Accreditation Requirements for Critical Access Hospitals ... · Based Dietetics Practice Resources CHAPTER 6, SECTION 08: NURSING SERVICES 06.08.04 Discharge Planning 06.08.04 For

Accreditation Requirements for Critical Access Hospitals, 2020

edition changes for 2020 v2

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Subsequent to CMS Final Rules published in the Federal Register on September 30, 2019, changes have been made to Accreditation Requirements for Critical Access Hospitals. The chart below details the revisions. These changes are tentatively projected to become effective for surveys on or after May 4, 2020.

The first column below is the standard ID and title from the original publication. Where that remains unchanged, the cell has been merged to include the second column. When there is a number or title change, each column will be completed to reflect the change. The third column indicates the type of change and where it appears, e.g. “Required Elements revised” or “New Standard.” The Detail column includes the specific change.

Deleted content appears with strikethrough and new content appears bolded. In the case of an entirely new standard, the entry appears in bold, maroon font. When a standard has been retired, the detail column is grayed out.

2020 Standard

2020 v2 Standard

Type of change and location

Detail

Chapter 4: ORGANIZATIONAL STRUCTURE

04.00.07 Disclosure: Owners

04.00.07 For future use

▪ Standard retired

Chapter 5: STAFFING

09.00.10 Evaluation of the Medical Staff

05.00.14 Periodic review of clinical privileges and performance

▪ Standard relocated from chapter 9 to chapter 5

▪ Title revised

▪ Standard revised

▪ CFRs revised

▪ Required Elements relocated from 09.00.01

▪ Scoring Procedure additions

STANDARD The CAH requires that – (1) The quality and appropriateness of the

diagnosis and treatment furnished by nurse practitioners, clinical nurse specialist, and physician assistants at the CAH are evaluated by a member of the CAH staff who is a doctor of medicine or osteopathic medicine or by another doctor of medicine or osteopathy under contract with the CAH.

(2) The quality and appropriateness of the diagnosis and treatment furnished by Doctor of Medicine or osteopathic medicine at the CAH are evaluated by— (i) One hospital that is a member of the

network, when applicable; (ii) One Quality Improvement Organization

(QIO) or equivalent entity; (iii) One other appropriate and qualified

entity identified in the State rural health care plan;

(iv) In the case of distant-site physicians and practitioners providing telemedicine services to the CAH’s patient under an agreement between the CAH and a

Accreditation Requirements for CAHs, 2020 v2 updates

January 2020 Page 2 of 39

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distant-site hospital, the distant-site hospital; or

(v) In the case of distant-site physicians and practitioners providing telemedicine services to the CAH’s patients under a written agreement between the CAH and a distant-site telemedicine entity, one of the entities listed in paragraphs (d)(2)(i) through (iii) of this section.

(3) The CAH staff consider the findings of the evaluation and make the necessary changes as specified in paragraphs (b) through (d) of this section.

§485.631(d)(1) §485.631(d)(2) §485.631(d)(2)(i) §485.631(d)(2)(ii) §485.631(d)(2)(iii) §485.631(d)(2)(iv) §485.631(d)(2)(v) §485.631(d)(3)

SCORING PROCEDURE ▪ Review the QIO reports for the last year.

Have any findings been reported, or any recommendations made?

▪ Has corrective action been taken and documented? Was the action taken effective in resolving the issue?

▪ How are QIO findings used in the reappointment process?

CHAPTER 6, SECTION 02: INFECTION CONTROL FOR FUTURE USE

The standards of Chapter 6, Section 2 have been substantially revised and moved to Chapter 18: INFECTION PREVENTION AND CONTROL and ANTIBIOTIC STEWARDSHIP (see relevant area below for detail). Chapter 6, Section 2 is now retained for future use.

CHAPTER 6, SECTION 03: NUTRITIONAL SERVICES

06.03.00 Nutritional Support ▪ Standard revised

▪ CFRs revised

▪ Req’d Elements augmented

STANDARD The policies include the following: ▪ Procedures that ensure that the nutritional

needs of inpatients are met in accordance with recognized dietary practices and the orders of the practitioner responsible for the care of the patients, and that the requirement of 42 CFR §483.25(i) is met with respect to inpatients receiving post hospital SNF care.



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▪ These policies are reviewed at least biennially by the group of professional personnel required under paragraph (a)(2) of this section and updated as necessary by the CAH.

§485.635(a)(3)(vii) §485.635(a)(3)(vi) Tag C-0279 §485.635(a)(4) §482.28(b)(1-2)

REQUIRED ELEMENTS RECOGNIZED DIETARY PRACTICES The CAH ensures it meets the nutritional needs of those patients in observation status whose stay is sufficiently long that they must be fed.

06.03.01 Qualified Staff



06.03.02 Therapeutic Diets



06.03.03 Diet Orders ▪ Standard revised

▪ CFR revised

▪ Req’d Elements revised

STANDARD All inpatient diets, including therapeutic diets, must be ordered by the practitioner responsible for the care of the patient or by a qualified dietitian or qualified nutrition professional as authorized by the medical staff in accordance with State law governing dietitians and nutrition professionals and that the requirement of §483.25(i) of this chapter is met with respect to inpatients receiving post CAH SNF care. Individual patient nutritional needs must be met in accordance with recognized dietary needs. §485.635(a)(3)(vii) §485.635(a)(3)(vi) Tag C-0279

REQUIRED ELEMENTS Therapeutic diets refer to a diet ordered as part of the patient’s treatment for a disease or clinical condition to eliminate, decrease, or increase certain substances in the diet (e.g., sodium or potassium), or to provide mechanically altered food when indicated…

06.03.05 Access to Professional





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and Evidence-Based Dietetics Practice Resources

CHAPTER 6, SECTION 08: NURSING SERVICES

06.08.04 Discharge Planning


▪ Discharge Planning relocated to chapter 19

See 19.00.00

06.08.05 Discharge Planning: Identification of Patients in Need



See 19.00.01

06.08.06 Reduce Avoidable Readmissions



See 19.00.08

CHAPTER 9: QUALITY ASSURANCE AND PERFORMANCE IMPROVEMENT

09.00.00 COP: Periodic Evaluation and Quality Assurance

09.00.00 COP: Quality Assurance and Performance Improvement

▪ Standard title revised


▪ CFR revised


▪ Scoring Procedure revised

STANDARD

The CAH must develop, implement, and maintain an effective, ongoing, CAH-wide, data-driven quality assessment and performance improvement (QAPI) program. The CAH must maintain and demonstrate evidence of the effectiveness of its QAPI program.

Definitions. For the purposes of this section-- ▪ Adverse event means an untoward,

undesirable, and usually unanticipated event that causes death or serious injury or the risk thereof.

▪ Error means the failure of a planned action to be completed as intended or the use of a wrong plan to achieve an aim. Errors can include problems in practice, products, procedures, and systems; and

▪ Medical error means an error that occurs in the delivery of healthcare services.

§485.641 Tag C-0330 §485.641(a) §482.21

REQUIRED ELEMENTS While conducting the survey…and standards of practice. In order…source of the practice.



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The facility demonstrates the ongoing review and analysis of the quality indicators to identify patterns and trends.

The hospital demonstrates that it uses data to monitor the effectiveness of services and the quality of care provided.

SCORING PROCEDURE ▪ Interview staff to learn …

If the CAH produces material such as a law, regulation, or... ▪ Evaluate whether… ▪ Review the hospital’s Quality Assessment

Performance Improvement program to determine it meets the requirement.

▪ The scope of the QAPI program is to identify and reduce medical errors and improve health outcomes.

▪ The focus of the QAPI program is to identify high-risk opportunities and take action to reduce errors.

▪ The annual Quality Plan has been approved by the governing body.

▪ The hospital has an ongoing QAPI program. ▪ The required processes are monitored,

including: □ Quality of care provided □ Effectiveness and safety of services

provided □ Adverse patient events

09.00.01 Periodic Evaluation

09.00.01 QAPI Program Design and Scope

▪ Standard title revised




STANDARD The CAH’s QAPI program must: (1) Be appropriate for the complexity of the

CAH’s organization and services provided. (2) Be ongoing and comprehensive.

(1) The CAH carries out or arranges for a periodic evaluation of its total program.

The evaluation is done at least once a year and includes review of—

§485.641(b)(1) §485.641(b)(2) §485.641(a) Tag C-0331 §482.21(a)(1)

REQUIRED ELEMENTS The annual QAPI Plan is approved by the governing body.

The annual QAPI Plan identifies:



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1. The goal of the quality assurance program is to identify and reduce medical errors and improve health outcomes.

2. The quality indicators, including adverse patient events, that will be measured, analyzed, and tracked on an ongoing basis.

3. The performance indicators and data collection activities for:

□ Every department □ Every service □ Every contracted service

4. The frequency and detail of data collection activities.

5. The methods to monitor the effectiveness and safety of services and quality of care.

6. The plan to use the data collected to monitor the effectiveness and safety of services.

7. The strategies to be used to identify opportunities for improvement and changes.

The facility provides evidence of the following: 1. Data is collected at the frequency

established by the governing body in the annual QAPI Plan

2. Ongoing review and analysis of the quality indicators.

3. Identification of patterns and trends in the services and care provided.

4. Action aimed at improving performance. The facility measures the effectiveness of the implemented actions to ensure improvement is sustained.

SCORING PROCEDURE ▪ How is information obtained … ▪ How does the CAH conduct … ▪ Who is responsible for … Review the CAH QAPI plan and other QAPI related documents, (e.g., meeting minutes, reports, and follow-up communication relative to corrective actions) to verify:

▪ The data collection activities are appropriate to the scope of the hospital.

▪ The governing body has specified the frequency and detail of data collection.

09.00.02 Evaluation of Utilization

09.00.02 QAPI

▪ Revised title and standard focus

STANDARD The CAH’s QAPI program must:



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▪ Revised Req’d Elements

▪ Revised Scoring Procedure

▪ Involve all departments of the CAH and services (including those services furnished under contract or arrangement).

§485.641(b)(3) §482.21(a)(2) §482.21(b)(1)

The evaluation is done at least once a year and includes review of— The utilization of CAH services, including at least the number of patients served and the volume of services §485.641(a)(1)(i) Tag C-0332 §482.30(c)(4)(i) §482.30(e)(2)

REQUIRED ELEMENTS The annual QAPI Plan identifies the performance indicators and data collection activities for: ▪ Every department and service ▪ Every contracted service

SCORING PROCEDURE

▪ How does the CAH ensure… ▪ Data collection activities include:

▪ Every hospital department and service. ▪ Each contracted service. ▪ Data is analyzed to identify patterns and

trends. Data is used to monitor the effectiveness of services provided.

09.00.03 Chart Review

09.00.03 Objective Measures

▪ Revised title and clarified standard focus



STANDARD The CAH’s QAPI program must: ▪ Use objective measures to evaluate its

organizational processes, functions and services.

§485.641(b)(4)

The evaluation is done at least once a year and includes review of— ▪ A representative sample of both active and

closed clinical records §485.641(a)(1)(ii) Tag C-0333 §482.30(c)(3)

REQUIRED ELEMENTS “A representative sample of both active and closed clinical records” means….

SCORING PROCEDURE ▪ Who is responsible for …



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▪ How are records selected … ▪ How does the evaluation process ensure … ▪ What criteria are used in … ▪ The quality program has identified

improvement indicators that will improve health outcomes and identify and reduce medical errors.

09.00.04 Policy and Procedure Review

09.00.04 Outcome Indicators and Adverse Events




STANDARD The CAH’s QAPI program must address outcome indicators related to:

1. Improved health outcomes and the prevention and reduction of medical errors.

2. Adverse events.

3. CAH-acquired conditions.

and

4. Transitions of care, including readmissions.

§485.641(b)(5) §482.21(a)(1) §482.21(a)(2) The evaluation is done at least once a year and includes review of— ▪ The CAH’s healthcare policies §485.641(a)(1)(iii) Tag C-0334

REQUIRED ELEMENTS Data must be used to achieve the objectives of the QAPI program, including addressing outcome indicators related to improved health outcomes and the prevention and reduction of medical errors, adverse events, CAH-acquired conditions, and transitions of care, including readmissions.

The CAH’s quality improvement efforts are evidenced based and focused on the needs of the population served by the CAH in a manner that best suits the unique characteristics of the CAH. SCORING PROCEDURE ▪ What evidence demonstrates that… ▪ The hospital has a process for measuring,

analyzing, and tracking quality, adverse patient events, and other aspects of performance.

▪ The data collection activities are appropriate to the scope of the hospital.



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09.00.05 Purpose of the Evaluation Process

09.00.05 Governance and Leadership




STANDARD The CAH’s governing body or responsible individual is ultimately responsible for the CAH’s QAPI program and is responsible and accountable for ensuring that the QAPI program meets the requirements of paragraph (b) of this section. §485.641(c) §482.21(e)

The purpose of the evaluation is to determine whether the utilization of services was appropriate, the established policies were followed, and any changes are needed. §485.641(a)(2)

REQUIRED ELEMENTS The governing body must determine priorities regarding which processes to monitor with data collection and the subsequent development of planned improvement efforts, as needed. The hospital’s governing body must provide strong, clear, and visible attention to setting expectations for safety and for allocating adequate resources for measuring, assessing, improving, and sustaining the hospital’s performance and for reducing risks to patients.

The medical staff and administrative officials must be held accountable for the implementation of an effective program consistent with Governing Body direction that demonstrates a sustained improvement in patient outcomes and a reduction in medical errors.

SCORING PROCEDURE

• How does the CAH use… ▪ How do the Governing Body, medical staff,

and hospital leadership demonstrate responsibility and accountability for ensuring the QAPI program is ongoing, defined, implemented, and maintained?

▪ Does the QAPI Program include patient safety initiatives, such as reduction of medical errors?

▪ What is the evidence that the Governing Body prioritized the performance improvement projects and data collection activities?



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▪ What is the evidence that performance improvement actions/strategic actions have been implemented and evaluated to ensure these have been effective with improving the quality of care and patient safety?

09.00.06 Quality Assurance

09.00.06 Program Activities




STANDARD For all departments and services, including contracted services each of the areas listed in paragraph (b) of this section, the CAH must:

1. Focus on measures related to improved health outcomes that are shown to be predictive of desired patient outcomes.

2. Use the measures to analyze and track its performance.

3. Set priorities for performance improvement, considering either high-volume, high-risk services, or problem-prone areas.

§485.641(d) §485.641(d)(1) §485.641(d)(2) §485.641(d)(3) §482.21(c) §482.21(c)(1) §482.21(c)(1)(i) §482.21(c)(1)(ii) §482.21(c)(1)(iii) The CAH has an effective quality assurance program to evaluate the quality and appropriateness of the diagnosis and treatment furnished in the CAH and of the treatment outcomes. • The program requires that— §485.641(b)

REQUIRED ELEMENTS Whether the CAH has a freestanding…

▪ …continuous basis.

The facility has a process to identify opportunities, prioritize, and select annual performance improvement activities based upon available resources.

▪ The facility considers the incidence, prevalence, and severity of problems.

▪ The facility takes action aimed at improving performance.



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▪ The facility measures the effectiveness of the implemented actions to ensure improvement is sustained.

SCORING PROCEDURE

▪ Review a copy of …

▪ The facility has a process to establish priorities for performance improvement activities that focus on high-risk, high volume, or problem prone areas.

09.00.07 Evaluation of Patient Care and Related Services

09.00.07 Program Data Collection and Analysis


▪ Req’d Elements added

STANDARD The program must incorporate quality indicator data including patient care data, and other relevant data, in order to achieve the goals of the QAPI program. §485.641(e) The program requires that— ▪ All patient care services and other services affecting patient health and safety, are evaluated §485.641(b)(1) §482.21(a)(2)

REQUIRED ELEMENTS The hospital must ensure that the program activities requirements are met.

Medical errors include but are not limited to such things as medication errors and the wrong site of surgery, etc. Each error incident can be an opportunity for education and learning for the individuals and areas involved.

The facility measures, analyzes, and tracks the quality indicators consistent with the annual QAPI plan. The facility implements a database for tracking medical errors and adverse patient events by category. Through analysis of these data, the facility determines patterns, implements strategies, and monitors the effectiveness of corrective actions implemented.

The facility provides measurable evidence of improvement in the following areas:

▪ Improved health outcomes

▪ Reduction of identified medical errors

SCORING PROCEDURE

▪ The hospital measures, analyzes, and tracks:



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Detail

▪ Quality indicators and other aspects of performance.

▪ Medical errors.

▪ Adverse patient events.

▪ That the hospital has implemented improvement mechanisms, based on data analysis, to reduce medical errors and adverse patient events.

09.00.09 Evaluation of Medical Care



09.00.10 Evaluation of Medical Staff


▪ Standard, Req’d Elements, and Scoring Procedure moved to 05.00.14 (see Chapter 5)

09.00.11 Takes Actions on Findings of QIO



▪ Scoring Procedure added to 05.00.14 (see Chapter 5)

CHAPTER 11: SWING BEDS

11.00.04 Skilled Nursing Facility Services

▪ Standard revised to delete 2 CfR references

STANDARD The CAH is substantially in compliance with the following SNF requirements which are scored individually.

(1) Resident rights (42 CFR (§483.10(b)(7), (c)(1), (c)(2)(iii), (c)(6), (d), (e)(2), (e)(4), (f)(4)(ii), (f)(4)(iii), (f)(9), (g)(8), (g)(17), (g)(18) introductory text, and (h)

(5) Social services (42 CFR §483.40(d) and 42 483.70(p))

11.01.01 Resident Rights


▪ Renumbered subsequent items in standard

STANDARD The CAH must be in substantial compliance with the following skilled nursing facility requirements:

11. To choose to or refuse to perform services for the facility and the facility must not require a resident to perform services for the facility. §483.10(f)(9)

12. 11. To send and receive mail, and to receive letters, packages and other materials delivered to the facility for the resident



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through a means other than the postal services. §483.10(g)(8)

13. 12. To be informed at time of admission, when the resident becomes eligible for Medicaid, and periodically during the resident’s stay of items and services included under the State plan for which the resident may not be charged; and those other items and services the facility offers for which the resident may be charged and the amount of charges for those services. §483.10(g)(17); §483.10(g)(18)

14. 13. To have personal privacy and confidentiality of personal and medical records. §483.10(h)

§485.645(d)(1)

11.01.05 Right to Request, Refuse, and/or Discontinue Treatment


SCORING PROCEDURE ▪ Review the records of sampled residents

admitted on or after December 1, 1991, for facility compliance with advance directive notice requirements.

11.01.06 Choice of Attending Physician

▪ Standard revised to delete CFR reference

STANDARD The resident has the right to choose his or her attending physician. (2) If the physician chosen by the resident

refuses to or does not meet requirements specified in this part, the facility may seek alternate physician participation as specified in 42 CFR 483.15(d)(4) and (5) of this section to assure provision of appropriate and adequate care and treatment.

11.01.10 Work



11.02.01 Admission, Transfer, and Discharge Rights

▪ Scoring procedure revised

SCORING PROCEDURE Standards within this… Deficiencies regarding transfers and discharge will be scored at the following specific standards.

11.04.01 Patient Activities Program





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11.05.01 Social Services

▪ CFR revised §485.645(d)(4) §485.645(d)(5)

11.05.02 Qualifications of Social Worker



11.06.01 Comprehensive Assessment

▪ CFRs revised


STANDARD §485.645(d)(5) §485.645(d)(6)

REQUIRED ELEMENTS The CAH has identified the components of a comprehensive assessment, including at a minimum, all elements listed in the standard.

11.06.02 Assessment Timeframes

▪ CFRs revised STANDARD §485.645(d)(5) §485.645(d)(6)

11.06.03 Re-assessments

▪ CFRs revised STANDARD §485.645(d)(5) §485.645(d)(6)

11.06.04 Comprehensive Care Plans

▪ Standard revised to delete CFR reference

▪ CFRs revised


STANDARD

(1)(i) The services that are to be furnished to attain or maintain the resident’s highest practicable physical, mental, and psychosocial well-being as required under 42 CFR §483.24, 42 CFR §483.25, 42 CFR §483.40; and

(ii) Any services that would otherwise be required under 42 CFR §483.24, 42 CFR §483.25, or 42 CFR §483.40 but are not provided due to the resident’s exercise of rights under 42 CFR §483.10, including the right to refuse treatment under 42 CFR §483.10(c)(6).

§485.645(d)(5) §485.645(d)(6)

REQUIRED ELEMENTS …The requirements reflect the facility’s responsibility to provide necessary care and services to attain or maintain the highest practicable physical, mental and psychosocial well-being, in accordance with the comprehensive assessment and plan of care. If the needs of the patient include interest-based group and/or individual activities that support



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the patient’s well-being, the CAH will provide these activities.

11.06.05 Care Plan Requirements

▪ CFR revised STANDARD

§485.645(d)(5) §485.645(d)(6)

11.06.06 Discharge Summary

▪ CFR revised STANDARD

§485.645(d)(5) §485.645(d)(6)

11.07.01 Specialized Rehabilitative Services: Provision of Services

▪ CFR revised STANDARD §485.645(d)(6) §485.645(d)(7)

11.07.02 Rehabilitative Service Orders: Qualifications

▪ CFR revised STANDARD §485.645(d)(6) §485.645(d)(7)

11.08.02 Skilled Nursing Facility: Dental Services


▪ CFR revised

STANDARD A facility –

(1) Must provide or obtain from an outside resource, in accordance with 42 CFR §483.70(g), routine and emergency dental services to meet the needs of each resident;

(1) May charge a Medicare resident an additional amount for routine and emergency dental services.

(2) Must have a policy identifying those circumstances when the loss or damage of dentures is the facility's responsibility and may not charge a resident for the loss or damage of dentures determined in accordance with facility policy to be the facility's responsibility;

§483.55(a)(1) §483.55(a)(2) §483.55(a)(3) §485.645(d)(7) §485.645(d)(8)

11.08.03 Skilled Nursing Facility: Dental Appointments

▪ CFR revised STANDARD §483.55(a)(4) §483.55(a)(5) §485.645(d)(7) §485.645(d)(8)

11.08.04 Nursing Facility: Provision of Dental Services

▪ CFR revised STANDARD §483.55(b)(1)(i) §483.55(b)(1)(ii)



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§483.645(d)(7) §483.645(d)(8)

11.08.05 Skilled Nursing Facility: Dental Appointments

▪ CFR revised STANDARD §483.55(b)(2) §483.55(b)(3) §483.55(b)(4) §483.55(b)(5) §483.645(d)(7) §483.645(d)(8)

11.09.01 Assisted Nutrition and Hydration

▪ CFR revised STANDARD §483.25(g)(1) §483.25(g)(2) §483.25(g)(3) §483.25(g)(4) §483.25(g)(5) §483.645(d)(8) §483.645(d)(9)

11.10.01 Quality of Life

▪ CFR revised

STANDARD §483.24 §483.24(a) §483.24(b) §485.645(d)(5) §485.645(d)(6)

11.11.01 Quality of Care

▪ CFR revised STANDARD §483.25 §483.25(a-f) §483.25(h-n) §485.645(d)(5) §485.645(d)(6)

11.12.01 Behavioral Health Services

▪ CFR revised

STANDARD §483.40 §485.645(d)(5) §485.645(d)(6)

CHAPTER 17: EMERGENCY MANAGEMENT

17.00.01 COP: Emergency preparedness


▪ Req’d elements revised (frequency of review)

▪ Scoring Procedure updated (frequency of review)

STANDARD …The requirements established by this Chapter apply to all facilities owned, rented, leased or used by the CAH that provides patient care and treatment services. This applies regardless of the NFPA “occupancy” designation of the facility. A CAH may have off-site facilities that are only used as physician exam offices, but all the requirements of this chapter must apply.



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§485.625

17.00.02 Hazard Vulnerability Analysis (HVA)



STANDARD ---The HVA is documented and reviewed by the oversight committee on emergency management for relevancy and accuracy on an annual biennial basis.

SCORING PROCEDURE ▪ Verify that the Hazard Vulnerability Analysis

(HVA) is reviewed by the organization and updated annually every two years (biennially)…

17.00.03 Emergency Operations Plan



STANDARD The EOP is based on the priorities established in the annual current Hazard Vulnerability Analysis (HVA)…

The EOP is reviewed on an annual basis every two years (biennially)…

The CAH uses it annual Hazard Vulnerability Analysis (HVA) as a foundation for the Emergency Operations Plan to determine the strategies and activities designed to reduce the risk associated with emergency events.

SCORING PROCEDURE ▪ Was the EOP reviewed with local authorities

per the policy of the CAH?

▪ Review documentation to ensure the EOP was shared with local authorities per the policy of the CAH and reviewed with the community emergency preparedness and response plan.

▪ Verify that the plan is reviewed and updated annually every two years (biennially) by looking for documentation of the date of the review and updates that were made to the plan based on the review.

17.00.05 Services



REQUIRED ELEMENTS …The EOP includes a plan for the continuation of

these services during the facility’s response to the emergency event. If specific equipment is required for services listed, as in radiological diagnostic services as an example, the plan must state how equipment will be made available under emergency power.

SCORING PROCEDURE



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▪ Check the services to be provided. If specific equipment is required, validate the provisions to keep the specific equipment available for use. In general, equipment that can be plugged into red emergency outlets is presumed to be available for the continuation of services during an emergency.

17.00.07 Collaboration



REQUIRED ELEMENTS …While the responsibility for ensuring a coordinated disaster preparedness response lies upon the state and local emergency planning authorities, the facility must document its efforts to contact these officials to engage in collaborative planning for an integrated emergency response. The facility must document its efforts to contact these officials to engage in collaborative planning for an integrated emergency response. The must include this integrated…

The EOP must provide…planning process.

CAHs must document…emergency preparedness officials.

In order to facilitate planning, facilities must share their plan with any officials or authorities listed within the plan.

SCORING PROCEDURE ▪ Does the EOP address how the CAH will

document their efforts to communicate with the authorities?

▪ Review evidence that copies of the EOP have been forwarded to listed collaborative authorities for their use and reference. Evidence of communication beyond making the EOP available to these entities is not required.

17.00.08 Clarifications and definitions

▪ New Standard consisting of definitions

Note: No new content; definitions provided for clarity of other standards. No scoring at this standard.

17.01.01 Policies and procedures


▪ Req’d elements revised

▪ Scoring Procedures revised

STANDARD

… These policies and procedures must be

reviewed and updated annually every two years (biennially) by the Emergency Management oversight committee. Review written agreements with vendors and/or suppliers to determine that they have



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been updated or renewed annually if their goods or services are required specific to Emergency Preparedness operations. The staff roster is dated and evidence retained to demonstrate it is updated at least semi-annually. §485.625(b) 485.625(d)(2) 485.68(d)(2) 485.727(d)(2) 485.920(d)(2)

REQUIRED ELEMENTS …All referenced policies and procedures must meet all requirements for review and documentation as if included in the EOP directly. Contracts with vendors and suppliers are more suspect to holding the terms of the agreement when extending greater than one year. Contracts are to be renewed annually or when vendors/suppliers are changed. Real-time electronic tracking systems of current and former staff members are deemed to meet the requirement for semi-annual updates to the call-back roster. SCORING PROCEDURE ▪ Review policies and procedures to ensure they

have been reviewed and updated annually per HFAP 17.01.01. Score review timeline issues of required policies and procedures under both this standard and the HFAP standard requiring the specific component of Emergency Preparedness.

▪ Review written agreements with vendors and/or suppliers to determine they have been updated annually.

17.01.02 Nutritional services




STANDARD

… These policies and procedures must be

reviewed and updated annually per HFAP Standard 17.01.01 by the Emergency Management oversight committee.

§485.625(b)(1)(i) §485.625(d)(2) §485.68(d)(2) §485.727(d)(2) §485.920(d)(2)



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REQUIRED ELEMENTS …The written agreements are updated on an annual basis per HFAP Standard 17.01.01.

The CAH calculates the volume of food, drinking water, paper products, and utensils needed to feed the patients, staff, and visitors for at least three (3) days. The calculation parameters used are documented. The CAH stores… SCORING PROCEDURES

▪ Review the written agreements with the food suppliers to determine that they have been updated annually per HFAP Standard 17.01.01.

▪ Review the plan and calculations used to determine the quantity of drinking water and food that meets the needs…

▪ Review policies and procedures to ensure they have been reviewed and updated annually per HFAP Standard 17.01.01.

17.01.03-17.01.14 17.02.01

▪ Standards revised

▪ Scoring Procedures revised

Note: All revisions reflect change from annual review of policies and procedures to review per HFAP standard 17.01.01.

17.03.01 Emergency training




STANDARD ▪ Provide emergency management training

when the emergency plan is significantly updated and at least annually biennially or every two years;

The training program must be reviewed and updated annually biennially or every two years. REQUIRED ELEMENTS A well organized, effective training program

must include…as well as biennial (every two year) refresher trainings.

The facility must offer biennial emergency preparedness training…

While facilities are required to provide biennial training to all staff, it is up to the facility to decide what level of training each staff member will be required to complete each year based on… SCORING PROCEDURE ▪ Are staff being trained on an annual biennial

basis?



2020 Standard

2020 v2 Standard


Detail

17.03.02 Emergency exercises



STANDARD 2. The CAH must participate in a second full-

scale exercise that is community-based or individual facility-based. The CAH must participate in a second exercise of their choice:

a. an individual facility-based functional exercise

b. a drill or c. a tabletop exercises.

REQUIRED ELEMENTS

2. The second must be a full-scale exercise that is a facility-based full-scale exercise choice of an individual facility-based functional exercise, a drill, or a tabletop exercise.

Table-top drills, while useful in the planning phase, are not an acceptable substitute for these exercises.

BUSINESS OCCUPANCIES Buildings that are classified as “business occupancies” and provide patient care activities are required to perform one emergency exercise per calendar year. Every other year, these providers must participate in either a community-based full-scale exercise (if available) or conduct an individual facility-based functional exercise. In the opposite years, these providers must conduct a testing exercise of their choice, which includes either a community-based full-scale exercise (if available); an individual, facility-based functional exercise; a drill; or a tabletop exercise or workshop that includes a group discussion led by a facilitator. The facilitator must have specialty experience or education in Emergency Preparedness operations for the later.

17.04.01 Emergency power


SCORING PROCEDURE Verify that newly installed generators (since July 5, 2016) have been located in an area to minimize the damage from flooding. Ask for the installation date of existing generators if they appear to be newer; alternately, the date can be verified on testing



2020 Standard

2020 v2 Standard


Detail

documentation for annual or 3-yr/4-hr generator load testing.

CHAPTER 18: INFECTION PREVENTION AND CONTROL and ANTIBIOTIC STEWARDSHIP

This new chapter reflects the addition by CMS of a new Condition for Participation. Standards previously found in Chapter 6, Section 2 have been retired or revised and moved. They are presented below in the order in which they appear in the new chapter.

06.02.00 Infection Control


18.00.00 COP: Infection Prevention and Control and Anitbiotic Stewardship Programs

▪ New standard with corresponding CFRs

▪ Replaces retired standard 06.02.00

▪ New Required Elements

▪ New Scoring Procedure

STANDARD The CAH must have active facility-wide programs, for the surveillance, prevention, and control of HAIs and other infectious diseases and for the optimization of antibiotic use through stewardship. The programs must demonstrate adherence to nationally recognized infection prevention and control guidelines, as well as to best practices for improving antibiotic use where applicable, and for reducing the development and transmission of HAIs and antibiotic-resistant organisms.

Infection prevention and control problems and antibiotic use issues identified in the programs must be addressed in coordination with the facility-wide quality assessment and performance improvement (QAPI) program. §485.640 §482.42

For complete detail, see manual.

18.00.01 Responsibilities of the Governing Body




STANDARD The governing body, or responsible individual, must ensure all of the following: (i) Systems are in place and operational for

the tracking of all infection surveillance, prevention and control, and antibiotic use activities, in order to demonstrate the implementation, success, and sustainability of such activities.

(ii) All HAIs and other infectious diseases identified by the infection prevention and control program as well as antibiotic use issues identified by the antibiotic stewardship program are addressed in



2020 Standard

2020 v2 Standard


Detail

collaboration with the CAH’s QAPI leadership.

§485.640(c)(1) §485.640(c)(1)(i) §485.640(c)(1)(ii) §482.42(c)(1) §482.42(c)(1)(i) §482.42(c)(1)(ii)


06.02.01 Designated Individual Responsible for Infection Control


18.00.02 Infection Prevention and Control Program Leadership




STANDARD The CAH must demonstrate that:

An individual (or individuals), who is qualified through education, training, experience, or certification in infection prevention and control, is appointed by the governing body, or responsible individual, as the infection preventionist(s)/infection control professional(s) responsible for the infection prevention and control program and that the appointment is based on the recommendations of medical staff leadership and nursing leadership.

§485.640(a)(1) §482.42(a)(1) For complete detail, see manual.

06.02.02 Nationally Recognized Infection Control Practices

▪ Standard retired.

▪ Req’d Elements incorporated into new 18.00.04.

18.00.03 Responsibilities of the Infection Control Professional




STANDARD The infection prevention and control professional(s) is responsible for:

(i) The development and implementation of facility-wide infection surveillance, prevention, and control policies and procedures that adhere to nationally recognized guidelines.



2020 Standard

2020 v2 Standard


Detail

(ii) All documentation, written or electronic, of the infection prevention and control program and its surveillance, prevention, and control activities.

(iii) Communication and collaboration with the CAH’s QAPI program on infection prevention and control issues.

(iv) Competency-based training and education of CAH personnel and staff, including medical staff, and, as applicable, personnel providing contracted services in the CAH, on the practical applications of infection prevention and control guidelines, policies and procedures.

(v) The prevention and control of HAIs, including auditing of adherence to infection prevention and control policies and procedures by CAH personnel.

(vi) Communication and collaboration with the antibiotic stewardship program.

§485.640(c)(2) §485.640(c)(2)(i) §485.640(c)(2)(ii) §485.640(c)(2)(iii) §485.640(c)(2)(iv) §485.640(c)(2)(v) §485.640(c)(2)(vi) §482.42(c)(2) §482.42 (c)(2)(i) §482.42 (c)(2)(ii) §482.42 (c)(2)(iii) §482.42 (c)(2)(iv) §482.42 (c)(2)(v) §482.42(c)(2)(vi)


18.00.04 Infection Prevention and Control Policies




STANDARD The infection prevention and control program, as documented in its policies and procedures, employs methods for preventing and controlling the transmission of infections within the CAH and between the CAH and other healthcare settings. §485.640(a)(2) §482.42(a)(2)




2020 Standard

2020 v2 Standard


Detail

18.00.05 Scope and Complexity of Services




STANDARD The infection prevention and control program reflects the scope and complexity of the CAH services provided.

§485.640(a)(4) §482.42(a)(4)


06.02.03 Surveillance and Corrective Action


06.02.04 Sanitary Environment


06.02.05 Mitigation of Risks


18.01.01 Responsibilities of the antibiotic stewardship program leader




STANDARD The leader(s) of the antibiotic stewardship program is responsible for:

(i) The development and implementation of a facility-wide antibiotic stewardship program, based on nationally recognized guidelines, to monitor and improve the use of antibiotics.

(ii) All documentation, written or electronic, of antibiotic stewardship program activities.

(iii) Communication and collaboration with medical staff, nursing, and pharmacy leadership, as well as the CAH’s infection prevention and control and QAPI programs, on antibiotic use issues.

(iv) Competency-based training and education of CAH personnel and staff, including medical staff, and, as applicable, personnel providing contracted services in the CAHs, on the practical applications of antibiotic stewardship guidelines, policies, and procedures.

§485.640(c)(3) §485.640(c)(3)(i) §485.640(c)(3)(ii) §485.640(c)(3)(iii)



2020 Standard

2020 v2 Standard


Detail

§485.640(c)(3)(iv) §482.42(c)(3) §482.42(c)(3)(i) §482.42(c)(3)(ii) §482.42(c)(3)(iii) §482.42(c)(3)(iv)


18.01.02 Antibiotic stewardship program leadership




STANDARD The CAH must demonstrate that: An individual (or individuals), who is qualified through education, training, or experience in infectious diseases and/or antibiotic stewardship, is appointed by the governing body, or responsible individual, as the leader(s) of the antibiotic stewardship program and that the appointment is based on the recommendations of medical staff leadership and pharmacy leadership.

§485.640(b)(1) §482.42(b)(1) For complete detail, see manual.

18.01.03 Facility-wide antibiotic stewardship program




STANDARD

The facility-wide antibiotic stewardship program:

(i) Demonstrates coordination among all components of the CAH responsible for antibiotic use and resistance, including, but not limited to, the infection prevention and control program, the QAPI program, the medical staff, nursing services, and pharmacy services;

(ii) Documents the evidence-based use of antibiotics in all departments and services of the CAH; and

(iii) Documents any improvements, including sustained improvements, in proper antibiotic use.

§485.640(b)(2) §485.640(b)(2)(i) §485.640(b)(2)(ii) §485.640(b)(2)(iii) §482.42(b)(2) §482.42(b)(2)(i) §482.42(b)(2)(ii) §482.42640(b)(2)(iii)



2020 Standard

2020 v2 Standard


Detail


18.01.04 Antibiotic stewardship guidelines




STANDARD The antibiotic stewardship program adheres to nationally recognized guidelines, as well as best practices, for improving antibiotic use.

§485.640(b)(3) §482.42(b)(3) For complete detail, see manual.

18.01.05 Scope and complexity of the Antibiotic Stewardship Program




STANDARD The antibiotic stewardship program reflects the scope and complexity of the services CAH provided.

§485.640(b)(4) §482.42(b)(4)


06.02.06 Training


18.02.01 Risk Mitigation Measures Infection Prevention

▪ New Standard with corresponding CFRs

▪ New Req’d Elements


STANDARD The hospital has identified activities to mitigate risks associated with acquiring infections.

The hospital infection prevention and control program, as documented in its policies and procedures, employs methods for preventing and controlling the transmission of infections within the hospital and between the hospital and other institutions and settings.

§482.42(a)(2)


18.02.02 Surveillance

▪ New Standard with corresponding CFRs



STANDARD The infection prevention and control program includes surveillance, prevention, and control of HAIs, including maintaining a clean and sanitary environment to avoid sources and transmission of infection, and that the program also addresses any infection control issues identified by public health authorities.

§485.640(a)(3) §482.42(a)(3)


18.02.03 Environmental Surveillance

▪ New Standard



STANDARD In addition to reports of actual infections and communicable diseases, the infection prevention and control leader submits reports



2020 Standard

2020 v2 Standard


Detail

to the Professional Medical Staff, Safety Committee, and the Infection Control Committee (function) regarding environmental surveillance activities. For complete detail, see manual.

18.02.04 Personal Protective Equipment

▪ New Standard



STANDARD The CAH, in accordance with nationally recognized standards of practice (OSHA, CDC, APIC), must:

▪ Define in policies and procedures the circumstances in which PPE must be worn and specifies the clinical conditions for which specific PPE should be used.

▪ Provide training on appropriate use of PPE to avoid the spread of contamination

▪ Provide adequate and available supplies necessary for adherence to proper personal protective equipment (PPE) use.


18.02.05 Hand-washing Guidelines

▪ New Standard



STANDARD The hospital adopts nationally recognized guidelines that are identified as effective in improving patient safety through the prevention of person-to-person transmission of infections.


06.02.07 Reduce Risk of Legionella in Water Systems

18.02.06 ▪ Standard relocated

06.02.09 Prevention of Central Venous Catheter Infections


06.02.10 Surgical Site Infections

18.02.08

▪ Standard relocated

06.02.15 Recall Process

18.02.09


18.03.01 Staff Orientation and Training

▪ New standard


▪ New Survey Procedures

STANDARD There is an infection prevention and control hospital-wide plan for staff orientation and ongoing training.



2020 Standard

2020 v2 Standard


Detail


18.03.02 Employee Health Policies

▪ New standard



STANDARD

The Infection Control Committee shall establish and evaluate employee health policies.


06.02.08 Employee Health: Influenza Vaccinations

18.03.03 Employee Health: Influenza Vaccinations




STANDARD

Healthcare workers will be vaccinated against influenza to protect both themselves and patients from influenza.

REQUIRED ELEMENTS

Employee health policies addressing influenza vaccinations are made available to employees. Such policies are based on national guidelines, such as the CDC (https://www.cdc.gov/flu/professionals/healthcareworkers.htm). Many high-risk elderly patients … Influenza causes… Vaccination of healthcare workers…

SCORING PROCEDURE

1. Verify the facility has taken actions to prevent influenza by implementing evidence-based practices, preferably those established by the CDC.

Review employee health files to verify:

1. All employees have been offered the influenza vaccination.

2. Employee refusal has been documented.

06.02.11 Decontamina-tion and Sterilization Policies

18.04.01 ▪ Standard revised



STANDARD

There are written policies and procedures based on manufacturer’s instructions and nationally recognized guidelines for the decontamination and sterilization techniques performed in any location of the facility that have been approved by the infection control committee/function.

REQUIRED ELEMENTS

…A policy identifies when sterilization, low-level, high-level disinfection, or chemical disinfection is acceptable and delineates the steps of any low-level or high-level disinfection and liquid chemical disinfection processes used in the hospital.

The policies address the equipment used for manual and automated processes. The policies

https://www.cdc.gov/flu/professionals/healthcareworkers.htm

https://www.cdc.gov/flu/professionals/healthcareworkers.htm



2020 Standard

2020 v2 Standard


Detail

are based on the manufacturer’s instructions for use and easily accessible to personnel.

The organization ensures scopes are cleaned and rinsed in accordance with manufacturer’s instructions for use. Scopes are stored in an appropriate area protected from contamination.

DECONTAMINATION AND STERILIZATION

The approved policies include at least: 1. Decontamination ... 2. Preparing, assembling, wrapping, storage of,

and distribution of … 3. Sterilization data requirements. 4. Recall process. 5. Environmental requirements…

6. Temperature and pressure readings …

7. Identification of the shelf life ….

8. Descriptions exist for cold sterilization procedures …

Load control numbers …

SCORING PROCEDURE

▪ Ongoing revisions are consistent with CDC guidelines, OSHA, state, and local laws.

06.02.13 Decontamination of Reusable Items and Reuse of Single Use Devices


06.02.14 Immediate Use Steam Sterilization (IUSS) in Surgical Settings

18.04.03

▪ Standard relocated and revised (simplified)


STANDARD

Immediate use sterilization (IUSS) practices are based on current nationally recognized infection control guidelines and standards of practice. Surgical disinfection and sterilization procedures are expected …

REQUIRED ELEMENTS

Surgical disinfection and sterilization… IUSS is used to describe the process for steam sterilizing an instrument that is needed immediately, not intended to be stored for later use, and which allows for minimal of no drying after the sterilization cycle. The availability of IUSS is not considered an appropriate substitute



2020 Standard

2020 v2 Standard


Detail

for maintaining a sufficient inventory of instruments.

It should be noted that …

PROFESSIONALLY ACCEPTED IUSS STANDARDS OF PRACTICE

Consistent with…

IUSS will accomplish…

IUSS entails an increased risk…

06.02.12 Monitoring Devices

18.04.04 Sterilization and Decontamina-tion Devices

▪ Standard clarified


STANDARD Policies and/or procedures describe the use of devices to monitor sterilization or decontamination results in compliance with manufacturer’s recommendations. The facility is in compliance with its policies.

REQUIRED ELEMENTS

Policies and procedures are…Practice reflects implementation of the policies.

Chemical indicators…

5. Gas or liquid sterilization is defined as ethylene oxide, carbon dioxide, hydrogen peroxide, or any other non-steam sterilization process.

18.04.05 Sterilization Data Requirements

▪ New standard



STANDARD Appropriate documentation, including temperature and pressure readings, is recorded and maintained for every sterilized load.


18.04.06 Preparing, Assembling, Wrapping, Storage and Distribution of Sterile Equipment and Supplies

▪ New standard



STANDARD There are approved policies for the preparing, assembly, wrapping, storage, and distribution of sterile equipment and supplies.


18.04.07 Shelf Life of Sterilized Products

▪ New standard



STANDARD There is identification of the shelf life for each type of sterilized product used on or around any hospital patient or in or around any product or equipment that is used for patient care.




2020 Standard

2020 v2 Standard


Detail

06.02.16 Environmental Requirements in Decontamina-tion Rooms

18.04.08


06.02.17 Housekeeping Services


▪ Req’d Elements revised; high risk content moved to 18.05.02

REQUIRED ELEMENTS Policies include, but are not limited to: 1.Cleaning products inventory

8.Use of personal protective equipment (PPE)

HIGH-RISK CLEANING PROCEDURES

18.05.02 High Risk Cleaning Procedures

▪ New standard based on Required Elements from previous 06.02.17



STANDARD There are policies and procedures for the cleaning of areas in the hospital deemed as high risk due to their special functions. These would include, but are not limited to:

1. Surgery

2. Labor and Delivery

3. Cardiac Catheterization Lab

4. Bone marrow rooms

5. Central Sterile Processing

6. Newborn nursery

7. Linen processing


06.02.18 Cleaning Products Inventory


06.02.19 Air Supply and Return Grilles

18.05.03


06.02.20 Maintenance of Ceilings


18.05.05 Maintenance of Housekeeping and Laundry Equipment

▪ New standard



STANDARD Policies and procedures govern the care and cleaning of housekeeping and laundry equipment.


18.05.06 Waste Disposal

▪ New standard


STANDARD



2020 Standard

2020 v2 Standard


Detail


Policies and procedures govern the proper storage and disposal of waste including biomedical and infectious.


06.02.21 Laundry

18.06.01 Soiled Linen Management

▪ Standard retitled and revised for clarity


STANDARD Contaminated linen will be placed and stored…

Contaminated linen collection bags or containers will be labeled and/or color coded to communicate that the contents contain infectious materials.

Soiled linen bags…

The clean dirty portion of the laundry area has positive negative pressure to prevent airborne contamination, in accordance with state and federal guidelines for healthcare laundry facilities.

REQUIRED ELEMENTS

Grossly soiled linen is stored in nonabsorbent, covered devices in both patient care areas and non-patient care areas. Measures are taken which reduce the potential for particles becoming airborne , exposed, and/or liquids dripping from, or absorption into, all holding devices. Staff are trained on the use of laundry products and processes. When laundering occurs in the facility, the cycles consist of flush, main wash, bleaching, rinsing, and souring and the procedures are based on national guidelines (e.g., CDC, OSHA, Association for Linen Management, Association for Professionals in Infection Control and Epidemiology (APIC)). When hot water is used, it is maintained at an appropriate temperature for the appropriate length of time. Low water temperatures are appropriately matched with chlorine bleach or other laundry additives for cleaning and decontamination.

06.02.22

Clean Linen Storage

18.06.02


▪ Required elements revised

REQUIRED ELEMENTS

Clean linen is stored in enclosed areas or in enclosed packaging.

Linen transported is appropriately contained and covered. Clean linens are packaged prior to transport to prevent inadvertent contamination from dust and dirt during loading, delivery, and



2020 Standard

2020 v2 Standard


Detail

unloading. Clean inventory is transported in a manner to prevent the spread of dust and soil onto clean linen from transport carts and/or wheels.

Clean inventory is transported in a manner to prevent the spread of dust and soil onto clean linen from transport carts and/or wheels.

The lowest shelf of the clean linen storage and transportation carts are enclosed and not open to the spread of dust and other potential contaminants cannot have open grates to prevent exposure to contamination.

06.02.23 Pest Control

18.07.01 Extermination Program

▪ Standard relocated, retitled, and revised

▪ Req’d Elements revised to include deleted standard language

STANDARD

All openings to the outside of …

There is a pest extermination program to control the presence and reproduction of pests.

The pest control program must be safe for use around patients and staff.

Use of poisons is not considered appropriate due to the potential of exposure to decomposing carcasses as well as the poison.

Traps must not present a hazard to patients or staff.

REQUIRED ELEMENTS

There is an ongoing pest extermination process within the hospital. This can be by provided by hospital employees or by a contracted outside service.

The pest control program addresses the exterior and interior of the building(s). Measure are taken…

All openings to the outside of the physical hospital are protected to effectively reduce the potential of the entrance of pests into the hospital.

Outside doors have…

Use of poisons is not considered appropriate due to the potential of exposure to decomposing carcasses as well as the poison.

Traps must not present a hazard to patients or staff.

CHAPTER 19: DISCHARGE PLANNING Note: This chapter represents a new CMS Condition of Participation. Standards in this section are new, or



2020 Standard

2020 v2 Standard


Detail

relocated from chapter 6, section 8 and are presented in the order in which they appear in chapter 19 (column 2).

19.00.00 COP: Discharge Planning

▪ New CMS Condition of Participation


▪ CFRs revised/added


▪ New Scoring Procedures

STANDARD A Critical Access Hospital (CAH) must have an effective discharge planning process that focuses on the patient’s goals and treatment preferences and includes the patient and his or her caregivers/support person(s) as active partners in the discharge planning for post-discharge care.

The discharge planning process and the discharge plan must be consistent with the patient’s goals for care and his or her treatment preferences, ensure an effective transition of the patient from the CAH to post-discharge care, and reduce the factors leading to preventable CAH and hospital readmissions. §485.642 Tag TBA §482.43

REQUIRED ELEMENTS Discharge planning is a process that involves determining the appropriate post-acute discharge destination for a patient and identifying what the patient requires for a smooth and safe transition to his/her discharge destination.

SCORING PROCEDURE

▪ Verify that the hospital has written policies and procedures for discharge planning.

▪ Evaluate compliance with each standard within the discharge planning CoP in accordance with the guidance below. Following standard practice, depending on the manner and degree of deficiencies identified related to specific discharge planning standards, determine whether deficiencies in one or more of these areas rises to the level of substantial, i.e., condition-level, noncompliance with this CoP.

06.08.05 Discharge Planning: Identification of Patients in Need

19.00.01 Discharge Planning Process

▪ Standard retitled, relocated, revised

▪ New title

▪ All new content

▪ New CFRs

The CAH’s discharge planning process must identify, at an early stage of hospitalization, those patients who are likely to suffer adverse health consequences upon discharge in the absence of adequate discharge planning and must provide a discharge planning evaluation for those patients so identified as



2020 Standard

2020 v2 Standard


Detail

well as for other patients upon the request of the patient, patient’s representative, or patient’s physician.

§485.642(a) §482.43(a)

REQUIRED ELEMENTS Medicare participating hosptials are afforded… The CAH must evaluate patients to identify those for whom the lack of an adequate discharge plan is likely to result in an adverse impact on the patient’s health.

SCORING PROCEDURE Verify that:

▪ Hospital policy requires the identification at an early stage of hospitalization those patients who are likely to suffer adverse health consequences upon discharge or readmission if there is inadequate discharge planning.

▪ Hospital policy addresses the procedure for providing a discharge planning evaluation at the request of the patient, patient’s representative, or patient’s physician.

▪ Ask staff to demonstrate the procedure for the early identification of discharge planning.

19.00.02 Timeliness of Assessment


▪ New Req’d Elements ▪ New Scoring

Procedure

STANDARD Any discharge planning evaluation must be made on a timely basis to ensure that appropriate arrangements for post-CAH care will be made before discharge and to avoid unnecessary delays in discharge.

§485.642(a)(1) §482.43(a)(1)

See manual.

19.00.03 Discharge Planning Evaluation



Procedure

STANDARD A discharge planning evaluation must include an evaluation of a patient’s likely need for appropriate post-CAH services, including, but not limited to, hospice care services, post-CAH extended care services, home health services, and non-health care services and community based care providers, and must also include a determination of the availability of the appropriate services as well as of the patient’s access to those services.

§485.642(a)(2)



2020 Standard

2020 v2 Standard


Detail

§482.43(a)(2)

See manual.

19.00.04 Documenta-tion in Medical Record



Procedure

STANDARD The discharge planning evaluation must be included in the patient’s medical record for use in establishing an appropriate discharge plan and the results of the evaluation must be discussed with the patient (or the patient’s representative).

§ 485.642(a)(3) §482.43(a)(3)

See manual.

19.00.05 Physician Request for Discharge Planning



Procedure

STANDARD Upon the request of a patient’s physician, the CAH must arrange for the development and initial implementation of a discharge plan for the patient.

§485.642(a)(4) §482.43(a)(4)

See manual.

19.00.06 Discharge Plan Developed or Supervised by RN or Social Worker



Procedure

STANDARD Any discharge planning evaluation or discharge plan required under this paragraph must be developed by, or under the supervision of, registered nurse, social worker, or other appropriately qualified personnel.

§485.642(a)(5) §482.43(a)(5)

See manual.

19.00.07 Re-evaluation of Patient Condition



Procedure

STANDARD The CAH’s discharge planning process must require regular re-evaluation of the patient’s condition to identify changes that require modification of the discharge plan. The discharge plan must be updated, as needed, to reflect these changes.

§485.642(a)(6) §482.43(a)(6)

See manual.

19.00.08 Assess the Discharge Planning Process


▪ CFRs revised/added


STANDARD The CAH must assess its discharge planning process on a regular basis.

The assessment must include ongoing, periodic review of a representative sample of discharge



2020 Standard

2020 v2 Standard


Detail

▪ New Scoring Procedures

plans, including those patients who were readmitted within 30 days of a previous admission, to ensure that the plans are responsive to patient post-discharge needs.

§485.642(a)(7) §482.43(a)(7)

See manual.

19.00.09 Selection of a Post-acute Care Provider



Procedure

STANDARD The CAH must assist patients, their families, or the patient’s representative in selecting a post-acute care provider by using and sharing data that includes, but is not limited to, HHA, SNF, IRF, or LTCH data on quality measures and data on resource use measures.

The CAH must ensure that the post-acute care data on quality measures and data on resource use measures is relevant and applicable to the patient’s goals of care and treatment preferences.

§485.642(a)(8) §482.43(a)(8)

See manual.

19.01.01 Transmission of Patient’s Medical Information



Procedure

STANDARD Discharge of the patient and provision and transmission of the patient’s necessary medical information.

The CAH must discharge the patient, and also transfer or refer the patient where applicable, along with all necessary medical information pertaining to the patient’s current course of illness and treatment, post-discharge goals of care, and treatment preferences, at the time of discharge, to the appropriate post-acute care service providers and suppliers, facilities, agencies, and other outpatient service providers and practitioners responsible for the patient’s follow-up or ancillary care.

§485.642(b) §482.43(b)

See manual.

