Hospital Survey Activity

 

To: Hospitals   From: CDPHE   Pursuant to guidance from CMS and the current capacity issues hospitals are facing in relation to capacity issues and the need to transfer patients to other hospitals (including rural hospitals), Health Facilities and Emergency Medical Services Division (HFEMSD) will delay entry into hospitals for lower prioritized complaints and for routine survey activity.   CMS identified two criteria that had to be met in order for CDPHE to halt hospital survey activity with the exception of potential immediate jeopardy complaints and revisit surveys. This criteria includes: COVID-19 ICU utilization higher than 35% AND ICU capacity higher than 80% based on hospital data submitted to HHS Protect.   Colorado as a state, currently meets this criteria according to current HHS data. CDPHE will continue to monitor the data and notify hospitals when the criteria is no longer met and routine hospital survey activities will began for the entire State.   CMS also identified a method to halt standard survey activity for individual hospitals experiencing capacity issues.   These individual hospitals may request CDPHE suspends standard survey activities, with the exception of potential immediate jeopardy complaints and revisit surveys based on the following criteria:   Notification/request for assistance from the appropriate State Public Health agency. The first priority for the hospital should be ensuring they have the resources available to manage the surge and coordinating with the appropriate state public health authorities for awareness and assistance; The proportion of hospital staff and resources dedicated to management of COVID-19 patients. Activation of the hospital’s emergency preparedness plan.   Individual hospitals who meet the criteria should send an email attesting the hospital meets the above criteria to Erica Brudjar (erica.brudjar@state.co.us) as soon as possible. CDPHE will then coordinate with CMS to consider a short-term, hospital-specific survey suspension. These requests will not stop the following survey actions:   Immediate jeopardy complaints. Revisit surveys Investigations that have already begun.   CDPHE is committed to a robust healthcare system and will take the steps necessary to protect patients and ensure access for all Coloradans.