36524 Federal Register / Vol. 79, No. 124 / Friday, June 27, 2014 / Notices 

complete on May 2, 2014. Under 

Section 1865(a)(2) of the Act and our 

regulations at § 488.8 (Federal review of 

accrediting organizations), our review 

and evaluation of the Joint Commission 

will be conducted in accordance with, 

but not necessarily limited to, the 

following factors: 

• The equivalency of the Joint 

Commission’s standards for ASCs as 

compared with our ASC CfCs. 

• The Joint Commission’s survey 

process to determine the following: 

++ The composition of the survey 

team, surveyor qualifications, and the 

ability of the organization to provide 

continuing surveyor training. 

++ The comparability of the Joint 

Commission’s processes to those of 

State agencies, including survey 

frequency, and the ability to investigate 

and respond appropriately to 

complaints against accredited facilities. 

++ The Joint Commission’s processes 

and procedures for monitoring an ASC 

found out of compliance with the Joint 

Commission’s program requirements. 

These monitoring procedures are used 

only when the Joint Commission 

identifies noncompliance. If 

noncompliance is identified through 

validation reviews or complaint 

surveys, the State survey agency 

monitors corrections as specified at 

§ 488.7(d). 

++ The Joint Commission’s capacity 

to report deficiencies to the surveyed 

facilities and respond to the facility’s 

plan of correction in a timely manner. 

++ The Joint Commission’s capacity 

to provide CMS with electronic data and 

reports necessary for effective validation 

and assessment of the organization’s 

survey process. 

++ The adequacy of the Joint 

Commission’s staff and other resources, 

and its financial viability. 

++ The Joint Commission’s capacity 

to adequately fund required surveys. 

++ The Joint Commission’s policies 

with respect to whether surveys are 

announced or unannounced, to assure 

that surveys are unannounced. 

++ The Joint Commission’s 

agreement to provide CMS with a copy 

of the most current accreditation survey 

together with any other information 

related to the survey that we may 

require (including corrective action 

plans). 

IV. Collection of Information 

Requirements 

This document does not impose 

information collection requirements, 

that is, no reporting, recordkeeping or 

third-party disclosure requirements. 

Consequently, it need not be reviewed 

by the Office of Management and 

Budget under the authority of the 

Paperwork Reduction Act of 1995 (44 

U.S.C. 35). 

V. Response to Public Comments 

Because of the large number of public 

comments we normally receive on 

Federal Register documents, we are not 

able to acknowledge or respond to them 

individually. We will consider all 

comments we receive by the date and 

time specified in the DATES section of 

this preamble, and, when we proceed 

with a subsequent document, we will 

respond to the comments in the 

preamble to that document. 

Upon completion of our evaluation, 

including evaluation of comments 

received as a result of this notice, we 

will publish a final notice in the Federal 

Register announcing the result of our 

evaluation. 

Dated: June 18, 2014. 

Marilyn Tavenner, 

Administrator, Centers for Medicare & 

Medicaid Services. 

[FR Doc. 2014–15101 Filed 6–26–14; 8:45 am] 

BILLING CODE P 

DEPARTMENT OF HEALTH AND 

HUMAN SERVICES 

Centers for Medicare & Medicaid 

Services 

[CMS–3290–FN] 

Medicare and Medicaid Programs; 

Continued Approval of The Joint 

Commission’s (TJC’s) Hospital 

Accreditation Program 

AGENCY: Centers for Medicare and 

Medicaid Services, HHS. 

ACTION: Final notice. 

SUMMARY: This final notice announces 

our decision to approve The Joint 

Commission (TJC) for continued 

recognition as a national accrediting 

organization for hospitals that wish to 

participate in the Medicare or Medicaid 

programs. A hospital that participates in 

Medicaid must also meet the Medicare 

conditions of participation (CoPs) as 

required under section 1905(a) of the 

Social Security Act (‘‘Act’’) and 42 CFR 

482.1(a)(5). This approval is effective 

July 15, 2014 through July 15, 2020. 

DATES: This final notice is effective July 

15, 2014 through July 15, 2020. 

FOR FURTHER INFORMATION CONTACT: 

Monda Shaver (410) 786–3410, Cindy 

Melanson, (410) 786–0310, or Patricia 

Chmielewski, (410) 786–6899. 

SUPPLEMENTARY INFORMATION: 

I. Background 

A healthcare provider may enter into 

an agreement with Medicare to 

participate in the program as a hospital 

provided certain requirements are met. 

Section 1861(e) of the Social Security 

Act (the Act) establishes criteria for 

providers seeking participation as a 

hospital. Regulations concerning 

Medicare provider agreements in 

general are at 42 CFR part 489 and those 

pertaining to the survey and 

certification for Medicare participation 

of providers and certain types of 

suppliers are at part 488. The 

regulations at part 482 specify the 

specific conditions that a provider must 

meet to participate in the Medicare 

program as a hospital. 

Generally, to enter into a Medicare 

hospital provider agreement, a facility 

must first be certified as complying with 

the conditions set forth in part 482 and 

recommended to us for participation by 

a state survey agency. Thereafter, the 

hospital is subject to periodic surveys 

by a state survey agency to determine 

whether it continues to meet these 

conditions. However, there is an 

alternative to certification surveys by 

state agencies. Accreditation by a 

nationally recognized Medicare 

accreditation program approved by us 

may substitute for both initial and 

ongoing state review. 

Section 1865(a)(1) of the Act provides 

that, if the Secretary finds that 

accreditation of a provider entity by an 

approved national accrediting 

organization meets or exceeds all 

applicable Medicare conditions, we may 

treat the provider entity as having met 

those conditions, that is, we may 

‘‘deem’’ the provider entity to be in 

compliance. Accreditation by an 

accrediting organization is voluntary 

and is not required for Medicare 

participation. 

Part 488, subpart A, implements the 

provisions of section 1865 and requires 

that a national accrediting organization 

applying for approval of its Medicare 

accreditation program must provide us 

with reasonable assurance that the 

accrediting organization requires its 

accredited provider entities to meet 

requirements that are at least as 

stringent as the Medicare conditions. 

Our regulations concerning the approval 

of accrediting organizations are set forth 

at § 488.4 and § 488.8(d)(3). The 

regulations at § 488.8(d)(3) require an 

accrediting organization to reapply for 

continued approval of its Medicare 

accreditation program every 6 years or 

sooner as determined by us. TJC’s 

current term of approval as a recognized 


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Medicare accreditation program for 

hospitals expires July 15, 2014. 

II. Application Approval Process 

Section 1865(a)(3)(A) of the Act 

provides a statutory timetable to ensure 

that our review of applications for CMSapproval of an accreditation program is 

conducted in a timely manner. The Act 

provides us 210 days after the date of 

receipt of a complete application, with 

any documentation necessary to make 

the determination, to complete our 

survey activities and application 

process. Within 60 days after receiving 

a complete application, we must 

publish a notice in the Federal Register 

that identifies the national accrediting 

body making the request, describes the 

request, and provides no less than a 30- 

day public comment period. At the end 

of the 210-day period, we must publish 

a notice in the Federal Register 

approving or denying the application. 

III. Provisions of the Proposed Notice 

In the January 29, 2014 Federal 

Register (79 FR 4727), we published a 

proposed notice announcing TJC’s 

request for continued approval of its 

Medicare hospital accreditation 

program. In the January 29, 2014 

proposed notice, we detailed our 

evaluation criteria. Under section 

1865(a)(2) of the Act and in our 

regulations at § 488.4 and § 488.8, we 

conducted a review of TJC’s Medicare 

hospital accreditation application in 

accordance with the criteria specified by 

our regulations, which include, but are 

not limited to the following: 

• An onsite administrative review of 

TJC’s: (1) Corporate policies; (2) 

financial and human resources available 

to accomplish the proposed surveys; (3) 

procedures for training, monitoring, and 

evaluation of its hospital surveyors; (4) 

ability to investigate and respond 

appropriately to complaints against 

accredited hospitals; and, (5) survey 

review and decision-making process for 

accreditation. 

• The comparison of TJC’s Medicare 

accreditation program standards to our 

current Medicare hospital CoPs. 

• A documentation review of TJC’s 

survey process to determine the 

following: 

++ Determine the composition of the 

survey team, surveyor qualifications, 

and TJC’s ability to provide continuing 

surveyor training. 

++ Compare TJC’s processes to those 

we require of state survey agencies, 

including periodic resurvey and the 

ability to investigate and respond 

appropriately to complaints against 

accredited hospitals. 

++ Evaluate TJC’s procedures for 

monitoring hospitals it has found to be 

out of compliance with TJC’s program 

requirements. (This pertains only to 

monitoring procedures when TJC 

identifies non-compliance. If 

noncompliance is identified by a state 

survey agency through a validation 

survey, the state survey agency monitors 

corrections as specified at § 488.7(d).) 

++ Assess TJC’s ability to report 

deficiencies to the surveyed hospitals 

and respond to the hospital’s plan of 

correction in a timely manner. 

++ Establish TJC’s ability to provide 

us with electronic data and reports 

necessary for effective validation and 

assessment of the organization’s survey 

process. 

++ Determine the adequacy of TJC’s 

staff and other resources. 

++ Confirm TJC’s ability to provide 

adequate funding for performing 

required surveys. 

++ Confirm TJC’s policies with 

respect to surveys being unannounced. 

++ Obtain TJC’s agreement to provide 

us with a copy of the most current 

accreditation survey together with any 

other information related to the survey 

as we may require, including corrective 

action plans. 

In accordance with section 

1865(a)(3)(A) of the Act, the January 29, 

2014 proposed notice also solicited 

public comments regarding whether 

TJC’s requirements met or exceeded the 

Medicare CoPs for hospitals. We 

received two unrelated comments in 

response to our proposed notice. 

IV. Provisions of the Final Notice 

A. Differences Between TJC’s Standards 

and Requirements for Accreditation and 

Medicare Conditions and Survey 

Requirements 

We compared TJC’s hospital 

accreditation requirements and survey 

process with the Medicare CoPs of 42 

CFR Part 482, and the survey and 

certification process requirements of 

Parts 488 and 489. Our review and 

evaluation of TJC’s hospital application, 

which were conducted as described in 

section III of this final notice, yielded 

the following areas where, as of the date 

of this notice, TJC is in the process of 

or has completed revising its standards 

and certification processes in order to 

meet the requirements at: 

• § 482.12(a)(1), to address the 

hospital’s responsibility to determine 

which categories of practitioners are 

eligible candidates for appointment to 

the medical staff. 

• § 482.12(a)(2), to ensure 

recommendations of the existing 

members of the medical staff are 

considered by the governing body 

during the medical staff appointment 

process. 

• § 482.12(c)(2), to include the 

requirement that patients are admitted 

to the hospital only on the 

recommendation of a licensed 

practitioner. 

• § 482.13(a)(1), to ensure hospitals 

inform each patient or patient’s 

representative of the patient’s rights, in 

advance of furnishing or discontinuing 

patient care whenever possible. 

• § 482.13(b)(4), to address the 

patient’s right to have a family member 

or representative of his or her choice 

notified promptly of the patient’s 

admission to the hospital. 

• § 482.13(h) and § 482.13(h)(1), to 

include the provisions that require 

hospitals inform each patient of his or 

her visitation rights and address the 

requirement for hospitals to have 

written policies and procedures 

regarding the visitation rights of 

patients, including those setting forth 

any clinical restriction or limitation that 

the hospital may need to place on such 

rights and the reasons for the clinical 

restriction or limitation. 

• To meet the requirements at 

§ 482.13(h)(2), TJC revised its standards 

to include the requirement that the 

hospital must inform each patient of 

their right to receive designated visitors. 

• § 482.13(h)(4), to ensure all visitors 

enjoy full and equal visitation privileges 

consistent with patient preferences. 

• § 482.21, to address the hospital 

governing body’s responsibility for 

maintaining an ongoing quality 

assessment and performance 

improvement (QAPI) program that 

includes services provided under 

arrangement; maintenance and 

demonstration of evidence of its QAPI 

program for review by us; and that the 

QAPI program is developed and 

executed in a manner that reflects the 

complexity of the hospital scope and 

focus. 

• § 482.22(a), to indicate that the 

medical staff may also include other 

categories of non-physician 

practitioners as eligible for appointment 

by the governing body. 

• § 482.23(b)(3), to require that a 

registered nurse must supervise the 

nursing care of each patient. 

• § 482.23(b)(5), to ensure a registered 

nurse assigns the nursing care of each 

patient to other nursing personnel. 

• § 482.23(c)(6)(i)(A) and 

§ 482.23(c)(6)(ii)(A), to require a written 

order permitting patient selfadministration of hospital issued 

medications and the patient’s own 

medications brought to the hospital. 


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• § 482.23(c)(6)(ii)(B), to include a 

provision for assessing the patient’s 

capacity to self-administer medications 

and determining if the patient needs 

instruction in the safe and accurate 

administration of medications. 

• § 482.24(a), to ensure the 

organization of the medical record 

service is appropriate to the scope and 

complexity of the services performed. 

• § 482.24(b), related to the form and 

retention of the medical record. 

• § 482.24(b)(2), to include a 

provision that hospitals have a system 

that allows for timely retrieval by 

diagnosis and procedure, in order to 

support medical care evaluation and 

studies. 

• § 482.24(c)(2), to require all orders, 

including verbal orders, be dated, timed, 

and authenticated promptly by the 

ordering practitioner or another 

practitioner who is responsible for the 

care of the patient. 

• § 482.24(c)(4)(iv), to require 

documentation of complications, 

hospital-acquired infections, and 

unfavorable reactions to drugs and 

anesthesia. 

• § 482.25(a), to include the 

requirement that the pharmacy or drug 

storage area must be administered in 

accordance with accepted professional 

principles. 

• § 482.26, to include therapeutic 

radiologic services and the requirement 

that radiologic services must meet 

professionally approved standards for 

safety and personnel qualifications. 

• § 482.26(b)(3), to require radiation 

workers be checked periodically for 

amounts of radiation exposure. 

• § 482.27, to require that the hospital 

maintain, or have available, adequate 

laboratory services to meet the needs of 

its patients and that such services are 

performed in a facility certified in 

accordance with part 493 of this 

chapter. 

• § 482.28, to address the hospital’s 

responsibility to have a dietitian who 

serves the hospital on a full-time, parttime, or consultant basis either directly 

or through a contractual arrangement. 

• § 482.28(a)(1), to require that 

hospitals have a full-time employee 

responsible for the food and dietetic 

service. 

• § 482.41, to address the hospital’s 

responsibility to provide facilities for 

special services appropriate to the needs 

of the community. 

• § 482.41(a)(1), to address the 

requirement for emergency power and 

lighting in intensive care and emergency 

rooms. 

• § 482.41(b)(1)(i) and chapters 18/

19.7.1.2 and 18/19.7.1.3 of the Life 

Safety Code (LSC), to address various 

fire drill requirements that include 

transmission of a fire alarm signal, 

simulation of emergency fire conditions, 

varying conditions, and employees 

being instructed in life safety 

procedures and devices. 

• § 482.41(b)(2), to require 

submission of an equivalency or waiver 

request, including the supporting 

documentation along with TJC’s 

recommendation for approval, to the 

applicable CMS Regional Office for 

processing. 

• § 482.41(b)(6), to address the proper 

routine storage and prompt disposal of 

trash. 

• § 482.41(b)(7), to include the 

requirement that the fire control plan 

must contain provisions for the prompt 

reporting of fires. 

• § 482.43(c)(4), to address the 

hospital’s responsibility to reassess the 

patient’s discharge plan if there are 

factors that may affect continuing care 

needs or the appropriateness of the 

discharge plan. 

• § 482.43(c)(6), to include the 

requirement that a home health agency 

(HHA) must request to be included on 

the list of HHAs a hospital provides to 

patients as part of their discharge plan. 

• § 482.51(a)(4), to include a 

requirement for surgical services to 

maintain a roster of practitioners, 

specifying the surgical privileges of each 

practitioner. 

• § 482.51(b)(2), to include a 

requirement that a properly executed 

informed consent for an operation must 

be in the patient’s chart before surgery, 

except in emergencies. 

• § 482.52(a)(5), to include a 

requirement that the supervising 

anesthesiologist for an anesthesiologist’s 

assistant be immediately available if 

needed. 

• § 482.53(b)(3), to ensure laboratory 

tests performed in the nuclear medicine 

service meet the applicable requirement 

for laboratory services specified in 

§ 482.27. 

• § 482.53(d)(3), to require the 

hospital maintain records of the 

disposition of radiopharmaceuticals. 

• § 482.55, to require the hospital to 

meet the emergency needs of patients in 

accordance with acceptable standards of 

practice. 

• § 482.56(a)(2), to ensure physical 

therapy, occupational therapy, speechlanguage pathology, and audiology 

services are provided by qualified 

therapists, as defined in 42 CFR part 

484. 

• § 482.56(b)(2), to require the 

personnel qualifications of those 

providing care must be in accordance 

with nationally accepted standards of 

practice and meet the requirements at 

§ 409.17. 

• § 482.57(b)(2), to require blood 

gases or other laboratory tests performed 

in the respiratory care unit to meet the 

applicable requirements for laboratory 

services specified in § 482.27. 

• § 488.3(a), to ensure that all 

services, including physician and 

ambulatory care services, which are 

furnished under the hospital’s Medicare 

provider agreement are surveyed for 

compliance with TJC’s CMS-approved 

Medicare hospital accreditation 

program. 

• § 488.4(a)(4), to clarify the 

minimum composition of its survey 

team for its Medicare hospital 

accreditation program. 

• § 488.4(a)(4)(ii) through (v), to 

ensure compliance with its own policies 

that require evidence that its surveyors 

are appropriately qualified, trained, and 

evaluated. 

• § 488.4(a)(6), to ensure compliance 

with its own policies that require plan 

of correction requests to be timely, 

follow-up surveys for ITL situations to 

be conducted timely, and that findings 

are accurately reported to us via the 

ASSURE database system. 

• § 488.4(b)(3)(iii) and § 488.8(d), to 

ensure we are notified of any proposed 

changes in its CMS-approved Medicare 

hospital accreditation program prior to 

implementation of such changes within 

30 days, and to confirm that it will not 

implement changes we have 

disapproved or required to be modified. 

• § 488.8, to provide us with data that 

ensures the following information is 

accurately reported: The date of a 

complaint receipt; determination of 

complaints as substantiated or 

unsubstantiated; determinations of ITL 

situations; final accreditation decisions 

for surveys where no deficiencies are 

found; and surveyor documentation that 

includes a detailed deficiency statement 

that clearly supports the determination 

of manner and degree of noncompliance and the appropriate level of 

citation. 

• To ensure comparability with the 

survey process requirements at 

§ 488.26(d), TJC: 

++ Updated its accreditation process 

policies to clarify that all surveys for 

TJC’s Medicare hospital accreditation 

program are conducted unannounced. 

++ Updated its accreditation process 

policies to ensure all required follow-up 

surveys for its Medicare hospital 

accreditation program meet the 

Medicare requirements. 

++ Revised its accreditation process 

policies to clarify that the appropriate 

level of citation be made when an 


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Immediate Threat to Health or Safety 

(ITL) is identified. 

++ Clarified its survey policies in the 

surveyor activity guide (SAG) to address 

how ‘‘Special Issue Resolution’’ is 

handled during surveys lasting only one 

day. 

++ Updated its accreditation process 

policies to ensure its definition of a 

small hospital is consistent across its 

policies. 

• § 488.28(a), to include all 

documented observations of noncompliance and all internal, 

uncompleted Plans for Improvement 

(PFI) listed in the accredited hospital’s 

‘‘Statement of Condition (SOC) to 

correct Life Safety Code Deficiencies’’ 

into the survey report. 

• § 489.13, related to the effective 

date of accreditation for facilities 

undergoing a survey for purposes of its 

initial participation in Medicare to 

ensure the survey process and effective 

date of accreditation when deficiencies 

have been identified are consistent with 

the regulatory requirements. 

• Complied with section 1861(e)(9)(C) 

of the Act, to require that waiver and 

equivalency requests submitted by 

accredited organizations for Life Safety 

Code deficiencies that would result in 

unreasonable hardship for such a 

facility to resolve and would not 

jeopardize patient health or safety, be 

reviewed by TJC, and forwarded to us 

for approval, as appropriate. 

B. Term of Approval 

Based on our review and observations 

described in section III of this final 

notice, we approve TJC as a national 

accreditation organization for hospitals 

that request participation in the 

Medicare program, effective July 15, 

2014 through July 15, 2020. 

To verify TJC’s continued compliance 

with the provisions of this final notice, 

we will conduct a follow-up corporate 

on-site visit and survey observation 

within 18 months of the date of 

publication of this notice. 

V. Collection of Information 

Requirements 

This document does not impose 

information collection and 

recordkeeping requirements. 

Consequently, it need not be reviewed 

by the Office of Management and 

Budget under the authority of the 

Paperwork Reduction Act of 1995 (44 

U.S.C. 35). 

Dated: June 16, 2014. 

Marilyn Tavenner, 

Administrator, Centers for Medicare & 

Medicaid Services. 

[FR Doc. 2014–15103 Filed 6–26–14; 8:45 am] 

BILLING CODE 4120–01–P 

DEPARTMENT OF HEALTH AND 

HUMAN SERVICES 

Administration for Community Living 

Agency Information Collection 

Activities; Proposed Collection; 

Comment Request; Evidence-Based 

Falls Prevention Program Standardized 

Data Collection 

AGENCY: Administration on Aging 

(AoA), Administration for Community 

Living (ACL), HHS. 

ACTION: Notice. 

SUMMARY: The Administration for 

Community Living (ACL), 

Administration on Aging (AoA) is 

announcing an opportunity for public 

comment on the proposed collection of 

certain information. Under the 

Paperwork Reduction Act of 1995 (the 

PRA), Federal agencies are required to 

publish notice in the Federal Register 

concerning each proposed collection of 

information, including each proposed 

extension of an existing collection of 

information, and to allow 60 days for 

public comment in response to the 

notice. This notice solicits comments on 

the information collection requirements 

relating to the Evidence-Based Falls 

Prevention Program. 

DATES: Submit written or electronic 

comments on the collection of 

information by August 26, 2014. 

ADDRESSES: Submit electronic 

comments on the collection of 

information to: Michele.boutaugh@

acl.gov. Submit written comments on 

the collection of information to Michele 

Boutaugh, U.S. Administration on 

Aging, 61 Forsyth Street SW., Suite 

5M69, Atlanta, GA 30303–8909. 

FOR FURTHER INFORMATION CONTACT: 

Michele Boutaugh, 404–987–3411 or 

Michele.boutaugh@acl.gov. 

SUPPLEMENTARY INFORMATION: Under the 

PRA (44 U.S.C. 3501–3520), Federal 

agencies must obtain approval from the 

Office of Management and Budget 

(OMB) for each collection of 

information they conduct or sponsor. 

‘‘Collection of information’’ is defined 

in 44 U.S.C. 3502(3) and 5 CFR 

1320.3(c) and includes agency request 

or requirements that members of the 

public submit reports, keep records, or 

provide information to a third party. 

Section 3506(c)(2)(A) of the PRA (44 

U.S.C. 3506(c)(2)(A)) requires Federal 

agencies to provide a 60-day notice in 

the Federal Register concerning each 

proposed collection of information, 

including each proposed extension of an 

existing collection of information, 

before submitting the collection to OMB 

for approval. To comply with this 

requirement, ACL/AoA is publishing 

notice of the proposed collection of 

information set forth in this document. 

With respect to the following collection 

of information, ACL/AoA invites 

comments on: (1) Whether the proposed 

collection of information is necessary 

for the proper performance of ACL/

AoA’s functions, including whether the 

information will have practical utility; 

(2) the accuracy of ACL/AoA’s estimate 

of the burden of the proposed collection 

of information, including the validity of 

the methodology and assumptions used; 

(3) ways to enhance the quality, utility, 

and clarity of the information to be 

collected; and (4) ways to minimize the 

burden of the collection of information 

on respondents, including through the 

use of automated collection techniques 

when appropriate, and other forms of 

information technology. ACL/AoA 

proposes to use this set of data 

collection tools to monitor grantees 

receiving cooperative agreements in 

response to the funding opportunity: 

‘‘PPHF–2014—Evidence-Based Falls 

Prevention Programs Financed Solely by 

2014 Prevention and Public Health 

Funds (PPHF–2014).’’ The statutory 

authority for cooperative agreements 

under this program announcement is 

contained in Section 411 of the Older 

Americans Act of 1965, as amended, 

and the Patient Protection and 

Affordable Care Act (ACA), Section 

4002, 42 U.S.C. 300u–11 (Prevention 

and Public Health Fund). 

This data collection is necessary for 

monitoring program operations and 

outcomes. ACL/AoA proposes to use the 

following tools: (1) Semi-annual 

performance reports to monitor grantee 

progress; (2) a Host Organization Data 

form to record location of agencies 

which sponsor programs which will 

allow mapping of the delivery 

infrastructure; and (3) a set of tools used 

to collect information at each program 

completed by the program leaders 

(Program Information Cover Sheet and 

Attendance Log) and a Participant 

Information Form and Post Program 

Survey completed by each participant. 

The Participant Information Form 

documents participants’ demographic 

and health characteristics, including 

age, gender, race/ethnicity, types of 

chronic conditions, disability status, 

and education level. It also assesses 

some key outcome variables, which will 

be re-assessed in the Post Program 

survey, including falls self-efficacy, falls 

and injury rates, fear of falling, and 

interference with social activities. ACL/ 

AoA intends to use an online data entry 

system for the program and participant 

survey data. 


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