COVID-19 Frequently Asked Questions

The Front Line of COVID-19

Updated 03/19/2020

Our clinical consultants are fielding new questions every day as hospitals across the nation respond to the COVID-19 pandemic. We have compiled our responses to the most commonly asked questions from the front line of healthcare, and will keep this information up to date as the situation progresses.

Additionally, we continue to perform on-site visits, mock surveys and provide interim staffing solutions to support our clients with their urgent and emerging needs. Our experts are also equipped to work and support remotely.

If you need our assistance or support, please contact us at 513.241.0142, or

Q: Can hospitals restrict patient visitors?

Medicare regulations require a hospital to have written policies and procedures regarding the visitation rights of patients, including those setting forth any clinically necessary or reasonable restriction or limitation that the hospital may need to place on such rights and the reasons for the clinical restriction or limitation. CMS sub-regulatory guidance identifies infection control concern as an example of when clinical restrictions may be warranted. Patients must be informed of his/her visitation rights and the clinical restrictions or limitations on visitation. The development of such policies and procedures require hospitals to focus efforts on preventing and controlling infections, not just between patients and personnel, but also between individuals across the entire hospital setting (for example, among patients, staff, and visitors) as well as between the hospital and other healthcare institutions, and settings and between patients and the healthcare environment. Hospitals should work with their local, State, and Federal public health agencies to develop appropriate preparedness and response strategies for communicable disease threats.

Q: We have activated our incident command center and need to temporarily shore up and support our clinical and non-clinical leadership team to sustain effective operations. Is this something you can help us with?

Yes, TiER1 Healthcare is able to provide interim leaders to support your operation. Call us at 513.241.0142 to discuss.


Q: When I was reviewing the EM Plan it was noted to “see a separate policy for influx of infectious patients.” How specific should I be? I have been asked to keep it as generic as possible, to remain responsive to the variability of each situation. Do you have any guidance for me?

You are correct in keeping the document somewhat generic, or you will be writing separate plans for specific outbreaks. Make sure to update your IC Risk Assessment/Plan as appropriate.

TJC Standard/EP: IC.01.06.01 EP4 The hospital describes, in writing, how it will respond to an influx of potentially infectious patients. (See also EM.01.01.01, EP 2)

Download this Influx of Infectious Disease Patients Policy.

Q: How will the recent bulletins and communications from CMS impact the fact that we are in our TJC window?

The Joint Commission would communicate any changes to those that they accredit via direct email and on their website if there were changes to the schedule due to COVID-19. If CMS showed up at an organization prior to their TJC survey, that may change the schedule somewhat. Organizations may contact their account manager at TJC for confirmation.

Q: Is it an automatic survey or a survey if there are complaints regarding infection prevention practices?

Surveys will be conducted according to the following regime:

  • All immediate jeopardy complaints (a situation in which entity noncompliance has placed the health and safety of recipients in its care at risk for serious injury, serious harm, serious impairment or death or harm) and allegations of abuse and neglect
  • Complaints alleging infection control concerns, including facilities with potential COVID-19 or other respiratory illnesses
  • Statutorily required re-certification surveys (Nursing Home, Home Health, Hospice, and ICF/IID facilities)
  • Any re-visits necessary to resolve current enforcement actions
  • Initial certifications
  • Surveys of facilities/hospitals that have a history of infection control deficiencies at the immediate jeopardy level in the last three years
  • Surveys of facilities/hospitals/dialysis centers that have a history of infection control deficiencies at lower levels than immediate jeopardy

With that said, it would make sense to be prepared, regardless if the above information applies directly to your organization or not, if you have been in the news for having COVID-19 patient(s). We recommend that you have implemented your Emergency Operations Plan that includes the Infection Prevention and Control section related to the Influx of Patients. PPE use, standard and transmission-based precautions (contact, and airborne) are implemented as appropriate. A screening tool/Travel Screen in-use at all points of entry is in place. Communications hospital-wide with updates, dispelling rumors/myths. Staying on top of CDC updates, changes, recommendations.

Please remember, that prior to COVID-19, CMS could still show-up at any time, based on very similar reasons that were stated in the CMS letter.

Resources and Guidance

CMS and other Federal agencies have been very busy responding to the COVID-19 situation. We wanted to draw your attention to additional resources that have just come out this week. Share these resources with appropriate staff as you plan out your responses.

Guidance to Hospitals re: Covid19 and EMTALA

Guidance to Hospice Agencies re: Covid19

Press Release Regarding Emergency Use of NIOSH Approved Respirators

Guidance to All Healthcare Provider Types re: NIOSH Approved Respirators Not Marketed for Healthcare

Guidance to Home Health Agencies re: Covid19

Guidance to ESRD Facilities re: Covid19

Telehealth Billing Press Release

CMS Press Release on FAQs

CMS Current Emergencies Website with Links to All Pertinent Covid19 Documents


Changes relative to our industry’s preparation for COVID-19 and the Federal/CMS response

Regarding Federal 1135 waivers there was significant action taken on Friday, March 13 with the declaration of the national emergency. You may be interested in the potential of applying for an 1135 waiver, but there were also several blanket waivers approved by CMS that may obviate your need to do an individual waiver. Below are additional links to the CMS website that contain the press release, technical information, and the list of blanket waivers.

Need Immediate Assistance?

TiER1 Healthcare is still providing on-site services for clients with urgent needs. We are also equipped to serve you remotely and are ready to help. Our team can also help you close any leadership gaps during this high-pressure time by placing quality interim leaders within your organization. Contact us at 513-241-0142, or


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