CMS, FEMA Temporarily Relieve Quality Report Requirements in Hurricane-Battered Are of Some Quality Reporting Requirements

Struggling to meet the quality reporting deadlines? Impacted by the recent hurricanes? You may be getting a bit of a break!

First, I want to acknowledge the incredible challenges you continue to face, and the recent hurricanes that have made difficult situations even harder. We see you. Whether you were in the path of the hurricane or are struggling to find IV fluids because of it, we understand your challenges and will continue to bring you information to support your success.

If the recent IV fluid shortage has you losing sleep, you may find my September OSM article “Your Blueprint for Supply Chain Preparedness” helpful. Unfortunately, a supply chain disruption was not a lucky guess, and the crystal ball I ordered years ago is yet to arrive. But this isn’t the first hit to our industry, and it won’t be the last.

Hurricanes Helene and Milton are the most recent natural disasters that are impacting your facilities either directly or indirectly. It is understood that those facilities directly impacted by the hurricanes may be dealing with many challenges and their focus right now is on survival, recovery and rebuilding while trying to resume some sense of operations.

If your facility fits that description, the Centers for Medicare & Medicaid Services (CMS) has a process to assist your providers and facilities while you focus resources toward caring for your patients by temporarily alleviating some of your quality reporting requirements.

CMS has granted exceptions to certain quality reporting requirements for those areas affected by these hurricanes. The affected areas covered by these exceptions are in areas of North Carolina, South Carolina, Georgia, Tennessee and Florida, which are detailed on these Disaster Areas: Disaster 4827, Disaster 4828, Disaster 4829, Disaster 4830, Disaster 4832, Disaster 4834. If the Federal Emergency Management Agency (FEMA) expands the emergency disaster declaration to include additional affected areas later, CMS will extend the reporting requirement exceptions to accommodate those areas.

What does this mean for you? If your facility is in the designated affected areas, you will receive automatic exceptions to some CMS program reporting requirements for specific reporting deadlines. An Extraordinary Circumstance Exception (ECE) does not need to be requested. The quality measures included in this exemption are:

ASCQR:

• COVID-19 Vaccination Coverage Among Healthcare Personnel Q2 2024, deadline 11/15/2024.

Hospital Outpatient Quality Reporting Program (OQR):

• Patient-level, chart-abstracted clinical data Q2 2024, deadline 11/1/2024.
• COVID-19 HCP Q2 2024, deadline 11/15/2024.

That means the quality measures listed are not required to be reported for that period. Any measures not included are still required to be reported as well as future reporting dates of the measures in this exception.

For you high performers who want to report the data anyway, there are a few things to consider. Any reporting on the measures included in the exemption list is considered voluntary, and although the data might not reflect your best performance, it will be publicly reported. It is always important to review your quality outcome measures but, at least for now, you can take a deep breath and focus on overcoming the challenges posed by the hurricanes.

If you need more information on quality reporting requirements, AORN’s ASC Academy: A Guide to Quality & Risk Management offers the education and customizable templated tools you need to make reporting a breeze. OSM