utilized the waivers to address surge must either revert their operations or take immediate action to move toward compliance by October 27, 2022. WA DOH will provide health care facilities a glide path to come into compliance, but you must act quickly to submit letters of intent and applications as described below. If your health care facility took advantage of the waivers in Proclamation 20-36 and you plan to maintain these changes beyond October 27, 2022, you must comply with state law applicable to your license type. This could include obtaining a certificate of need, obtaining construction review approval, and/or updating your license.

For those facilities requiring a Certificate of Need:

  1. By August 28, 2022, facilities must submit a Letter of Intent to WA DOH conforming to WAC 246-310-080. Letters of Intent must describe the increase in capacity and/or new locations the facility wants to maintain and be accompanied by a patient transition plan should DOH not approve the application. Send the Letter of Intent to COVIDwaiver@doh.wa.gov.  
  2. By October 27, 2022, facilities must submit a CN application and the appropriate fee to WA DOH following existing CN application processes and requirements. Facilities must also submit applications to modify their facility license within this same timeframe, as appropriate. If your CN application is denied, you must execute your patient transition plan and revert your operations to your previously approved CN.
  3. Exception: Health care facility types on a concurrent review cycle for CN applications (including ESRD facilities) will be required to submit a second Letter of Intent, CN application, and appropriate fee in compliance with WA DOH’s published schedule the next time the application cycle opens. Facilities must also submit applications to modify their facility license within this same timeframe, as appropriate. If your CN application is denied, you must execute your patient transition plan and revert your operations to your previously approved CN.

For those facilities requiring Construction Review:

  1. By August 28, 2022, facilities must submit a construction review application to COVIDwaiver@doh.wa.gov and appropriate fee. Applications must include a clear description of the scope of work (physical changes, additions, renovations) made to the facility.
  2. By October 27, 2022, facilities must submit formal engineering plans, functional programs, and associated documentation needed to evaluate compliance with the state licensing rules OR submit a technical assistance application to WA DOH to confirm the scope of work and establish documentation requirements. Facilities must respond quickly and in good faith to correct non-compliant construction, eliminate hazards within the environment and complete the review project.
  3. By January 25, 2023, and every 90 days after that until the project is fully approved, submit to WA DOH quarterly progress reports that address project status, updates since the last report, and planned completion date.

Following the process above will not adversely affect a facility’s CN, CR, or license application. Failure to follow the steps outlined above will be considered non-compliance and the department may take appropriate enforcement action. If you have any questions about what actions you should take now, technical assistance is available at COVIDwaiver@doh.wa.gov.

Informational Webinars: WA DOH will also host webinars about the glide path described above on the following dates:

8/8+ New EQRS Vaccination Tab and Module

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Beginning approximately August 8, 2022, EQRS users will be required to enter any new vaccination data for Hepatitis B, Influenza, and Pneumococcal vaccinations on the Manage Patient screen under the new Vaccinations tab in EQRS, shown at right.

During the new Vaccination Module rollout, the most recent vaccination records for patients will be migrated from the Manage Clinical screen and will be visible on the new screens. On approximately October 1, 2022, the vaccination fields will no longer appear on the Manage Clinical screen.

Additionally, this new EQRS reporting process for vaccinations is an event-based reporting process. This means that EQRS users must submit vaccination data when a vaccination event occurs. A vaccination event occurs when a patient:

  • Receives a vaccine dose administered by the reporting facility.
  • Receives a vaccine dose by an outside provider with documentation.
  • Receives a vaccine dose which is self-reported with or without documentation.
  • Does not receive a vaccine dose offered by the reporting facility.

In addition to reporting vaccination information when a vaccination event occurs, facilities must also review patient vaccination history and enter any confirmed vaccination information into EQRS upon each patient admission to the facility. Facilities have until approximately October 1, 2022 to fully transition their Hepatitis B, Influenza and Pneumococcal vaccination reporting process in EQRS to the new Vaccinations Module (shown below) that is located under the Vaccinations tab on the Manage Patient screen.

For more information about the new EQRS reporting process for vaccinations, please refer to the EQRS Vaccination Data Submission Requirements and Frequently Asked Questions resource at https://mycrownweb.org/wp-content/uploads/2022/07/EQRS-Vaccination-Data-Submission-Requirements-and-Frequently-Asked-Questions-FAQ_vFINAL508.pdf.

If you are having technical issues with the EQRS user interface, contact the Center for Clinical Standards and Quality (CCSQ) Service Center, Monday-Friday 5am-5pm Pacific Time, at 866-288-8912, qnetsupport-esrd@cms.hhs.gov, or https://cmsqualitysupport.servicenowservices.com/ccsq_support_central. For general EQRS questions and questions about the ESRD QIP, please use the QualityNet Q&A Tool at https://cmsqualitysupport.servicenowservices.com/qnet_qa.

The notice from EQRS does not mention COVID-19 vaccinations, which are usually considered separately from Influenza vaccinations.

8/5+ EQRS Maintenance, Update, Training

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EQRS will be down for maintenance from late Friday night till early Monday morning, August 5-8, 2022. For full details, see https://mycrownweb.org/2022/07/eqrs-alert-eqrs-clinical-data-submission-downtime/. June 2022 EQRS Clinical Data submissions are due by August 31, 2022.

EQRS has also added new admission and discharge reasons for temporary dialysis ancillary to transplant operations. See https://mycrownweb.org/2022/07/eqrs-news-flash-new-eqrs-feature-release-admission-in-support-of-transplant/ for details.

The August New User Training for EQRS will be held August 16, 2022; for full details see https://mycrownweb.org/2022/07/nut-august-2022-announce/.

8/22 Comments Due on CY2023 and PY2024-26 QIP

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CMS has published a Proposed Rule with changes to the CY2023 ESRD QIP. Your comments are due by August 22, 2022. The Proposed Rule includes:

  • Updated payment rates and policies for CY2023 including the outlier threshold, the Bundled market basket, labor-related share, wage index, and facility-level adjustments.
  • Updated AKI payment rates for CY2023.
  • Updated QIP Requirements, Measures, and Baseline for CY2023 including COVID-related adjustments.
  • Requests for Information on QIP Measures including new and oral drugs, health equity, pediatric payment rates, home dialysis, Disparities, Social Drivers of Health.
  • Adjustments to PY2024 Measures.
  • Adjustments to PY2025-26 Measures.
  • Refinements to the ESRD Treatment Choices Model.

Find:

6/21+ EQRS New Users, Town Hall, News

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EQRS will present a 90-minute June 21, 2022 New User Training. For details and registration, see https://mycrownweb.org/pcw_lems/june-2022-new-user-training/.

EQRS will also present a June 23, 2022 Town Hall event. For more information and registration, see https://globalmeetwebinar.webcasts.com/starthere.jsp?ei=1551952&tp_key=16ff240327.

The June EQRS Newsletter is available at https://mycrownweb.org/wp-content/uploads/2022/05/June-2022-Newsletter_FINAL508.pdf. This issue includes articles on

  • General EQRS Data Submission schedules,
  • The June 23, 2022 EQRS Town Hall agenda,
  • The April 27, 2022 Care Compare Dialysis Data Release,
  • The Extraordinary Circumstances Exception (ECE) Submission Process,
  • The QIP UFR Reporting Measure,
  • A Chat Box question on Ultrafiltration,
  • Instructions on How to Route Questions to EQRS, and
  • June 30, 2022 through February 28, 2023 EQRS Data Submission Deadlines.