CMS Revises Appendix A and Appendix W in State Operations Manual: Here’s What You Need to Know

Key Revisions to CMS’ State Operations Manual Include Changes to Discharge Planning, Infection Control, Emergency Preparedness, and Swing Bed

On September 30, 2019, Centers for Medicare and Medicaid Services (CMS) published final rules that revised regulatory requirements for various providers, including hospitals and critical access hospitals (CAH). The majority of new or revised regulations became effective on November 29, 2019.

According to CMS, the final rules reform Medicare regulations that were “unnecessary, obsolete, or excessively burdensome on health care providers and suppliers.”

The final rules published in the Federal Register included:

  1. Medicare and Medicaid Programs; Regulatory Provisions to Promote Program Efficiency, Transparency, and Burden Reduction (CMS 3346-F)
  2. Medicare and Medicaid Programs; Revisions to Requirements for Discharge Planning for Hospitals, Critical Access Hospitals, and Home Health Agencies (CMS 3317-F)

On February 21, 2020, CMS published updates to State Operations Manuals including Appendix A for Hospitals and Appendix W for Critical Access Hospitals. The most notable updates include changes to discharge planning, infection control, and emergency preparedness, as well as a handful of important changes for swing beds.

“Many hospitals had many of the new regulations in place prior to the change in the CoPs, and most hospitals will need only minor modifications in practice,” said Carolyn St.Charles, RN, BSN, MBA, Chief Clinical Officer for HealthTechS3. “However, the biggest change in practice will probably be those regulations related to discharge planning.”

Here are some of the appendices’ key revisions:

Discharge Planning

Discharge planning regulations now require hospitals to provide and discuss publicly available data on quality and resource use measures with patients as part of their decision-making processes for post-acute care (PAC). This requirement includes providing information when patients are discharged from acute care and admitted to a swing bed.

“This can be a challenge for CAHs, since there is no publicly available data specific for swing beds,” said St.Charles. “I recommend providing patients with data for the CAH, such as MBQIP if it’s available, as well as other data, such as length of stay, readmission rate, discharge disposition, et cetera.”

St.Charles also cautioned that some hospitals who routinely refer patients to a CAH swing bed may not be including the CAH as a PAC provider since they don’t have quality and resource use data.  She recommends contacting referral sources to make sure the CAH’s swing bed is still included as a PAC provider.

The new Conditions of Participation (CoPs) also require that hospitals assess their discharge planning process on a regular basis. This review requires an ongoing, periodic review of a representative sample of discharge plans, including for patients who were readmitted within 30 days of a previous admission.

Infection Control

While there are quite a few new infection control standards in the appendices, one important change is the requirement to develop and implement a facility-wide antibiotic stewardship program.

“Although most hospitals and CAHs already have an antibiotic stewardship program in place, the regulations have specific requirements that must be met,” said St.Charles. “The goal of antibiotic stewardship is to improve patient outcomes, reduce microbial resistance, and decrease the spread of infections caused by multidrug-resistant organisms.”

The regulations regarding antibiotic stewardship had an implementation date of March 30, 2020.

Emergency Preparedness

The regulations also changed some of the requirements for emergency preparedness. Hospitals and CAHs now only have to complete a biennial review of their program, rather than an annual review.  Training requirements also changed from annually to biennially, and testing the emergency preparedness plan gives facilities more flexibility in the type and frequency of drills.

Swing Beds

There were several changes for CAHs with swing beds, including the elimination of a requirement to provide a formal activities program. However, CMS still requires, “care that holistically meets the needs of the patient, taking into consideration physiological and psychosocial factors.”

Critical Access Hospitals

A big change for CAHs is that review and approval of policies and procedures are now only required biennially instead of annually. Starting in March of 2021, the CAH periodic evaluation and report will also only be required biennially. The change to a biennial evaluation and report coincides with the requirement for CAHs to develop and implement a Quality Assurance and Performance Improvement (QAPI) program.

Final Thoughts & Additional Resources

Despite the CMS’ recently published updates, there may still be some hindrances to implementation in hospitals and CAHs.  

“Unfortunately, although the new regulations are included in both Appendix A and Appendix W revisions, the interpretative guidelines, which provide guidance on how to implement the new standards, were not included,” said St.Charles. “According to CMS, these will be published at a later date.”

If you are interested in a mock survey for your hospital, CAH, or swing bed, contact Carolyn St.Charles at

Join our webinar, Appendix A and Appendix W Revised by CMS: A Road Trip Through the New Standards and Interpretive Guidelines, on April 17 where HealthTechS3’s Chief Clinical Officer, Carolyn St.Charles, RN, BSN, MBA walks hospitals and CAHs through the key CMS revisions, as well as discusses useful tips and strategies for meeting the new CoPs.