Crosswalk -1135 Web Portal (Health Care Facility portion)

Revisions to Form CMS-10752 Submissions of 1135 Web Portal (Health Care Facility (HCF) Operational Status Portion)
Issue
#
1.

Page #

Section

Action to be
performed
Revised as follows:

Changes to the Application

Reason for the Change

Removed: Public Health Emergency (PHE)dropdown
selection

The information collected from this form
(Health Care Facility Status) is used to
determine if a PHE exists therefore a
PHE won’t be identified yet.
We moved CMS Certification Number
(CCN) to this section because it will
auto-populate the blue shaded fields
(e.g., Organization Name, Organization
Category, Zip Code, City, State/US
Territory/Federal District and Number of
Beds) if a valid CCN is entered. This
will decrease the amount of information
that Health Care Facility (HCF) will
need to provide in the midst of an
Emergency/Disaster
Added checkbox to allow HCF to select
if their organization category is not
listed as a value in the dropdown box.

1

Section 1

2.

1

Section 2:
Facility
Information/Org
anization
Information

Revise as follows:

Changed order: Moved CMS Certification Number
(CCN) to the top of the section

3.

1

Revise as follows

Added: Checkbox for ‘Other’

4.

1

Section 2:
Facility
Information/Org
anization
Information
Section 2:
Facility
Information/Org
anization
Information

Revise as follows

Added: ‘Sufficient Staffing’ section

5.

1

Revise as follows:

Revised: Changed Census to a required field

6.

1

Section 2:
Facility
Information/Fac
ility Census
Information
Section 2:
Patient/ Facility
Census
Information

Revise as follows:

Added: Number of patients/residents evacuated to
‘Health Care Facilities (HCFs),’ to ‘Non- Health Care
Facilities (Non-HCFs)’ and with ‘Family Members’
sections

During emergencies and disasters,
patients/residents/clients in understaffed
Health Care Facilities (HCFs) are at risk
(e.g., increased rate of mortality, higher
risk of infection, etc.). As a result, a
‘Sufficient Staffing’ section was added
Based on recent discussions with Health
and Human Services (HHS), this was
changed to a required field because this
information was crucial during
emergencies and disasters
To reduce negative health impacts
during emergencies and disasters, high
quality evacuation locations are
necessary. To assess possible risks,
patient/resident evacuation status further

1

Issue
#

Page # Section

Action to be
performed

7.

1

Section 2:
Patient/ Facility
Census
Information

Revise as follows:

8.

1

Revise as follows

9.

1

Section 3:
Impact to
Facility/ Other
Impacts to
Facility
Section 3:
Impact to
Facility/ Details
of the Health
Care Facility
Status

Revise as follows:
To ‘Impact to Facility’
section from ‘Facility
Information’ section

Changes to the Application

Reason for the Change

drilled down to identify temporary
disposition location
Changed: Number of patients/residents evacuated field to The ‘Number of Patients/Residents
auto-calculate
Evacuated’ field auto-calculates based
on data entered in the Number of
patients/residents evacuated to ‘Health
Care Facilities (HCFs),’ to ‘Non- Health
Care Facilities (Non-HCFs)’ and with
‘Family Members’ sections
Added: ‘Supply/Equipment Concerns’ option to Other
Added ‘Supply/Equipment Concerns’
Impacts to Facility section
option because people with medical
needs have extra concerns during
emergencies and disasters.
Moved: Details of Health Care Facility (HCF) status to
this section and changed it to check boxes from a text
area

We moved the section to improve the
readability and flow of questions. In
addition, changed from a text area to
check boxes for ease of use during
emergencies and disasters

2