CMS: Recent Standards Changes for Deemed Status Hospitals

C Recent Standards

MChanges for Deemed

S Status Hospitals

n 2014 The Joint Commission moved through the final phases of securing another six years of hospital deeming

authority with the US Centers for Medicare & Medicaid Services (CMS). Deeming authority is a status conferred by CMS on an organization whose standards and survey process are determined to meet or exceed those of CMS Conditions of Participation or other federal laws, such as

the Clinical Laboratory Improvement Amendments of 1988 (CLIA ’88).

The Joint Commission has realigned its standards for hospitals that use Joint Commission accreditation for deemed status purposes and critical access hospitals with

rehabilitation and psychiatric distinct part units with CMS

requirements and revisions to how CMS interprets certain requirements. To help keep track of all the changes from the past year, the following table lists all of the deemed status– related revised requirements and their effective dates.

Abbreviations included in the chart below are defined as follows:

DS: For hospitals that use Joint Commission accreditation for deemed status purposes
PSY: For psychiatric hospitals that provide longer term care (more than 30 days)
SB: For hospitals that use Joint Commission accreditation for deemed status purposes and have swing beds used for long term care

Standard Number	Setting	Revised Language	Effective Date
EC.02.02.01, New EP 18	DS	Radiation workers are checked periodically, by the use of exposure meters or badge tests, for the amount of radiation exposure.	July 2, 2014
EC.02.02.01, New EP 19	DS	The hospital has procedures for the proper routine storage and prompt disposal of trash.	July 2, 2014
EC.02.04.01, EP 2	DS	The hospital maintains a written inventory of all medical equipment.	July 2, 2014
EC.02.04.03, EP 1	DS	Before initial use and after major repairs or upgrades of medical equipment on the medical equipment inventory, the hospital performs safety, operational, and functional checks.	July 2, 2014
EC.02.05.01, EP 2	DS	The hospital maintains a written inventory of all operating components of utility systems.	July 2, 2014
EC.02.05.01, New EP 5	DS	The hospital’s activities and frequencies for inspecting, testing, and maintaining the following items must be in accordance with manufacturers’ recommendations: Equipment subject to federal or state law or Medicare Conditions of Participation in which inspecting, testing, and maintaining be in accordance with the manufacturers’ recommendations, or otherwise establishes more stringent maintenance requirements New operating components with insuffi maintenance history to support the use of alternative maintenance strategies Note: Maintenance history includes any of the following documented evidence: Records provided by the hospital’s contractors Information made public by nationally recognized sources Records of the hospital’s experience over time	July 2, 2014
EC.02.05.01, New EP 6	DS	A qualifi individual(s) uses written criteria to support the determination whether it is safe to permit operating components of utility systems to be maintained in an alternate manner that includes the following: How the equipment is used, including the seriousness and prevalence of harm during normal use Likely consequences of equipment failure or malfunction, including seriousness of and prevalence of harm Availability of alternative or back-up equipment in the event the equipment fails or malfunctions Incident history of identical or similar equipment Maintenance requirements of the equipment	July 2, 2014
EC.02.05.01, New EP 7	DS	The hospital identifi operating components of utility systems on its inventory that is included in an alternative equipment maintenance program.	July 2, 2014

Standard Number	Setting	Revised Language	Effective Date
EC.02.05.05, EP 1	DS	The hospital tests utility system components on the inventory before initial use and after major repairs or upgrades. The completion date of the tests is documented.	July 2, 2014
HR.01.01.01, New EP 2	DS	The hospital has a qualifi dietician on a full-time, part-time, or consultative basis.	July 2, 2014
HR.01.02.05, New EP 17	SB	A qualifi social worker is an individual who has a bachelor’s degree in social work or a bachelor’s degree in a human services fi including but not limited to sociology, special education, rehabilitation counseling, or psychology and has one year of supervised social work experience in a health care setting working directly with individuals.	September 29, 2014
LD.01.03.01, New EP 21	DS	The governing body is responsible for making sure that performance improvement activities refl the complexity of the hospital’s organization and services, involve all departments and services, and include services provided under contract.	July 2, 2014
LD.04.02.03, New EP 13	SB	Each resident who is entitled to Medicaid benefi is informed in writing, either at the time of admission or when the resident becomes eligible for Medicaid, of the following: The items and services included in the state plan for which the resident may not be charged Those items and services that the facility offers and for which the resident may be charged, and the amount of charges for those services	September 29, 2014
LD.04.02.03, New EP 14	SB	Residents are informed when changes are made to the services that are specifi in LD.04.02.03, EP 13.	September 29, 2014
LD.04.02.03, New EP 15	SB	When a resident becomes eligible for Medicaid after admission to the hospital, the hospital charges the resident only the Medicaid-allowable charge.	September 29, 2014
LD.04.02.03, New EP 16	SB	Residents are informed before or at the time of admission, and periodically during the resident’s stay, of services available in the facility and of charges for those services not covered under Medicare or by the facility’s per diem rate.	September 29, 2014
MM.01.01.03, EP 5	DS	The hospital reports abuses and losses of controlled substances, in accordance with law and regulation, to the individual responsible for the pharmacy department or service and, as appropriate, to the chief executive. Note: This element of performance is also applicable to sample medications.	July 2, 2014
MM.03.01.01, EP 19	DS	The hospital has a pharmacy directed by a registered pharmacist or a supervised drug storage area, in accordance with law and regulation. Note: This element of performance is also applicable to sample medications.	July 2, 2014
MM.04.01.01, EP 15	DS	Processes for the use of pre-printed and electronic standing orders, order sets, and protocols for medication orders include the following: Review and approval of standing orders and protocols by the medical staff and the hospital’s nursing and pharmacy leadership Evaluation of established standing orders and protocols for consistency with nationally recognized and evidence-based guidelines Regular review of such standing orders and protocols by the medical staff and the hospital’s nursing and pharmacy leadership to determine the continuing usefulness and safety of the standing orders and protocols Dating, timing, and authenticating of standing orders and protocols by the ordering practitioner or another practitioner responsible for the patient’s care in accordance with professional standards of practice; law and regulation; hospital policies; and medical staff bylaws, rules, and regulations.	September 1, 2014
MS.01.01.01, New EP 37	DS	When a multihospital system has a unifi and integrated medical staff, the bylaws describe the process by which medical staff members at each separately accredited hospital (that is, all medical staff members who hold privileges to practice at that specifi hospital) are advised of their right to opt out of the unifi and integrated medical staff structure after a majority vote by the members to maintain a separate and distinct medical staff for their respective hospital.	September 29, 2014
New Standard MS.01.01.05	DS	Multihospital systems can choose to establish a unifi and integrated medical staff in accordance with state and local laws.	September 29, 2014
MS.01.01.05, New EP 1	DS	If a multihospital system with separately accredited hospitals chooses to establish a unifi and integrated medical staff, each separately accredited hospital within a multihospital system that elects to have a unifi and integrated medical staff demonstrates that the medical staff members of each hospital (that is, all medical staff members who hold privileges to practice at that specifi hospital) have voted by majority either to accept the unifi and integrated medical staff structure or to opt out of such a structure and maintain a separate and distinct medical staff for their hospital.	September 29, 2014
MS.01.01.05, New EP 2	DS	The unifi and integrated medical staff takes into account each member hospital’s unique circumstances and any signifi differences in patient populations and services offered in each hospital.	September 29, 2014

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Standard Number	Setting	Revised Language	Effective Date
MS.01.01.05, New EP 3	DS	The unifi and integrated medical staff establishes and implements policies and procedures to make certain that the needs and concerns expressed by members of the medical staff at each of its separately accredited hospitals, regardless of practice or location, are given due consideration.	September 29, 2014
MS.01.01.05, New EP 4	DS	The unifi and integrated medical staff has mechanisms in place to make certain that issues localized to particular hospitals within the system are duly considered and addressed.	September 29, 2014
MS.03.01.03, New EP 13	DS	Patients are admitted to the hospital only on the decision of a licensed practitioner permitted by the state to admit patients to a hospital.	July 2, 2014
MS.06.01.05, New EP 15	DS	The surgical service maintains a current roster listing each practitioner’s surgical privileges. Note: The roster may be in paper or electronic format.	July 2, 2014
NR.02.03.01, New EP 8	DS	A registered nurse assigns the nursing care for each patient to other nursing personnel in accordance with the patient’s needs and the qualifi and competence of the nursing staff available.	July 2, 2014
PC.01.02.09, New EP 8	SB	The hospital reports to the state nurse aide registry or licensing authorities any knowledge it has of any actions taken by a court of law against an employee that would indicate unfi for service as a nurse aide or other facility staff.	September 29, 2014
PC.02.01.01, New EP 5	DS	A registered nurse supervises and evaluates the nursing care for each patient.	July 2, 2014
PC.02.01.03, EP 1	DS	Prior to providing care, treatment, and services, the hospital obtains or renews orders (verbal or written) from a licensed independent practitioner or other practitioner in accordance with professional standards of practice; law and regulation; hospital policies; and medical staff bylaws, rules, and regulations. Note: Outpatient services may be ordered by a practitioner not appointed to the medical staff as long as he or she meets the following: Responsible for the care of the patient Licensed in the state where he or she provides care to the patient Acting within his or her scope of practice under state law Authorized in accordance with state law and policies adopted by the medical staff and approved by the governing body to order the applicable outpatient services Footnote: For law and regulation guidance pertaining to those responsible for the care of the patient, refer to 42 CFR 482.12(c).	September 29, 2014

PC.02.02.01, New EP 8	SB	The hospital provides activity services directly or through referral for ambulatory and nonambulatory residents at various functional levels.	September 29, 2014
PC.02.02.01, New EP 9	SB	The hospital provides services (directly or through referral) to facilitate family support, social work, nursing care, dental care, rehabilitation, primary physician care, or discharge.	September 29, 2014
PC.02.02.01, New EP 12	SB	The hospital provides 24-hour emergency dental services directly or through arrangement with an external provider.	September 29, 2014
New Standard PC.02.02.09	SB	Residents participate in social and recreational activities according to their abilities and interests.	September 29, 2014
PC.02.02.09, New EP 1	SB	The hospital offers residents a variety of social and recreational activities according to their abilities and interests.	September 29, 2014
PC.02.02.09, New EP 3	SB	The hospital helps residents to participate in social and recreational activities according to their abilities and interests.	September 29, 2014
PC.03.01.01, EP 10	DS	In accordance with the hospital’s policy and state scope-of-practice laws, anesthesia is administered only by the following individuals: An anesthesiologist A doctor of medicine or osteopathy other than an anesthesiologist A doctor of dental surgery or dental medicine A doctor of podiatric medicine A certifi registered nurse anesthetist (CRNA) supervised by the operating practitioner except as provided in 42 CFR 482.52(c) regarding the state exemption for this supervision An anesthesiologist’s assistant supervised by an anesthesiologist who is immediately available if needed A supervised trainee in an approved educational program Note 1: In accordance with 42 CFR 413.85(e), an approved nursing and allied health education program is a planned program of study that is licensed by state law or, if licensing is not required, is accredited by a recognized national professional organization. Such national accrediting bodies include, but are not limited to, the Commission on Accreditation of Allied Health Education Programs and the National League of Nursing Accrediting Commission. Note 2: “Anesthesiologist assistant” is defi in 42 CFR 410.69(b).	July 2, 2014

Standard Number	Setting	Revised Language	Effective Date
PC.04.01.01, EP 23	DS	When the discharge planning evaluation indicates a need for home health care, the hospital includes in the discharge plan a list of participating Medicare home health agencies (which have requested to be on the list) that are available and serve the patient’s geographic area. For patients enrolled in managed care organizations, the hospital lists home health agencies that have a contract with the managed care organization.	July 2, 2014
PC.04.01.03, New EP 5	SB	Except when specifi in the CoP from 42 CFR 483.12(a)(5)(ii), the written notice of transfer or discharge required under paragraph 42 CFR 483.12(a)(4) must be made by the hospital at least 30 days before the resident is transferred or discharged. Note: Notice may be made as soon as is practical before transfer or discharge when the safety of the individuals in the facility would be endangered; the health of the individuals in the facility would be endangered; the resident’s health improves suffi to allow a more immediate transfer or discharge, and immediate transfer or discharge is required by the resident’s urgent medical needs; or a resident has not resided in the facility for 30 days.	September 29, 2014
PC.04.01.03, New EP 6	SB	The written notice before transfer or discharge specifi in the CoP from 42 CFR 483.12(a)(4) includes the following: The reason for transfer or discharge The effective date of transfer or discharge The location to which the resident is transferred or discharged A statement that the resident has the right to appeal the action to the state The name, address, and telephone number of the state’s long term care ombudsman For a resident who is developmentally disabled, the mailing address and telephone number of the agency responsible for the protection and advocacy, established under Part C of the Developmental Disabilities Assistance and Bill of Rights Act For a resident who is mentally ill, the mailing address and telephone number of the agency responsible for the protection and advocacy, established under the Protection and Advocacy for Mentally Ill Individuals Act	September 29, 2014
New Standard PC.04.01.07	SB	Residents are not transferred or discharged from the hospital unless they meet specifi criteria, in accordance with law and regulation.	September 29, 2014
PC.04.01.07, New EP 1	SB	The hospital transfers or discharges residents only when at least one of the following conditions is met: The resident’s health has improved to the point where he or she no longer needs the hospital’s services. The transfer or discharge is necessary for the resident’s benefi or if the hospital cannot meet the The health or safety of the resident is endangered by remaining in the hospital. The hospital has provided the resident, who has not paid for his or her stay, with reasonable notice of The hospital ceases operation. The resident leaves against medical advice and signs a form stating that his or her action runs contrary to medical advice. resident’s needs. transfer or discharge, as defi by the hospital and in accordance with law and regulation.	September 29, 2014
RC.02.04.01, EP 1	SB	Documentation in the medical record includes discharge information provided to the resident and/or to the receiving organization.	September 29, 2014
RC.02.04.01, EP 2	SB	The resident’s discharge information includes the following: The reason for transfer, discharge, or referral Treatment provided, diet, medication orders, and orders for the resident’s immediate care Referrals provided to the resident, the referring licensed independent practitioner’s name, and the name of the licensed independent practitioner who has agreed to be responsible for the resident’s medical care and treatment, if this person is someone other than the referring licensed independent practitioner Medical fi and diagnoses; a summary of the care, treatment, and services provided; and progress Information about the resident’s behavior, ambulation, nutrition, physical status, psychosocial status, and potential for rehabilitation Nursing information that is useful in the resident’s care Any advance directives Instructions given to the resident before discharge reached toward goals	September 29, 2014
RI.01.06.05, EP 8	SB	The hospital provides accommodations for residents with signifi others living in the same facility when both individuals consent to the arrangement.	September 29, 2014
RI.01.06.05, EP 14	SB	The resident has the right to have access to stationery, postage, and writing implements at the resident’s own expense.	September 29, 2014
New Standard RI.01.06.09	SB	The resident has the right to choose his or her medical, dental, and other licensed independent practitioner care providers.	September 29, 2014

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Standard Number	Setting	Revised Language	Effective Date
RI.01.06.09, New EP 1	SB	The hospital supports the resident’s right to choose an attending physician, dentist, and other licensed independent practitioner.	September 29, 2014
RI.01.06.09, New EP 2	SB	The hospital supports the resident’s right to request a different licensed independent practitioner upon admission and throughout the course of care.	September 29, 2014
RI.01.06.09, New EP 3	SB	The hospital makes reasonable attempts to respond to requests from residents to choose a different licensed independent practitioner upon admission and throughout the course of care.	September 29, 2014
New Standard RI.01.06.11	SB	The resident has the right to communicate with his or her medical, dental, and other licensed independent practitioner care providers.	September 29, 2014
RI.01.06.11, New EP 3	SB	The hospital helps the resident make and keep appointments with medical, dental, and other licensed independent practitioners.	September 29, 2014
New Standard RI.01.07.05	SB	The resident has the right to receive and restrict visitors.	September 29, 2014
RI.01.07.05, New EP 1	SB	The hospital establishes liberal visiting hours that are limited only by the resident’s personal preferences.	September 29, 2014
RI.01.07.05, New EP 3	SB	The hospital provides space for the resident to receive visitors in comfort and privacy.	September 29, 2014
RI.01.07.05, New EP 5	SB	The hospital supports the resident’s right to choose with whom he or she communicates.	September 29, 2014
RI.01.07.05, New EP 6	SB	The hospital complies with law and regulation regarding individuals who are exempted from visiting hour restrictions in order to gain immediate access to the resident.	September 29, 2014
Standard RI.01.07.07	PSY/ SB	The hospital protects the rights of patients and residents who work for or on behalf of the hospital.	September 29, 2014
RI.01.07.07, EP 1	PSY/ SB	The hospital has a written policy that addresses situations in which patients and residents work for or on behalf of the hospital.	September 29, 2014
RI.01.07.07, EP 2	PSY/ SB	The hospital implements its policy regarding patients and residents who work for or on behalf of the hospital.	September 29, 2014
RI.01.07.07, EP 3	PSY/ SB	Wages paid to patients and residents who work for or on behalf of the hospital are in accordance with law and regulation.	September 29, 2014
RI.01.07.07, EP 4	PSY/ SB	The hospital incorporates work performed by the patient or resident for or on behalf of the hospital into the plan of care.	September 29, 2014
RI.01.07.07, EP 5	PSY/ SB	Patients and residents have the right to refuse to work for or on behalf of the hospital.	September 29, 2014
New Standard RI.01.07.13	SB	The resident has the right to transportation services, as appropriate to his or her care or service plan.	September 29, 2014
RI.01.07.13, New EP 1	SB	The hospital arranges transportation for the resident to and from physician or dentist appointments and other activities identified in the resident’s care or service plan.	September 29, 2014