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June 27, 2016

Bureau of Facility Standards
INFORMATIONAL LETTERS INDEX FOR HOSPITALS

IL#:                Issue Date:      Title:
1986-03        07/03/86         Use of RN’s and PA’s in Emergency Rooms

1989-04        04/25/89         Continuous Cardiac Monitoring

1992-12        09/28/92         TB Skin Testing (IDAPA 16.03.14200,03.B.II)

1994-06        07/18/94         Revised Interpretive Guidelines for Condition of Participation: Infection Control

1997-01        03/06/97         Clarification Regarding Providers that Expand Service Area Provider-Based Designation Discharge Planning Interpretive Guidelines

1998-16       12/28/98          Reporting of Abuse, Neglect, or Exploitation Idaho Code, Section 39-5303

2001-02       01/26/01          Appendix Q:  Guidelines for Determining Immediate Jeopardy

2001-03       02/02/01          Waiver Revocation

2001-11       10/31/01          Transfilling of Small Portable Liquid Oxygen Units

2002-04       03/11/02          Effective Date of Medicare Approval of the American Osteopathic Association Deeming Authority for Critical Access Hospital (CAHs)

2002-06       03/11/02         Clarification of Hospital Admission and Pre-surgical History and Physical Examination Requirements

2002-07       04/01/02         Certified Nurse Aide (CNA) Registry and Nurse Aide Training and Competency Evaluation Program (NATCEPT) Address and Phone Number Update

2002-20      12/16/02         Critical Access Hospital (CAH) Regulations

2004-01      02/02/04         Survey and Certification Branch, State Agency Letter No. 759 dated December 17, 2003

                                                 2004-01 Attachment

2004-06      03/30/04         Procedures in the Event of a Fire in a Medicare- or Medicaid-Certified Health Care Facility 

                                        2004-06 Attachment                             

2004-07      06/22/04        Tentative Interim Amendment (TIA) Alcohol-based Hand Sanitizers; Chapters 18 and 19, Life Safety Code, 2000 and 2003 Editions

2004-13      12/03/04        State Operations Manual – Appendix V – Interpretive Guidelines – Responsibilities of Medicare Participating Hospitals in Emergency Cases (EMTALA)                     

2004-14      12/03/04       CMS Requirements for Hospital Medical Staff Privileging

                                      2004-14 Attachment

2004-16      12/03/04       Clarification of Survey Agency Responsibilities in Obtaining Information for Civil Rights Clearances for Initial Certifications and Changes of Ownership (CHOW)

                                      2004-16 Attachment                                        

2005-03      05/02/05       Idaho Food Code

2005-13      12/20/05       Location and Relocation of Critical Access Hospitals (CAHs) and Relocation of Necessary Provider CAHs

2007-05      04/25/07       Clarification of Provider Name Nomenclature CMS S&C-07-16 dated March 2, 2007

2007-09      10/01/07       CMS S&C-08-03 dated November 5, 2007 Initial Surveys for New Medicare Providers

                                     2007-09 Attachment

2010-03      05/25/10      S&C-10-18-LSC Revision of S&C-04-41 dated August 12, 2004, Corridor Width & Corridor Mounted Computer Touch Screens in Health Care Facilities – Clarification Effective Immediately

                                    2010-03 Attachment

2010-04      06/23/10      Idaho Diet Manual, 10th Edition

2011-02     06/30/11      Updated NFPA Alert Regarding Antifreeze – Important Safety Information Regarding Antifreeze in New and Existing Sprinkler Systems

2012-05     12/18/12      CMS S&C-12-35 dated June 15, 2012 ~ Safe Use of Single Dose/Single Use Medications to
Prevent Healthcare- Associated Infections

                                     2012-05 Attachment

2013-03     05/24/13     S&C-13-32 Revision to State Operations Manual (SOM), Hospital Appendix A - Interpretive Guidelines for 42 CFR 482.43, Discharge Planning

2013-06     12/18/13     S&C-14-06-Hospitals Emergency Medical Treatment and Labor Act (EMTALA) Requirements & Conflicting Payor Requirements or Collection Practices

2014-06     05/23/14     S&C-14-31-EHR Navigator for Hospital/CAH Surveys

2014-07     06/03/14     S&C-14-26-Long Term Care Hospitals (LTCH) Moratorium Preliminary Instructions

2014-09     06/03/14     S&C-14-27 Restraint/Seclusion Deaths Reported Using the Centers for Medicare and Medicaid Services (CMS) Form (CMS)-10455, Report of a Hospital Death Associated with Restraint or Seclusion

2014-11     07/02/14     S&C-14-36 Dated May 30, 2014 ~ Infection Control Breaches Which Warrant Referral to Public Health Authorities

2014-13     08/29/14     S&C-14-44 Dated August 29, 2014 ~ Change in Terminology and Update of Survey and Certification (S&C Memorandum 09-55 Regarding Immediate Use Steam Sterilization (ISUS) in Surgical Settings

2014-14     08/29/14     S&C-14-41 Dated August 8, 2014 ~ Critical Access Hospital (CAH) Equipment Maintenance Requirements

2014-15     12/04/14     S&C: 15-12 ~ Public Release of Three Hospital Surveyor Worksheets

CMS S&C 15-12 Letter

Attachment 1: Infection Control Worksheet

Attachment 2: Hospital QAPI Worksheet

Attachment 3: Hospital Discharge Planning Worksheet

2015-02     01/15/15     S&C-15-13 Dated December 14, 2014 ~ Clarification of Terms Implicating the Spousal Relationship in Regulations and Guidance for Medicare-Certified Providers and Suppliers

2015-04     01/22/15     S&C-15-19 ~ Revised State Operations Manual (SOM) Appendix W, Critical Access Hospitals

2015-06     02/17/15     S&C-15-24 ~ Emergency Medical Treatment and Labor Act (EMTALA) and Ebola Virus Disease (EVD) – Questions and Answers (Q+A)

2015-07     02/23/15     S&C-15-27 ~ Potential Adverse Impact of Lower Relative Humidity (RH) in Operating Rooms (ORs)

2015-09     03/20/15     2015 Idaho Diet Manual, 11th Edition

2015-16     10/30/15     Revised Hospital Guidance for Pharmaceutical Services and Expanded Guidance Related to Compounding of Medications

2016-01      03/04/16     New Non-Long Term Care Supervisor

2016-02   03/18/16    Sharing Tags At Exit Conferences S&C 16-11

2016-04   03-24-16    S&C 16-08-CAH ~ Critical Access Hospital Recertification Checklist for Evaluation of Compliance with 

2016-05      05/05/16     CMS S&C 16-21: Justice Involved Individuals

2016-07   05/11/16    CMS S&C 16-22-LSC: Adoption of 2012 LSC Standards