CMS Releases New S&C Memos

Nancy Leveille and Karen Morris in Clinical & Quality

AHCA received two Survey & Certification memos from CMS today.  The first memo relates to changes to state survey agency responsibilities in obtaining information for Civil Rights clearances for initial certifications and changes of ownership (CHOSWs). Key provisions of this memo:

  • Office for Civil Rights Clearance Process – A health care provider that applies for participation in the Medicare Part A program must receive a civil rights clearance from OCR, as set forth in 42 CFR 480.10(b).
  • Initial Enrollment or CHOW - State Survey Agencies (SAs) are to include the OCR Civil Rights Certification Information Request Packet (Civil Rights Packet) with their initial enrollment package that is sent to a potential provider or to a provider undergoing a CHOW. 
  • Civil Rights Packet may be submitted on line - SAs must now also offer the potential provider the option to answer all questions and submit the entire civil rights clearance package on line at
  • Online Application Submission Start Date - This change will be effective July 15, 2013

The second memo relates to compliance with the Life Safety Code in End Stage Renal Dialysis facilities and includes a sample attestation letter.  Key provisions of the memo:

  • Limited LSC Applicability to ESRD Facilities:  Effective July 16, 2012, compliance by certified ESRD facilities with the applicable requirements of the 2000 edition of the National Fire Protection Association (NFPA) Life Safety Code 101 is limited to those ESRD facilities that are located adjacent to high hazardous occupancies and those facilities that do not exit to the outside at grade level from the patient treatment area.
  • Retained Compliance by ESRD Facilities:  All ESRD facilities are still required to comply with State and local fire codes and other safety standards required by 42 CFR Part 494 Conditions for Coverage (CfC) for ESRD facilities.
  • Attestation by ESRD Facilities for Exemption:  ESRD providers may submit an attestation to claim an exemption to the NFPA LSC requirements if they are not located adjacent to high hazard occupancies and they do provide exits at grade level from the patient treatment area level.
  • Effective Immediately.



Nancy Leveille, RN, MS
Sr. Director, Member Operational Support
518-462-4800 x20
  Karen Morris, RN, MS
Director, Clinical & Quality Services
518-462-4800 x15