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Clarification: 1135 waivers, temporary suspension of rules during a disaster

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February 9, 2020

by Brian Ward

Joint Commission (TJC)–accredited hospitals and critical access hospitals must have a process in their policies for requesting an 1135 waiver from CMS, which is issued during a disaster or emergency when conditions necessitate modifying or temporarily lifting CMS requirements.

 TJC’s recent clarification was to Emergency Management (EM) Standard EM.02.01.01, element of performance (EP) 14. The accreditor explained that surveyors don’t expect to review an actual 1135 waiver during survey; however, they will want to review your 1135 waiver request process and confirm that leadership is knowledgeable about the requirements.

Joint Commission–accredited hospitals and critical access hospitals must have a process in their policies for requesting an 1135 waiver from CMS, which is issued during a disaster or emergency when conditions necessitate modifying or temporarily lifting CMS requirements.



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