Source: https://www.federalregister.gov/documents/2013/07/26/2013-18014/medicare-and-medicaid-programs-initial-approval-of-center-for-improvement-in-healthcare-qualitys
Timestamp: 2017-08-22 10:02:41
Document Index: 158743422

Matched Legal Cases: ['art 488', '§\u2009488', '§\u2009488', '§\u2009488', '§\u2009488', '§\u2009488', '§\u2009488', '§\u2009482', '§\u2009482', '§\u2009482', '§\u2009489', '§\u2009489', '§\u2009489', '§\u2009482', '§\u2009482', '§\u2009482', '§\u2009482', '§\u2009482', '§\u2009482', '§\u2009482', '§\u2009482', '§\u2009482', '§\u2009482', '§\u2009482', '§\u2009482', '§\u2009482', '§\u2009482', '§\u2009482', '§\u2009482', '§\u2009482', '§\u2009482', '§\u2009482', '§\u2009482', '§\u2009482', '§\u2009482', '§\u2009482', '§\u2009482', '§\u2009482', '§\u2009482', '§\u2009482', '§\u2009482', '§\u2009482', '§\u2009482', 'art 484', '§\u2009498']

Federal Register :: Medicare and Medicaid Programs; Initial Approval of Center for Improvement in Healthcare Quality's (CIHQ's) Hospital Accreditation Program
This final notice is effective July 26, 2013 through July 26, 2017.
CMS-3280-FN
CMS-2013-0177
Medicaid Program; State Allotments for Payment of Medicare Part B Premiums for Qualifying Individuals (QIs): Federal Fiscal Years 2012 and 2013 (CMS-2387-N)
A. Differences Between CIHQ's Standards and Requirements for Accreditation and Medicare's Conditions and Survey Requirements
https://www.federalregister.gov/d/2013-18014 https://www.federalregister.gov/d/2013-18014
Cindy Melanson, (410) 786-0310. Monda Shaver, (410) 786-3410. Patricia Chmielewski, (410) 786-6899.
If an AO is recognized by the Secretary as having standards for accreditation that meet or exceed Medicare requirements, any provider entity accredited by the national accrediting body's approved program would be deemed to have met the Medicare conditions. A national AO applying for approval of its accreditation program under part 488, subpart A, must provide CMS with reasonable assurance that the AO requires the accredited provider entities to meet requirements that are at least as stringent as the Medicare conditions. Our regulations concerning the approval of AOs are set forth at § 488.4 and § 488.8(d)(3). The regulations at § 488.8(d)(3) require AOs to reapply for continued approval of their accreditation program every 6 years, or sooner, as determined by CMS.
On February 22, 2013, we published a proposed notice in the Federal Register (78 FR 12325) announcing CIHQ's request for approval of its hospital accreditation program. In the 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 CIHQ's application in accordance with the criteria specified by our regulations, which include, but are not limited to, the following:
An onsite administrative review of CIHQ's: (1) Corporate policies; (2) financial and human resources available to accomplish the proposed surveys; (3) procedures for training, monitoring, and evaluation of its surveyors; (4) ability to investigate and respond appropriately to complaints against accredited facilities; and, (5) survey review and decision-making process for accreditation.
A documentation review of CIHQ's survey process to determine the following:
++ Evaluate CIHQ's procedures for monitoring hospitals out of compliance with CIHQ's program requirements. The monitoring procedures are used only when CIHQ identifies noncompliance. If noncompliance is identified through validation reviews, the State survey agency monitors corrections as specified at § 488.7(d).
In accordance with section 1865(a)(3)(A) of the Act, the February 22, 2013 proposed notice also solicited public comments regarding whether CIHQ's requirements met or exceeded the Medicare conditions of participation for hospitals. We received 56 comments in response to our proposed notice. The commenters expressed unanimous support for CIHQ's hospital Start Printed Page 45232accreditation program. In addition, the commenters stated CIHQ's standards are closely aligned with the hospital conditions of participation, thus allowing hospitals to be in compliance with the Medicare requirements.
We compared CIHQ's hospital requirements and survey process with the Medicare conditions of participation and survey process as outlined in the State Operations Manual (SOM). Our review and evaluation of CIHQ's hospital application, which were conducted as described in section III of this final notice, yielded the following:
To meet the requirements at § 482.13(a)(2), CIHQ revised its standards to address the hospital's responsibility to provide a process for prompt resolution of patient grievances.
To meet the requirements at § 482.13(b)(2), CIHQ revised its standards to address the role of the patient's representative (as allowed under State law) .
To meet the requirements at § 482.13(b)(3), CIHQ revised its standards to include the requirements at § 489.100, § 489.102, and § 489.104 regarding advance directives.
To meet the requirements at § 482.13(d)(2), CIHQ revised its standards to ensure that hospitals have a responsibility to meet patient requests for access to information as quickly as its record keeping system permits.
To meet the requirements at § 482.13(e)(4)(i), CIHQ modified its standards to require the hospital update the patient's plan of care when restraints or seclusion are utilized.
To meet the requirements at § 482.13(e)(5), CIHQ modified its standards to include the provision allowing other licensed independent practitioners, who are responsible for the care of the patient, to write orders for restraint or seclusion.
To meet the requirements at § 482.13(e)(8)(ii), CIHQ modified its standards to include the reference to a physician or other licensed independent practitioner, as delineated at § 482.12(c).
To meet the requirements at § 482.13(e)(11), CIHQ modified its standards to address that the physician and other licensed independent practitioners training requirements must be specified in hospital policy.
To meet the requirements at § 482.13(g)(1), CIHQ modified its standards to permit the hospital to communicate deaths to CMS by facsimile or electronically as determined by CMS.
To meet the requirements at § 482.13(h)(1), CIHQ modified its standards to require the hospital to inform each patient of his or her visitation rights.
To meet the requirements at § 482.22(a)(2), CIHQ modified its standards to require that a candidate who has been recommended by the medical staff and appointed by the governing body be subject to all medical staff bylaws, rules, and regulations, in addition to the requirements contained at § 482.22.
To meet the requirements at § 482.23(b)(3), CIHQ modified its standards to include language that a registered nurse must supervise the care of each patient.
To meet the requirements at § 482.23(c)(1), CIHQ modified its standards to address biologicals.
To meet the requirements at § 482.23(c)(1)(ii), CIHQ modified its standards to address pre-printed and electronic standing orders, order sets, and protocols for orders related to the preparation and administration of drugs and biologicals.
To meet the requirements at § 482.23(c)(4), CIHQ modified its standards to address the requirement that blood and intravenous medication administration occurs only in accordance with state law and approved medical staff policies and procedures.
To meet the requirements at § 482.24(c)(1) through (c)(3)(iv), CIHQ modified its standards to address the requirements related to the appropriate authentication of all orders, including verbal orders; the appropriate use of standing orders, order sets and protocols within nationally recognized guidelines; the periodic review of such orders and protocols; and the authentication of such orders and protocols within the medical record.
To meet the requirements at § 482.25, CIHQ modified its standards to address the medical staff's responsibility to oversee the development of policies and procedures to minimize drug errors.
To meet the requirements at § 482.25(a), CIHQ modified its standards to require that the pharmacy or drug storage area be administered in accordance with accepted professional principles.
To meet the requirements at§ 482.25(b)(4), CIHQ modified its standards to limit the removal of drugs and biologicals from the pharmacy or storage area only by personnel designated in the policies of the medical staff and pharmaceutical service, in accordance with federal and sState law.
To meet the requirements at § 482.25(b)(5), CIHQ modified its standards to address the medical staff's responsibility to predetermine a reasonable time to automatically stop drugs and biologicals.
To meet the requirements at § 482.25(b)(6), CIHQ modified its standards to address the immediate reporting of drug errors, adverse reactions, and incompatibilities to the attending physician.
To meet the requirements at § 482.26, CIHQ modified its standards to clearly identify radiologic services as a service that the hospital is required to provide its patients.
To meet the requirements at § 482.41(a), CIHQ modified its standards to delineate that building inspections and maintenance are to be conducted on an on-going basis. CIHQ also modified its standards to specify that if a hospital intends to provide medical treatment to the victims of a disaster, it must be in compliance with NFPA99, Section 11-3.
To meet the requirements at § 482.41(b)(7) and NFPA 101 (LSC) 18/19.7.1, CIHQ modified its standards to require: a written evacuation and relocation plan be available to all supervisory personnel and employees; that employees are informed of their duties under the plan; and that a copy of the plan is to be readily available at all times in the telephone operator's position or at the security center. In addition, CIHQ modified its standards to require that the hospital instruct employees on life safety procedures and devices.
To meet the requirements at § 482.41(b)(7), the NFPA 101 (LSC) 18/19.7.2.1, and the Life Safety Code Annex A 19.7.1.2, CIHQ modified its standards to require signal transmission of alarms for all fire drills and that all fire drills be scheduled unannounced on a random basis.
To meet the requirements at § 482.43, CIHQ modified its standards to address the hospital's responsibility to have a discharge planning process in writing that applies to all patients.
To meet the requirements at § 482.43(b)(6), CIHQ modified its standards to require that the results of the discharge planning evaluation be discussed with the patient or an individual acting on behalf of the patient.
To meet the requirements at § 482.51, CIHQ modified its standards to specify that if outpatient surgical services are offered, the services must be Start Printed Page 45233consistent in quality with inpatient surgical services.
To meet the requirements at § 482.51(b)(5), CIHQ modified its standards to require that the operating room register be complete and up-to-date.
To meet the requirements at § 482.51(b)(6), CIHQ modified its standards to address the requirement that an operative report must be written or dictated immediately following surgery and signed by the surgeon.
To meet the requirements at § 482.56(a)(2), CIHQ modified its standards to include the reference to part 484 of the Code of Federal Regulations.
To meet the requirements at § 498.13 and Section 2008D of the SOM, CIHQ revised its policies to clearly state that the final accreditation decision is based on the final survey report in which the provider meets all requirements or the date, which the provider is found to meet all conditions but has lower level deficiencies and CIHQ has received an acceptable plan of correction.
To eliminate any real or perceived conflict of interest between CIHQ's consulting services through “Accreditation Resource Services” and its accreditation activities, CIHQ updated its plan to ensure that both entities are separated by a firewall and that information is not shared.
Based on our review and observations described in section III of this final notice, we have determined that CIHQ's requirements for hospitals meet or exceed our requirements. Therefore, we approve CIHQ as a national accreditation organization for hospitals that request participation in the Medicare program, effective July 26, 2013. through July 26, 2017.
[FR Doc. 2013-18014 Filed 7-25-13; 8:45 am]