The CMS The Compliance Crosswalk

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The CMSComplianceCrosswalk2017 Edition

TheCMS Compliance Crosswalk2017 Edition

The CMS Compliance Crosswalk, 2017 Edition, is published by HCPro, an H3.Group division of SimplifyCompliance, LLC.Copyright 2017 HCPro, an H3.Group division of Simplify Compliance, LLC.All rights reserved. Printed in the United States of America.5 4 3 2 1Download the additional materials of this book at www.hcpro.com/downloads/12594ISBN: 978-1-68308-577-5No part of this publication may be reproduced, in any form or by any means, without prior written consent of HCPro or the Copyright Clearance Center (978-750-8400). Please notify us immediately if youhave received an unauthorized copy.HCPro provides information resources for the healthcare industry.HCPro is not affiliated in any way with The Joint Commission, which owns the JCAHO and Joint Commission trademarks.Matt Phillion, EditorKurt Patton, MS, R.Ph, ReviewerJay Kumar, Associate Product ManagerErin Callahan, Vice President, Product Development & Content StrategyElizabeth Petersen, President, H3.GroupMatt Sharpe, Production SupervisorVincent Skyers, Design Services DirectorVicki McMahan, Sr. Graphic DesignerTyson Davis, Cover DesignerJason Gregory, Graphic Design/LayoutAdvice given is general. Readers should consult professional counsel for specific legal, ethical, or clinicalquestions.Arrangements can be made for quantity discounts. For more information, contact:HCPro100 Winners Circle, Suite 300Brentwood, TN 37027Telephone: 800-650-6787 or 781-639-1872Fax: 800-639-8511Email: customerservice@hcpro.comVisit HCPro online at www.hcpro.com and www.hcmarketplace.com

The CMS Compliance Crosswalk, 2017 EditionContentsIntroduction. vCrosswalk. 1§482.11 CoP: Compliance with Federal, State, and Local Laws. 1§482.12 CoP: Governing Body. 3§482.13 CoP: Patient Rights.16§482.21 CoP: Quality Assessment and Performance Improvement Program.35§482.22 CoP: Medical Staff.41§482.23 CoP: Nursing Services.51§482.24 CoP: Medical Record Services.60§482.25 CoP: Pharmaceutical Services.67§482.26 CoP: Radiologic Services.74§482.27 CoP: Laboratory Services.79§482.28 CoP: Food and Dietetic Services.86§482.30 CoP: Utilization Review.89§482.41 CoP: Physical Environment.96§482.42 CoP: Infection Control.102§482.43 CoP: Discharge Planning.105§482.45 CoP: Organ, Tissue, and Eye Procurement.113§482.51 CoP: Surgical Services.116§482.52 CoP: Anesthesia Services.121§482.53 CoP: Nuclear Medicine Services.127§482.54 CoP: Outpatient Services.131§482.55 CoP: Emergency Services.133§482.56 CoP: Rehabilitation Services.136§482.57 CoP: Respiratory Services.139Appendix A.143Appendix B.149Appendix C.153Appendix D.157Appendix E.159 2017 HCPro, an H3.Group division of Simplify Compliance, LLCiii

The CMS Compliance Crosswalk, 2017 EditionAppendix F.185Clinic/Physician Office Tracer.186CMS Survey Tips/Documents.191CMS/OSHA Regulatory Training Requirements.193Departmental Tracer.195ED Tracer.202ICU Tracer.208Medical Staff File Review.214OR/Procedural Tracer.217Restraint Documentation Audit.223iv 2017 HCPro, an H3.Group division of Simplify Compliance, LLC

The CMS Compliance Crosswalk, 2017 EditionIntroductionIn today’s world, consumers can select from many different choices. Walk down any grocery aisle, shopat any hardware store, or Google any topic—the choices of what brand to buy, what light bulb to obtain, or which website to access are numerous and varied. The same is now true for hospitals in choosing an accreditation agency for deemed status; there are more choices than in the past.In 2010, the Centers for Medicare & Medicaid Services (CMS) mandated that states ensure that allnonaccredited, non-deemed hospitals and critical access hospitals are surveyed at least every three yearsand that targeted surveys occur for not less than 5% of all hospitals and critical access hospitals in thestate. Given the differences in survey process (state inspections versus accreditation survey/consultation),there is good reason for hospitals to consider accreditation by a deemed status accreditor.Any hospital that receives Medicare or Medicaid reimbursement for services must meet the federal requirements outlined by CMS called Conditions of Participation (CoP). In addition, most hospitals and healthcare systems participate in a voluntary survey process through an accreditation agency, such as The JointCommission. However, in recent years, other accrediting bodies have been formed and received deemingauthority from CMS.One thing that has not changed is that CMS and other accrediting agencies all regulate the administration ofcare—that is, they regulate the same aspect of healthcare. And most facilities can’t or don’t choose to followone or the other. Both the hospital and the regulatory/accrediting agency surveying the facility want todemonstrate that the organization meets the necessary requirements for compliance. This is done primarilythrough document review, interviews with leaders and staff, observations, and tracer methodology.Organizations must maintain a constant state of readiness and ongoing compliance in order to havesuccessful outcomes. Doing so can seem overwhelming when you have multiple surveys for which to beready, but healthcare facilities do not necessarily need to prepare different documents or different processesto meet the regulatory standards.To help healthcare organizations maintain preparations for surveys, this book outlines and providestools to assist in assessing compliance and survey readiness. It helps hospitals understand the requirements and related standards, see the similarities as well as differences between the requirements, andidentify documents or processes that are already in place so survey preparation can be done withoutduplicating efforts. Thanks to Cheryl A. Niespodziani, MBA, CHC, and Beth A. Hepola, RN, BSN, MBA,who authored previous editions of this book, and Matt Phillion and Kurt Patton, MS, R.Ph, who updated itfor 2017. 2017 HCPro, an H3.Group division of Simplify Compliance, LLCv

The CMS Compliance Crosswalk, 2017 EditionThe main building blocks for survey readiness included throughout this publication are: The CMS CoP, which were taken from the State Operations Manual, Appendix A—Survey Protocol,Regulations, and Interpretive Guidelines for Hospitals (revised November 2015) Related standards from multiple accrediting agencies, including the Center for Improvement ofHealthcare Quality (CIHQ), National Integrated Accreditation for Healthcare Organizations/DNVGLHealthcare USA (NIAHO/DNVGL), and The Joint Commission A summary and analysis section outlining the similarities and differences between CMS and theseaccrediting agencies’ standards Other survey tips and recommendations for helpful documents to have available where applicable A variety of tools and resources to assist with survey preparation and readiness (located inthe attachments)Following is a general table of contents comparison between CMS, The Joint Commission, NIAHO/DNVGL, and CIHQ to show some of the similarities.CMSThe JointCommissionNIAHO/DNVGLCIHQCompliance with Federal,State and Local LawAccreditation ParticipationRequirements andLeadershipGoverning BodyGovernance &LeadershipGoverning BodyLeadershipGoverning BodyGovernance &LeadershipChief Executive OfficerPatient RightsPatient RightsPatient RightsPatient RightsQuality Assessment andPerformance Improvement Quality Management System Quality AssessmentPerformance Improvement& PerformanceProgramImprovement, plusTargeted Patient Quality& Safety PracticesMedical StaffMedical StaffMedical StaffMedical StaffNursing ServicesNursing and MedicationManagementNursing Services andMedication ManagementNursing ServicesMedical Record ServicesInformation Managementand Record of CareMedical Record ServicesManagement of theMedical RecordPharmaceutical ServicesMedication ManagementMedication ManagementMedicationManagementRadiological ServicesProvision of Care,Medical ImagingTreatment and Services,Medical Staff, PerformanceImprovement, MedicalRecords and HumanResourcesRadiology ServicesLaboratory ServicesWaived TestingLaboratory ServicesviLaboratory Services 2017 HCPro, an H3.Group division of Simplify Compliance, LLC

The CMS Compliance Crosswalk, 2017 EditionCMSThe JointCommissionNIAHO/DNVGLCIHQFood and Dietetic Services Provision of Care,Dietary ServicesTreatment and Services,Medical Staff, Performance Utilization ReviewUtilization ReviewImprovement, MedicalRecords and HumanResourcesDietary (Nutrition)ServicesPhysical EnvironmentEnvironment of Care andLife SafetyPhysical EnvironmentManaging the CareEnvironmentInfection ControlInfection Prevention andControlInfection Prevention andControlInfection Prevention &ControlDischarge PlanningProvision of Care,Discharge PlanningTreatment and Services,Medical Staff, PerformanceImprovement, MedicalRecords and HumanResourcesDischarge PlanningServicesOrgan, Tissue and EyeProcurementTransplant SafetyOrgan, Eye and TissueProcurementOrgan, Tissue & EyeProcurementSurgical ServicesProvision of Care,Treatment and Services,Medical Staff, PerformanceImprovement, MedicalRecords and HumanResourcesSurgical ServicesOperative & InvasiveServicesAnesthesia ServicesAnesthesia ServicesNuclear Medicine ServicesNuclear MedicineServicesOutpatient ServicesOutpatient ServicesEmergency ServicesEmergency DepartmentEmergency ServicesRehabilitation ServicesRehabilitation ServicesRehabilitation ServicesRespiratory ServicesRespiratory Care ServicesRespiratory ServicesEmergency ManagementPhysical EnvironmentEmergencyPreparednessHuman ResourcesStaffing ManagementHuman ResourcesAnesthesia ServicesNuclear Medicine ServicesOutpatient ServicesNote: CMS proposedsignificant new rules addressed throughout CoPNational Patient SafetyGoalsUtilization ReviewNote: Includes separate section on Use ofRestraint & SeclusionIn addition, there are similarities and differences in how the various agencies survey, as outlined inthe following.CMSCMS is part of the Department of Health and Human Services and is responsible for issuing the CoP asstandards of care. Surveys are at no cost and occur annually, unless an organization has deemed status.CMS surveys are typically conducted by surveyors from the state health department agency and focusmuch more closely on patient care documentation and the corresponding policies and procedures thatdrive care implementation. Surveyors tend to be less interactive with staff and physicians; they look at 2017 HCPro, an H3.Group division of Simplify Compliance, LLCvii

The CMS Compliance Crosswalk, 2017 Editionpatient records for absence of compliance with relevant CoP and will turn to staff to ask why somethingwas not documented or why a process deviated from stated policy. Typically, they spend less time on thepatient care units than Joint Commission surveyors do.The Joint CommissionEstablished in 1951, The Joint Commission is the oldest of the accrediting agencies. Standards were developedin the early 1900s when the American College of Surgeons created its hospital standardization program, theprecursor to today’s survey process. The Joint Commission is also the most well known of the accreditingbodies. In addition, it fulfills regulatory and payer requirements and provides education and guidance. Surveycost can be expensive. The Joint Commission has proprietary standards (e.g., National Patient Safety Goals) aswell as prescriptive standards, along with complex scoring methods. Over the years, The Joint Commission hasbecome more aligned with CMS CoP, but there are still differences. Using hospital staff’s responses to questionsto guide further queries, Joint Commission surveyors are more interactive than CMS. Documentation is examined within the context of elements of performance validation. The response of clinical staff and physicianscan keep Joint Commission surveyors from dwelling too deeply in patient records. Policies/procedures, medicalstaff bylaws, and other documents are reviewed against actual practice. Additionally, surveyors utilize tracermethodology to identify areas of noncompliance.NIAHO/DNVGLNIAHO/DNVGL started in 1864 as a global entity in Norway. DNV Healthcare is an internationalaccrediting body that incorporates ISO 9000 into its standards. It was approved by CMS as a deemingauthority in 2008. Surveys are conducted annually. Like The Joint Commission, NIAHO/DNVGL fulfillsregulatory and payer requirements and provides education and guidance. With a focus on quality outcomes, NIAHO/DNVGL standards are closely aligned with CMS CoP. The company recently added someproprietary standards, and survey cost can be somewhat expensive.CIHQCIHQ is the newest accrediting body and was granted deeming authority in July 2013. A former consultingcompany for accreditation and regulatory compliance support, CIHQ can accredit acute and critical accesshospitals. Almost 90% of their standards align with CMS CoP.State Health Department AgencyState agencies survey according to CMS CoP to determine certification to participate in Medicare andMedicaid programs. There is no requirement to be surveyed by one of the other agencies listed earlieroutside of the hospital’s respective state. The agencies use the Medicare State Operations Manual to determine compliance with minimal standards.The bottom line is that all healthcare organizations will undergo some kind of survey at some point intime. The key is to understand and educate staff about the changes and at the same time remain flexible to manage the changes and processes. Many similarities between CMS and the various accreditingagencies exist. Hopefully, by understanding these similarities as well as the nuances, ongoing surveypreparation can be efficient and can help your organization achieve excellent results. After all, the goal ofall participants—the hospital, the regulatory agency, and the patient—is high-quality care and service thatmeets and exceeds standards and expectations. The choice is yours!viii 2017 HCPro, an H3.Group division of Simplify Compliance, LLC

The CMS Compliance Crosswalk, 2017 EditionHappy reading and good luck in whichever accreditation program your organization pursues. Contactinformation for the accrediting bodies discussed in this publication is listed next.Center for Improvement in Healthcare Quality (CIHQ)P.O. Box 3620McKinney, TX 75070Phone: 866-324-5080Fax: 805-934-8588Website: www.cihq.orgCenters for Medicare & Medicaid Services (CMS)7500 Security BoulevardBaltimore, MD 21244Phone: 410-786-3000Website: www.cms.govNational Integrated Accreditation for Healthcare Organizations/DNVGL Healthcare USA(NIAHO/DNVGL)400 Techne Center Drive, Suite 100Milford, OH 45150Phone: 866-523-6842Website: www.dnvglhealthcare.comThe Joint CommissionOne Renaissance BoulevardOakbrook Terrace, IL 60181Phone: 630-792-5000Fax: 630-792-5005Website: www.jointcommission.org 2017 HCPro, an H3.Group division of Simplify Compliance, LLCix

The CMS Compliance Crosswalk, 2017 EditionCLINIC/PHYSICIAN OFFICE TRACERNAME OF CLINIC:DATE:STANDARD/QUESTIONEnvironment of careGeneral Cleanliness of unit—vents,waiting areas, etc. Fire extinguishers checkedmonthly? Exit signs visible (maincorridors must be able tosee two) Exit corridors clear Linen covered Doors latch Doors without gaps (nogreater than 1/8 inches wideand undercuts no greater than3/4 inches) Does anyone from thehospital come and performenvironmental rounds fromtime to time?186NotOKHOSPITAL:COMMENTS STANDARD/QUESTIONNot COMMENTSOKFront Desk Patient informationkept confidential andis secure?»» Sign-in proceduresprotect confidentiality»» Computer, opencharts, reports outof sight?»» How are patientscalled to rooms—isidentity of patientprotected? No unsecured meds Hand hygiene readilyavailable Patient rights andresponsibilities postedMedical RecordsStorage Area Secure Adequate firesuppression (sprinklers) Does the hospitalhealth informationmanagement (HIM)department providesupport and monitormedical records fromtime to time? 2017 HCPro, an H3.Group division of Simplify Complian

Crosswalk 2017 Edition The CMS Compliance Crosswalk 2017 Edition The CMS Compliance Crosswalk, 2017 Edition, is the latest and greatest edition of HCPro’s highly regarded accreditation crosswalk. This book shows you how to comply with each Condition of Participation (CoP) set forth by CMS and highlights which

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