2015 Old Standards to New Standards 031415 - HFAPhfap.org/.../10/055_2015_Old_Standards_to_New_Standards.pdf · HFAP Acute Care Hospital Manual Crosswalk of 2014 v 3 Standards against

HFAP Acute Care Hospital Manual

Crosswalk of 2014 v 3 Standards against 2015 Standards

2014 v 3

Standard

CMS Acute Care

Hospital CfR

2014 v 3 Standard

TitleRevised Deleted 2015 Standard Changes

01.00.00 §482.11

Condition of

Participation:

Compliance with

Federal, State, and

Local Laws

01.00.01 Governance Plan

01.00.02 §482.11(a)Compliance with

Laws

01.00.03§482.11(b)(1)

§482.11(b)(2)Hospital Licensure

01.00.04 §482.11(c)Licensure of

Personnel

01.00.05 §482.12

Condition of

Participation:

Governing Body

XRe‐numbered

01.01.00CMS update

01.00.06

Articles of

Incorporation &

Documentation of

Actions

01.00.07Governing Body

ResponsibilitiesX Clarifications

01.00.08§482.12(a)

§482.12(a)(1)

Categories Eligible

for AppointmentX

Re‐numbered

01.01.01CMS update

01.00.09 §482.12(a)(2)Medical Staff

Appointment

Re‐numbered

01.01.02

01.00.10 §482.12(a)(3)

Provision of

Medical Staff

Bylaws

Re‐numbered

01.01.03

Chapter 1 Administration of the Organizational Environment Page 1



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01.00.11 §482.12(a)(4)

Approval of

Medical Staff

Bylaws

Re‐numbered

01.01.04

01.00.12 §482.12(a)(5)Medical Staff

Quality of Care

Re‐numbered

01.01.05

01.00.13 §482.12(a)(6)

Selection Criteria

for Appointment

to the Staff

Re‐numbered

01.01.06

01.00.14 §482.12(a)(7)Required Criteria

for Appointment

Re‐numbered

01.01.07

01.00.15 §482.12(a)(8)

Telemedicine

Agreements with

Distant Hospitals

XRe‐numbered

01.01.08CMS update

01.00.16 §482.12(a)(9)

Telemedicine

Agreements with

Distant Sites

XCombine into

01.01.08CMS update

01.00.17 §482.12(b) CEO AppointmentRe‐numbered

01.01.11

01.00.18

§482.12(c)

§482.12(c)(1)(i)

§482.12(c)(1)(ii)

§482.12(c)(1)(iii)

§482.12(c)(1)(iv)

§482.12(c)(1)(v)

§482.12(c)(1)(vi)

Licensed

Practitioner Care

Requirements

Re‐numbered

01.01.12 & New

title, "Care of

Patients"

01.00.19 §482.12(c)(2)State Privilege

Requirements

Re‐numbered

01.01.13

01.00.20 §482.12(c)(3)Physician

Availability

Re‐numbered

01.01.14




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2014 v 3 Standard


01.00.21 §482.12(c)(4)Medical Staff

Oversight

Re‐numbered

01.01.15

01.00.22

§482.12(d)

§482.12(d)(1)

§482.12(d)(2)

§482.12(d)(3)

§482.12(d)(4)

Institutional Plan &

Budget

Re‐numbered

01.01.16

01.00.23 §482.12(d)(5) Plan SubmissionRe‐numbered

01.01.17

01.00.24 §482.12(d)(6)Plan Review &

Update

Re‐numbered

01.01.18

01.00.25 §482.12(d)(7) Plan PreparationRe‐numbered

01.01.19

01.00.26

Oversight of the

Physical

Environment

XRe‐numbered

01.01.20Clarifications

01.00.27Oversight of the

QAPI Plan

Re‐numbered

01.01.21

01.00.28 §482.12(e)Contracted

ServicesX

Re‐numbered

01.01.22CMS update

01.00.29 §482.12(e)(1)Contractor Quality

Monitoring

Re‐numbered

01.01.23

01.00.30 §482.12(e)(2)List of Contracted

Services

Re‐numbered

01.01.24




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01.00.31

Policy, Procedure

Review, &

Approval

Re‐numbered

01.01.25

01.00.32

Medically‐related

Patient Care

Services

XRe‐numbered

01.01.26Clarifications

01.00.33 §482.12(a)(10)

Governing Body

Periodically

Consults with the

Medical Staff

X 01.01.10 CMS update

01.01.01Compliance

ProgramX Retired

01.01.02Coding Policies &

ProceduresX Retired

01.01.03Compliance Officer

ResponsibilitiesX Retired

01.01.04

Mandatory

Education on

Fraud & Abuse

Regulations

X Retired

01.01.05

Fraud & Abuse

Reporting

Mechanism

X Retired

01.01.06Fraud & Abuse ‐

Corrective ActionX Retired

01.01.07Investigation of

MisconductX Retired




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01.01.08Reporting of Fraud

& Abuse to the OIGX Retired

01.02.01 §482.12(f)Emergency

Services X Format

01.02.02 §482.12(f)(1)

Emergency

Services

Compliance with

Federal Laws

X Format

01.02.03 §482.12(f)(2)

Policies Regarding

Emergency Care

When Services Are

Not Provided

X Format

01.02.04 §482.12(f)(3)Off‐site Emergency

CareX Format




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02.00.01

Allied Health

Practitioner

Categories

X

Incorporated into

the Medical Staff

standards (refer

to 03.00.01 and

03.01.03)

02.00.02

Credentialing

Procedures and

Scope of Practice

X

Incorporated into

the Medical Staff

standards (refer

to 03.00.02,

03.01.03, and

03.01.06)

02.00.03

Federal and State

Regulations

Regarding

Privileges

X

Incorporated into

the Medical Staff

standards (refer

to 03.00.01 and

03.00.02)

02.00.04 Not Applicable

02.00.05

Supervision of

Allied Health

Practitioners

X

Incorporated into

the Medical Staff

standards (refer

to 03.00.01 and

03.00.02)

02.00.06

Quality

Assessment‐

Performance

Improvement

X

Incorporated into

the Medical Staff

standards (refer

to 03.15.01 and

03.15.02)

02.00.07

Allied Health

Professional

Membership

X

Incorporated into

the Medical Staff

standards (refer

to 03.00.01)

Chapter 2 Allied Health Practitioners Page 6



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03.00.00 §482.22

Condition of

Participation:

Medical Staff

X CMS Updates

03.00.01 §482.22(a)Composition of

the Medical Staff X

Retitled,

"Eligibility and

Process for

Appointment to

the Medical

Staff"

CMS Updates

03.00.02 §482.22(a)(1)Periodic Appraisal

of MembersX

CMS Update

addresses

Non‐physician

Practitioners



03.00.05

Responsibilities of

Credentialed

Professionals

03.00.06 §482.22(a)(2)

Recommendation

of Appointment to

Governance

X CMS Updates

03.00.07

Duties &

Responsibilities to

Patients

03.00.08

§482.22(a)(3)

§482.22(a)(3)(i)

§482.22(a)(3)(ii)

§482.22(a)(3)(iii)

§482.22(a)(3)(iv)

Telemedicine

Privileging

Provisions

Through Distant‐

Site Hosptial

Agreements

X CMS Updates

03.00.09

§482.22(a)(4)

§482.22(a)(4)(i)

§482.22(a)(4)(ii)

§482.22(a)(4)(iii)

§482.22(a)(4)(iv)

Telemedicine

Privileging

Provisions

Through Distant‐

Site Telemedicine

Entity Agreements

X CMS Updates

Chapter 3 Medical Staff Page 7



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03.00.10

§482.22(b)

§482.22(b)(1)

§482.22(b)(2)

§482.22(b)(3)

§482.22(b)(3)(i)

§482.22(b)(3)(ii)

§482.22(b)(3)(iii)

Medical Staff

Responsibilities to

the Governing

Body

X CMS Updates

03.01.01 §482.22(c)Medical Staff

Bylaws

03.01.02 §482.22(c)(1)

Medical Staff

Bylaws: Approval

by Governance

X Title Change Format

03.01.03 §482.22(c)(2)

Medical Staff

Bylaws:

Categories, Duties,

& Responsibilities

of the Medical

Staff


03.01.04 §482.22(c)(3)

Medical Staff

Bylaws:

Organization of

the Medical Staff


03.01.05

Attestation

Statements in

Bylaws

03.01.06 §482.22(c)(4)

Medical Staff

Bylaws: Process

for Application

and Reapplication

and Criteria for

Membership

X Title Change

CMS Update

addresses Non‐

physician

practitioners

03.01.07§482.22(c)(5)

§482.22(c)(5)(i)

Medical Staff

Bylaws: History

and Physical

Requirement

X Title Change Clarification

03.01.08 §482.22(c)(5)(ii)

Medical Staff

Bylaws: History

and Physical Prior

to Admission





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03.01.09 §482.22(c)(6)

Medical Staff

Bylaws: Granting

of Privileges


03.01.10

Medical Staff

Policies and

Procedures

03.01.11

Medical Staff

Bylaws: Periodic

Review


03.01.12

Uniform

Application of

Membership

Criteria


03.01.14

Non‐

discrimination in

Application of

Membership

Criteria

03.01.15

Required

Application‐

Reapplication

Information for

Review

X Clarification


03.01.17Emergency

PrivilegesX Format

03.01.18Temporary

PrivilegesX Format

03.01.19Suspension of

PrivilegesX Format

03.01.20Fair Hearing

ProcessX Format

03.01.21

Medical Staff

Bylaws: Definition

of a Clinical

Emergency





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03.01.23

Medical Staff

Bylaws: Meeting

Frequency and

Attendance


03.01.24

Medical Staff

Bylaws: Clinical

Department

Structure


03.02.01 Autopsies X Clarification

03.03.01Medical Executive

CommitteeX Format

03.03.02Medical Executive

Committee ScopeX Format

03.04.01 §482.30

Condition of

Participation:

Utilization Review

X 03.04.00 Clarification

03.04.02 §482.30(a) Applicability X 03.04.01 Clarification

03.04.03

§482.30(b)(1)

§482.30(b)(2)

§482.30(b)(3)

Composition of

Utilization Review

Committee (URC)

03.04.02

03.04.04

§482.30(c)

§482.30(c)(1)

§482.30(c)(1)(i)

§482.30(c)(1)(ii)

§482.30(c)(1)(iii)

§482.30(c)(2)

§482.30(c)(3)

§482.30(c)(4)

§482.30(c)(4)(i)

§482.30(c)(4)(ii)

UR Review

Requirements03.04.03




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03.04.05

§482.30(d)

§482.30(d)(1)

§482.30(d)(1)(i)

§482.30(d)(1)(ii)

§482.30(d)(2)

§482.30(d)(3)

Determination

Regarding

Admissions or

Continued Stays


03.04.06 §482.30(e)

Utilization Review

Scope in Non‐PPS

Hospitals ‐

Extended Stay

Reviews


03.04.07 §482.30(f)

Review of

Professional

Services


03.04.08

The Utilization

Review

Committee

Meeting

Frequency and

Attendance

03.04.07

03.05.01

Utilization of

Osteopathic

Methods and

Concepts

Committee

(OMCC)

03.05.02

OMCC Functions

(Osteopathic

Methods and

Concepts

Committee)

03.05.03

OMCC

Documentation

and Meeting

Frequency and

Attenance

Requirements

(Osteopathic

Methods and

Concepts

Committee)




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03.06.01

Credentials

Committee

(function)

03.06.02

Credentials

Committee

Responsibility

03.06.03Credentials

Committee ScopeX Clarification



03.06.06Incomplete

Applications


03.06.08

Timeframe for

Processing of

Applications

03.06.09

Meeting

Frequency and

Attendance


03.08.01

Joint Advisory

Committee

Responsibility

X Retired

03.08.02

Meeting

Frequency and

Attendance

X Retired


03.10.01Mortality Review

Committee ScopeX Clarification




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2014 v 3 Standard


03.10.02

Mortality Review

Committee

Responsibility‐

Appropriateness

of Care

X Clarification

03.10.03

Mortality Review

Committee

Responsibility‐

Attending

Physician

Involvement

X Clarification

03.10.04Mortality Chart

ReviewX Clarification

03.10.05Mortality Review

Education X Retired

03.10.06

Meeting

Frequency and

Attendance


03.12.01

Availability of

Professional

Literature


03.14.01

Transfusion

Review

Committee

(function)

X Clarification

03.14.02

Scope of the

Transfusion

Review

Committee

X Clarification

03.14.03Performance

ImprovementX Clarification

03.15.01

Ongoing

Professional

Practice

Evaluation (OPPE)

X Clarification




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03.15.02

Focused

Professional

Practice

Evaluation (FPPE)




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2014 v 3 Standard


04.00.01

Governance

Responsibility for

Staffing

04.00.02 Licensure


04.00.04

License Pending &

Lapse or

Restriction of

Licensure/

Certification

04.00.05 Competency

04.00.06

Federal

Employment

Regulations

04.00.07 Staffing Plans

04.00.08

Staffing

Assignment

Criteria

04.00.09Evaluation of

Competence

04.00.10New Employee

Orientation

04.00.11

Required

Orientation

Curriculum

04.00.12Annual Required

Competencies

04.00.13

Employee

Identification

System

X 04.00.11 Revised

Chapter 4 Human Resources Page 15



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2014 v 3 Standard


Chapter 5 For Future Use Page 16



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2014 v 3 Standard


Chapter 6 For Future Use Page 17



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2014 v 3 Standard


07.00.00 §482.42 Infection Control X

07.01.01 §482.42(a)Infection Control

Officer (ICO)X Clarification

07.01.02 §482.42(a)(1)Infection

PreventionX CMS Update

07.01.03 §482.42(a)(2) Incident Log X Retired

07.01.04

§482.42(b)

§482.42(b)(1)

§482.42(b)(2)

Responsibilities of

Chief

Executive Officer,

Medical

Staff & Director of

Nursing

Services

X



07.01.07 Corrective Action

07.01.08Classification of

Infections

07.01.09 Infections Clusters

07.01.10Infection Control

Precautions

07.01.11 Staff Orientation

07.01.12State & Local

Reporting

07.01.13Committee/

Function StructureX Clarification

Chapter 7 Infection Control Page 18



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07.01.14Infection Control

PlanX Clarification

07.01.15Reporting

RequirementsX

07.01.16Periodic Review of

the PlanX Clarification

07.01.17

Healthcare‐

Associated

Infections (HAI)

X Clarification

07.01.18

Quality

Improvement

Priorities

X Clarification

07.01.19

Prevention of

Infection‐Central

Venous Catheters

XPATIENT SAFETY

INITIATIVE

07.01.20Surgical Site

InfectionsX

PATIENT SAFETY

INITIATIVE

07.01.21Hand‐washing

GuidelinesX

PATIENT SAFETY

INITIATIVE

07.01.22Environmental

SurveillanceX Clarification

07.01.23 Employee Health X Clarification

07.01.24Employee Health

PoliciesX Clarification

07.01.25Employee Health‐

Influenza VaccineX

PATIENT SAFETY

INITIATIVE

07.01.26 Annual Report X Clarification

07.02.00 Central Supply X Clarification

07.02.01Decontamination

& Sterilization




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2014 v 3 Standard


07.02.02 Required Policies

07.02.03

Decontamination

of Reusable Items

& Reuse of Single

Use Devices

07.02.04

Preparing,

Assembling,

Wrapping, Storage

of & Distribution

of Sterile

Equipment &

Supplies

07.02.05Monitoring

DevicesX Clarification

07.02.06Sterilization Date

Requirements

07.02.07 Shelf Life

07.02.08 Cold Sterilization

07.02.09Load Control

Numbers

07.02.10 Recall Process

07.02.11

Environment

Requirements in

Decontamination

Rooms

07.03.00 Housekeeping X Clarification

07.03.01Cleaning Products

InventoryX Clarification

07.03.02High Risk Cleaning

ProceduresX Clarification




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2014 v 3 Standard


07.03.03Air Supply &

Return Grills

07.03.04Maintenance of

CeilingsX Clarification

07.03.05Hand‐washing

Sink

07.03.06

Maintenance of

Housekeeping &

Laundry

Equipment

07.03.07 Waste Disposal

07.03.08

Use of Personal

Protective

Equipement

07.04.01 Laundry


07.04.03Clean Linen

Storage

07.05.01 Pest Control

07.05.02Extermination

Program




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2014 v 3 Standard


08.00.01 Inventory

08.00.02Supplies for

Patient Care

08.00.03Safe Storage of

SuppliesX Clarification

08.00.04Policies on Supply

Availability

08.00.05Special Storage

Requirements

08.00.06 Product Recall X Clarification

Chapter 8 Materials Management Page 22



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09.00.01Emergency

Operations PlanX Clarification

09.00.02

Emergency

Hazard

Vulnerability

Analysis (HVA)

X Clarification

09.01.01Emergency Safety

& Security

09.01.02Emergency

Supplies

09.01.03Emergency

Utilities

09.01.04Emergency

DecontaminationX Clarification

09.01.05

Emergency

Personal

Protective

Equipment

09.01.06

Emergency

Nutritional

Services

09.01.07Emergency

CommunicationsX Clarification

09.01.08Incident

Command Center

09.01.09 Emergency Triage X Clarification

09.01.10Emergency

EvacuationX Clarification

09.01.11Volunteer

ManagementX Clarification

09.01.12Business

Continuity

Chapter 9 Emergency Management Page 23



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09.02.01Emergency

ExercisesX Clarification

09.02.02Emergency

Education

Chapter 9 Emergency Management Page 24



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10.00.01 §482.24

Condition of

Participation:

Medical Record

Services

10.00.00 Re‐numbered

10.00.02 §482.24(a)Organization &

StaffingX 10.00.01 Clarification

10.00.03 §482.24(b)Retention of

Medical RecordsX 10.00.02 Clarification

10.00.04 §482.24(b)(1)

Record Security &

Retention

Requirements

10.00.03

10.00.05 §482.24(b)(2) Coding & Indexing X 10.00.04 Clarification

10.00.06 §482.24(b)(3)

Security of

Medical

Information

X 10.00.05 CMS Update

10.01.01 §482.24(c)Content of the

RecordX Clarification

10.01.02Information in

Medical RecordsX Clarification

10.01.03 §482.24(c)(1)Legible &

Complete

10.01.04 §482.24(c)(2)

Dating, Timing, &

Authentication of

Orders

X Clarification

10.01.05

§482.24(c)(3)

§482.24(c)(3)(i)

§482.24(c)(3)(ii)

§482.24(c)(3)(iii)

§482.24(c)(3)(iv)

Pre‐printed

Orders, Order

Sets, & Protocols

X CMS Update

10.01.06Abbreviations &

SymbolsX

Patient Safety

Initiative

Chapter 10 Medical Records Page 25



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10.01.07§482.24 (c)(4)

§482.24(c)(4)(i)(A)

History & Physical

RequirementsX Clarification

10.01.08§482.24(c)(4)(i)

§482.24(c)(4)(i)(B)

History & Physical

Update

Requirements

X Clarification

10.01.09 §482.24(c)(4)(ii)Admitting

Diagnosis

10.01.10 §482.24(c)(4)(iii)Required

ConsultationX

Retitled:

"Consultative

Reports

10.01.11

Required

Consultations ‐

Categories

X Retired

10.01.12Consultation

Requirements

10.01.13Indications for

Consultation X Retired

10.01.14 Second Opinions X Retired

10.01.15 §482.24(c)(4)(iv)Required

Documentation X

Retitled:

Documentation

of Complications

Clarification

10.01.16 §482.24(c)(4)(v) Informed ConsentPatient Safety

Initiative

10.01.17§482.24(c)(2)(vi)

Adequacy of

Available

Information

10.01.18§482.24(c)(2)(vii) Discharge

Summary

10.01.19§482.24(c)(2)(viii) Medical Record

DelinquencyX Clarification




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10.01.20§485.641(a)(1)(ii)

Multi‐disciplinary

Medical Record

Review & Audit

Requirements

X Retired

10.01.21

Patient

Assessments ‐

Content &

Authentication

X Retired

10.01.22Patient / Family

EducationX Retired

10.01.23

For Doctors of

Osteopathic

Medicine only)

Osteopathic

Musculoskeletal

Exam (OME)

10.01.24Initial

Assessments

10.01.25 Progress Notes

10.01.26Multi‐disciplinary

Plan of Care

10.01.27Outpatient

Problem List

10.01.28

Plan of Care ‐

Assessment &

Re‐assessment

10.01.29 Newborn Care

10.01.30

Pediatric /

Adolescent

Patients

10.01.31 Obstetric Patients X Clarification




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10.01.32

Actions Taken to

Improve Glycemic

Control

Patient Safety

Initiative

10.01.33Discharge

Summary

10.02.01

Medical Records

Committee ‐

Scope

X Retired

10.02.02

Medical Records

Committee ‐

Responsibility

X Retired

10.02.03

Medical Records

Committee ‐

Written Reports

X Retired

10.02.04Record Use or

Format ChangesX Retired


10.02.06

Policies on

Confidentiality &

Release of

Records

10.02.07

Medical Records

Committee ‐

Meeting

Frequency &

Attendance

Requirements

X Retired



Crosswalk of 2014 V 3 Standards against 2015 Standards

2014 v 3

Standard

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2014 v 3 Standard


11.00.01 §482.41

Condition of

Participation:

Physical

Environment

11.00.02

Required Plans &

Performance

Standards

X Clarification

11.01.01

Building Safety ‐

Periodic

Monitoring for

Safety Issues

X Clarification

11.01.02 §482.41(a)(1) Building Safety X Clarification

11.01.03Safety Team /

Committee

11.01.04

Safety

Team/Committee

Facilitator

X

Retitled,

"Safety Team /

Committee

Chairperson"

Clarification

11.01.05 Safety Officer

11.01.06

Teams Appointed

for Specific Safety

Areas

X Retired

11.01.07

Safety Team/

Committee

Functions

11.01.08

Review of Safety

Policies/

Procedures

X Clarification

11.01.09

Smoking /

Tobacco Products

Policy

11.02.01 Building Security

Chapter 11 Physical Environment Page 29



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Hospital CfR

2014 v 3 Standard


11.02.02Security

Management

11.02.03Local Security

Support

11.02.04Security Sensitive

Areas

11.02.05Security Incident

Procedures

11.03.01

Hazardous

Materials & Waste

Program

11.03.02 §482.41(b)(6)Storage &

Disposal of Trash

11.03.03

Program

Minimizes

Exposure

11.03.04Labels, Inventory

& MSDSX

Changed to

"SDS"Clarification

11.03.05

Personal

Protective

Equipment (PPE)

11.03.06

Hazardous

Materials ‐

Routine

Monitoring

11.04.01 §482.41(b)(6)Written Fire

Control Plans

11.04.02Fire Drills ‐

QuarterlyX Clarification

11.04.03 Fire Drill ‐ Critique X Clarification




2014 v 3

Standard

CMS Acute Care

Hospital CfR

2014 v 3 Standard


11.04.04 §482.41(b)(8)

Approval by State

& Local Fire

Agencies

X Clarification

11.04.05

Minimize the Risk

of Danger from

Fire

X Clarification

11.05.01

Medical

Equipment &

Sytems:

Maintenance

11.05.02

Medical

Equipment

Inventory

11.05.03Patient Call

System

11.05.04

Safe Medical

Device Act

(SMDA)

11.05.05

Medical

Equipment

Procurement

11.06.01 §482.41(a)(1)Emergency Power

& Lighting

11.06.02Emergency Power

Electrical System

11.06.03Generator

Inspection13.05.04

11.06.04Generator

Monthly Load Test13.05.05

11.06.05Generator 3‐Year

Load Test13.05.06

11.06.06

Automatic

Transfer Switch

Test

13.05.07




2014 v 3

Standard

CMS Acute Care

Hospital CfR

2014 v 3 Standard


11.06.07 Potable Water

11.06.08Medical Gas Shut‐

Off Valves13.05.08

11.06.09

Plant Equipment

& Systems:

Maintenance

11.06.10Plant Equipment

Inventory

11.06.11

Medical Gas

Systems &

Equipment ‐

Maintenance

13.05.10

11.06.12

Water

Temperature

Control

11.07.01

§482.41(c)

§482.41(c)(2)

§482.41(c)(3)

Adequate

Facilities and

Supplies

11.07.02 §482.41(c)(1)

Facilities Located

for Safety of

Patients

11.07.03 §482.41(c)(4)

Ventilation, Light,

& Temperature

Controls

X Clarification

11.07.04

Americans with

Disabilities Act

(ADA)

Retired

11.07.05

Occupational

Safety & Health

Act (OSHA)

Retired

11.07.06

Assessing Risk

Prior to

Construction

11.07.07

Monitoring the

Physical

Environment




2014 v 3

Standard

CMS Acute Care

Hospital CfR

2014 v 3 Standard


11.08.01Fire Response ‐

Staff Training11.04.06




2014 v 3

Standard

CMS Acute Care

Hospital CfR

2014 v 3 Standard


12.00.01 §482.21

Condition of

Participation:

Quality Assurance

Performance

Improvement


12.00.02

Quality

Management

Position

12.01.01

12.00.03 §482.21(a)(1) Program Scope X 12.00.01 CMS Updates

12.00.04Leadership

AccountabilityX 12.01.03

12.00.05

Quality

Committee /

Function

12.01.02

12.00.06

Meetings &

Documentation of

Activities

12.01.03

12.00.07Annual Quality

ReportsX 12.01.04 Clarification

12.00.08Education

ProgramX 12.01.05 Clarification

12.00.09 §482.21(a)(2)Program

Accountability12.00.01 CMS Updates

12.00.10§482.21(b)(1)

§482.21(b)(2)(i)

§482.21(b)(2)(ii)

Program Data X12.00.01

12.00.02CMS Updates

12.00.11 Quality Principles X12.00.01

12.00.02

12.00.12 §482.21(b)(3) Data Collection X12.00.01

12.00.02CMS Updates

Chapter 12 Quality Assessment Performance Improvement Page 34



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2014 v 3 Standard


12.00.13

§482.21(c)(1)(i)

§482.21(c)(1)(ii)

§482.21(c)(1)(iii)

§482.21(c)(iv)

Program Activities X 12.00.02 CMS Updates

12.00.14 §482.21(c)(2) Medical Errors X 12.00.03 CMS Updates

12.00.15 §482.21(c)(3)Sustained

ImprovementsX 12.00.03 CMS Updates

12.00.16§482.21(d)

§482.21(d)(1)

Performance

Improvement

Projects

X 12.00.04 CMS Updates

12.00.17 §482.21(d)(2)

Information

Technology

Systems


12.00.18 §482.21(d)(3)Required

DocumentationX 12.00.04 CMS Updates

12.00.19 §482.21(d)(4)

Quality

Improvement

Organization

Projects


12.00.20

HFAP Clinical

Quality

Measurement

Program

12.01.06

12.00.21

§482.21(e)(1)

§482.21(e)(2)

§482.21(e)(3)

§482.21(e)(4)

§482.21(e)(5)

Governing Body

ResponsiblitiesX 12.00.05 CMS Updates

12.00.22 Culture of Safety X 12.02.01PATIENT SAFETY

INITIATIVE

12.00.23Adverse Event

Review ProcessX 12.02.02

12.01.01Tracking Medical

ErrorsX

12.00.01

12.00.03




2014 v 3

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2014 v 3 Standard


12.01.02

Monitoring

System

Accountability

X12.00.01

12.00.03

12.01.03

Participation in

Analysis of

Medical Errors

X12.00.01

12.00.03

12.01.04Analysis of

Medical ErrorsX

12.00.01

12.00.03

12.01.05 Corrective Action X12.00.01

12.00.03

12.01.06Medical Error

ReportingX

12.00.01

12.00.03

12.01.07Reporting of QAPI

DataX Retired

12.01.08Reporting to the

Board of TrusteesX 12.01.07

12.01.09 Statistical Analysis X 12.00.01

12.01.10

Communication to

the Patient of an

Adverse Event

X 12.02.03PATIENT SAFETY

INITIATIVE

12.01.11Support of

CaregiversX 12.02.04

PATIENT SAFETY

INITIATIVE




2014 v 3

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CMS Acute Care

Hospital CfR

2014 v 3 Standard


13.00.01

§482.41(b)(1)(i)

§482.41(b)(1)(ii)

§482.41(b)(3)

Life Safety Code

Compliance

13.00.02

Alternative Life

Saety Measures ‐

Policy

X Clarification

13.00.03

Alternative Life

Saety Measures ‐

Implementation

13.00.04

Notification of

Emergency

Response Forces

13.00.05

Facility

Demographic

Report (FDR)

X Clarification

13.00.06

Testing &

Inspection ‐

Definition of Time

13.00.07

Testing &

Inspection ‐

Documentation

X Clarification

13.01.01Corridor Door

LatchingX Retitle, "Doors" Clarification

13.01.02 Door Locks X Clarification

13.01.03 Corridor Width X

Retitle,

"Corridor

Clutter"

Clarification

13.01.04 Suites

13.01.05 Exit Signs XRetitle,

"Signage"Clarification

Chapter 13 Life Safety Code Page 37



2014 v 3

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Hospital CfR

2014 v 3 Standard


13.01.06 Exit Discharge X Clarification

13.01.07 Corridor

ProjectionsX

Retitle,

"Corridor"Clarification

13.02.01 Fire Alarm System ‐

InstallationX Clarification

13.02.02 Fire Alarm System ‐

Testing

13.02.03

Fire Alarm System ‐

Transmitting

Signal

X Clarification

13.02.04

Fire Alarm System ‐

Technician

Qualifications

X Clarification

13.03.01

Water‐Based Fire

Protection System ‐

Installation

X Clarification

13.03.02

Water‐Based Fire


Testing &

Inspection

X Clarification

13.03.03

Water‐Based Fire


Control Valves,

Piping and

Hangers

13.03.04Fire Pumps ‐

Weekly Test

13.03.05Fire Pumps ‐

Annual Test

13.03.06

Alternative Fire

Suppression

Systems ‐

Installation &

Testing




2014 v 3

Standard

CMS Acute Care

Hospital CfR

2014 v 3 Standard


13.03.07

Water‐Based

Standpipes &

Hoses ‐ Inspection

& Test

X Clarification

13.03.08

Water‐Based Fire

Department

Connections ‐

Inspection

X Clarification

13.03.09

Portable Fire

Extinguishers ‐

Installation,

Inspection and

Maintenance

X Clarification

13.04.01 Fire Rated Barriers

13.04.02

Smoke

Compartment

Barriers

13.04.03Fire & Smoke

Damper ‐ TestingX Clarification

13.04.04

Overhead Rolling /

Horizontal Sliding

Fire Doors ‐

Testing

13.04.05 Construction Type X Clarification

13.04.06Separated

Occupancies

13.04.07Fire Rated Door

Assemblies

13.04.08 Hazardous Areas

13.04.09 Ceilings




2014 v 3

Standard

CMS Acute Care

Hospital CfR

2014 v 3 Standard


13.04.10 Corridor Walls

13.05.01 Fireplaces

13.05.02 Elevator Recall X Clarification

13.05.03Trash & Linen

Chutes

13.06.01 Decorations

13.06.02 Trash Receptacles

13.06.03 Portable Heaters

13.06.04Life Safety

DrawingsX Clarification

13.06.05 §482.41(b)(9)(ii)

Alcohol Based

Hand‐Rub

Dispensers

X Clarification

13.06.06

Definition of New

Construction &

Existing Conditions

13.07.01 §482.41(b)(2)CMS Waiver of

Life Safety Code

13.07.02

Fire Safety

Evaluation System

(FSES)

X Clarification




2014 v 3

Standard

CMS Acute Care

Hospital CfR

2014 v 3 Standard


14.00.01 §482.45

Condition of

Participation:

Organ, Tissue, and

Eye Procurement


14.00.02§482.45(a);

§482.45(a)(1)

Organ/Tissue

Donation and

Transplantation

14.00.01

14.00.03 §486.316(e)OPO Waiver

Requests14.00.02

14.00.04§482.45(a)(2) Tissue and Eye

Bank Agreements14.00.03

14.00.05§482.45(a)(3) Informed Consent


14.00.06 §482.45(a)(3)Designated

Requestors14.00.05

14.00.07 §482.45(a)(4)Sensitivity

Training14.00.06

14.00.08 §482.45(a)(5)OPO

Responsibilities14.00.07

14.00.09§482.45(b)(1);

§482.45(b)(2)

Organ Transplant

Facilities14.00.08

14.00.10 §482.45(b)(3)Data Collection

and Reporting14.00.09

14.00.11§482.24(b)(3);

§486.306(o)

Confidentiality of

Patient Records14.00.10

Chapter 14 Organ Procurement Page 41



2014 v 3

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CMS Acute Care

Hospital CfR

2014 v 3 Standard


Chapter Title

Changed to:

Patient Rights &

Discharge

Planning

15.00.00 §482.13

Condition of

Participation:

Patient's Rights



15.01.02§482.13(a)

§482.13(a)(1)

Notice of Patient

Rights

15.01.03 §482.13(a)(2)Patient

Grievances

15.01.04 §482.13(a)(2)

Governing Body

Responsibility for

the

Grievance Process

15.01.05 §482.13(a)(2) Timely Referrals

15.01.06 §482.13(a)(2)(i) Grievance Process

15.01.07 §482.13(a)(2)(ii)

Grievance Process

Response

Timeframes

15.01.08 §482.13(a)(2)(iii)

Patient

Notification of the

Grievance Process

Chapter 15 Patient Rights and Discharge Planning Page 42



2014 v 3

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CMS Acute Care

Hospital CfR

2014 v 3 Standard


15.01.09

§482.13(b)(1)

§482.13(b)(2)

§482.13(b)(3)

§482.13(b)(4)

§482.13(c)(1)

§482.13(c)(2)

§482.13(c)(3)

§482.13(d)(1)

§482.13(d)(2)

§482.13(e)(1)§482.13(h)(1)(2)(3)(4)

Exercise of

Patient’s Rights

15.01.10 §482.13(b)(1)Participation in

the Plan of Care

15.01.11 §482.12(b)(2)Participation in

Decision Making

15.01.12 §482.13(b)(3)Advance

Directives


15.01.14 §482.13(b)(4)Admission

Notification


15.01.16§482.13(c)

§482.13(c)(1)

Privacy & Safety:

Personal Privacy

15.01.17 §482.13(c)(2)Privacy & Safety:

Safe Setting

15.01.18 §482.13(c)(3)Privacy & Safety:

Free From Abuse






2014 v 3

Standard

CMS Acute Care

Hospital CfR

2014 v 3 Standard


15.01.21§482.13(d)

§482.13(d)(1)

Confidentiality of

Patient Records:

Confidentiality of

Medical Records

15.01.22 §482.13(d)(2)Access to Medical

Records



15.01.25 §482.13(h) Visitation Rights

15.01.26§482.13(h)(1)

§482.13(h)(2)

Patient Visitation

Rights


15.01.28§482.13(h)(3)

§482.13(h)(4)

Visitation Rights ‐

Discrimination


15.02.00 §482.13(e)Restraint or

Seclusion

15.02.01 §482.13(e)(1)(i)(A)Restraint

Definitions

15.02.02 §482.13(e)(1)(i)(B)Medication as a

Restraint

15.02.03 §482.13(e)(1)(i)(C) Non‐Restraints X Clarification

15.02.04 §482.13(e)(1)(ii)Definition of

Seclusion




2014 v 3

Standard

CMS Acute Care

Hospital CfR

2014 v 3 Standard


15.02.05 §482.13(e)(2)Least Restrictive

Interventions


15.02.07 §482.13(e)(3)Effective

Restraints

15.02.08§482.13(e)(4)

§482.13(e)(4)(i)

Modification of

the Plan of Care ‐

Restraint or

Seclusion

15.02.09 §482.13(e)(4)(ii) Safe Application

15.02.10 §482.13(e)(5)

Orders for

Restraint or

Seclusion

15.02.11 §482.13(e)(6)Use of Standing or

PRN Orders

15.02.12 §482.13(e)(7)

Physician

Notification of

Restraint Use

15.02.13 §482.13(e)(8)(i)

Restraint Orders

for Management

of Violent

Behavior

15.02.14 §482.13(e)(8)(ii)Physician

Assessment

15.02.15 §482.13(e)(8)(iii)Renewal of

Restraint Orders

15.02.16 §482.13(e)(9)Discontinuation of

Restraints

15.02.17 §482.13(e)(10)Monitoring of the

Patient




2014 v 3

Standard

CMS Acute Care

Hospital CfR

2014 v 3 Standard


15.02.18 §482.13(e)(11) Physician Training

15.02.19 §482.13(e)(12)(i)One Hour Face‐to‐

Face

15.02.20 §482.13(e)(12)(ii)

Physician

Assessment

Requirements

15.02.21 §482.13(e)(13)State

Requirements

15.02.22 §482.13(e)(14)Physician

Notification

15.02.23 §482.13(e)(15)

Simultaneous Use

of Restraint and

Seclusion

15.02.24 §482.13(e)(16)(i)Requirements for

Documentation

15.02.25 §482.13(e)(16)(ii)Requirements for

Documentation

15.02.26 §482.13(e)(16)(iii)Requirements for

Documentation

15.02.27 §482.13(e)(16)(iv)Requirements for

Documentation

15.02.28 §482.13(e)(16)(v)Requirements for

Documentation

15.02.29 §482.13(f)

Staff Training

Requirements ‐

Use of Restraints

or Seclusion

15.02.30

§482.13(f)(1)(i)

§482.13(f)(1)(ii)

§482.13(f)(1)(iii)

Training Intervals




2014 v 3

Standard

CMS Acute Care

Hospital CfR

2014 v 3 Standard


15.02.31 §482.13(f)(2)(i) Training Content

15.02.32 §482.13(f)(2)(ii)

Training

Requirements:

Nonphysical

Intervention

15.02.33 §482.13(f)(2)(iii)

Training

Requirements:

Least Restrictive

Intervention

15.02.34 §482.13(f)(2)(iv)

Training

Requirements:

Safe Application

15.02.35 §482.13(f)(2)(v)

Training

Requirements:

Restraint Removal

15.02.36 §482.13(f)(2)(vi)

Training

Requirements:

Patient

Monitoring

15.02.37 §482.13(f)(2)(vii)

Training

Requirements:

CPR Training

15.02.38 §482.13(f)(3)Trainer

Requirements

15.02.39 §482.13(f)(4)Training

Documentation





2014 v 3

Standard

CMS Acute Care

Hospital CfR

2014 v 3 Standard


15.02.41

§482.13(g)(1)

§482.13(g)(1)(i)(ii)(iii)

§482.13(g)(2)

§482.13(g)(2)(i)(ii)

§482.13(g)(3)

§482.13(g)(3)(i)(ii)

§482.13(g)(4)

§482.13(g)(4)(i)(ii)(iii)

Death Related to

Restraint or

Seclusion ‐

Reporting

Requirements

15.03.00 §482.43

Condition of

Participation:

Discharge

Planning

15.03.01 §482.43(a)

Discharge

Planning ‐

Identification of

Patients in Need

15.03.02

§482.43(b)

§482.43(b)(1)

§482.43(b)(3)

§482.43(b)(4)

Discharge

Planning

Evaluation

15.03.03 §482.43(b)(2)

Discharge

Planning ‐ Staff

Qualifications



15.03.06 §482.43(b)(5)Timeliness of

Assessment

15.03.07 §482.43(b)(6)

Patient

Involvement &

Documentation

Requirements





2014 v 3

Standard

CMS Acute Care

Hospital CfR

2014 v 3 Standard


15.03.09§482.43(c)

§482.43(c)(1)

Discharge

Planning:

Required

Supervision

15.03.10 §482.43(c)(2)Discharge Plan ‐

Physician Request

15.03.11§482.43(c)(3)

§482.43(c)(5)

Implementation

of the Discharge

Plan

15.03.12 §482.43(c)(4)Plan

Reassessment


15.03.14

§482.43(c)(6)

§482.43(c)(6)(i)

§482.43(c)(6)(ii)

§482.43(c)(6)(iii)

§482.43(c)(7)

§482.43(c)(8)

Selection of

Discharge Care

Providers











2014 v 3

Standard

CMS Acute Care

Hospital CfR

2014 v 3 Standard



15.03.23 §482.43(d)Transfer or

Referral

15.03.24 §482.43(e)Discharge Plan

Reassessment


15.03.26Discharge

InstructionsX Clarification

15.03.27Discharge

Checklist




2014 v 3

Standard

CMS Acute Care

Hospital CfR

2014 v 3 Standard


16.00.00 §482.23

Condition of

Participation:

Nursing Services



16.00.03 §482.23(a) Nursing

OrganizationX Clarification

16.00.04 §482.23(b)Staffing and

Delivery of CareX

Title change:

Staffing and

Delivery of Care

16.00.05 §482.23(b)(1) 24‐Hour Provision

of Services

16.00.06 §482.23(b)(2) Licensure



16.00.09 §482.23(b)(3)Supervision of

Care

16.00.10 §482.23(b)(4) Plan of Care

16.00.11 §482.23(b)(5) Care Assignments


16.00.13 §482.23(b)(6)

Supervision of

Non‐employee

Staff


Chapter 16 Nursing Department Page 51



2014 v 3

Standard

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Hospital CfR

2014 v 3 Standard




16.01.01

§482.23(c)

§482.23(c)(1)(i)

§482.23(c)(2)

Preparation and

Administration of

Drugs


16.01.03

§482.23(c)(1)(ii)

§482.23(c)(3)

§482.23(c)(3)(iii)

Medication

Orders

16.01.04 §482.23(c)(3)(i) Verbal Orders

16.01.05 §482.23(c)(3)(ii)Accepting Verbal

Orders

16.01.06 §482.23(c)(4)

Administration of

Blood Products

and IV

Medications

16.01.07 §482.23(c)(5)

Adverse Drug

Reactions,

Transfusion

Reaction, &

Medical Error

Reporting


16.01.09

§482.23(c)(6)

§482.23(c)(6)(i)

§482.23(c)(6)(i)(A)

§482.23(c)(6)(i)(B)

§482.23(c)(6)(i)(C)

§482.23(c)(6)(i)(D)

§482.23(c)(6)(i)(E)

Self‐

Administration of

Medications:

Hospital‐Issued

Medications




2014 v 3

Standard

CMS Acute Care

Hospital CfR

2014 v 3 Standard


16.01.10

§482.23(c)(6)(ii)

§482.23(c)(6)(ii)(A)

§482.23(c)(6)(ii)(B)

§482.23(c)(6)(ii)(C)

§482.23(c)(6)(ii)(D)

§482.23(c)(6)(ii)(E)

Self‐

Administration of

Medications:

Medications

Brought into the

Hospital



16.02.02 Patients at RiskPatient Safety

Initiative

16.02.03List of Patient

ProblemsX Retired


16.02.05Reassessements

of PatientsX Retired

16.03.00Standards of

Practice & CareX Retired

16.03.01Standards of

PracticeX Retired

16.03.02Clinical Practice

StandardsX Retired

16.03.03 Standards Content X Retired

16.03.04 Standards of Care X Retired

16.03.05Standards

AvailabilityX Retired

16.03.06 Standards Review X Retired




2014 v 3

Standard

CMS Acute Care

Hospital CfR

2014 v 3 Standard


16.04.01

Nursing Quality

Assessment

Performance

Improvement

(QAPI)

X Retired

16.04.02 Use of QAPI Data X Retired




2014 v 3

Standard

CMS Acute Care

Hospital CfR

2014 v 3 Standard

TitleRevised Deleted

2015

StandardChanges

17.00.00 §482.57

Condition of

Participation:

Respiratory

Services

X Clarification

17.00.01 §482.57(a)Organization &

Staffing

17.00.02 §482.57(a)(1) Medical Director X Clarification

17.00.03 §482.57(a)(2)Staffing &

Qualifications

17.00.04 §482.57(b)Policies &

ProceduresX Clarification

17.00.05 §482.57(b)(1) Qualified Staff X Clarification

17.00.06 §482.57(b)(2)

Clinical

Laboratory

Testing

X Clarification

17.00.07 §482.57(b)(3) Services Provided X Clarification

17.00.08 §482.45(b)(4)Respiratory Care

Services Orders

17.00.09Therapeutic

Medical Gases

17.00.10

Adverse Drug

Reactions &

Medication Errors


17.00.12Equipment

Availability

17.00.13 Assessment

Chapter 17 Respiratory Care Page 55



2014 v 3

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2014 v 3 Standard


18.00.00

Cardiovascular

Services and

Interventional

Radiology Services


18.00.01Applicable

StandardsX 18.00.05 Clarification

18.00.02Physical

EnvironmentX 18.00.02 Clarification

18.00.03

Availability of

Applicable Rules

and Regulations

X Retired

18.00.04

Moderate

Sedation ‐

Monitoring

X18.00.08

18.00.09Clarification

18.00.05

Moderate

Sedation ‐

Assisting with

Procedure


18.00.06 Instrumentation X 18.00.04 Clarification

18.00.07Preoperative

AssessmentX 18.00.11 Clarification

18.00.08 Patient Eligibility X 18.00.01 Clarification

18.00.09Physical

EnvironmentX 18.00.03 Clarification

18.00.10Outpatient

ProceduresX 18.00.01 Clarification

18.00.11

Outpatient

Discharge

Requirements


18.00.12Discharge

InstructionsX 18.00.14 Clarification

Chapter 18 Cardiovascular Services and Interventional Radiology Page 56



2014 v 3

Standard

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Hospital CfR

2014 v 3 Standard


18.00.13

Outpatient

Discharge

Summary


18.00.14 Outpatient Follow‐

upX 18.00.15 Clarification

Chapter 18 Cardiovascular Services and Interventional Radiology Page 57



2014 v 3

Standard

CMS Acute Care

Hospital CfR

2014 v 3 Standard


19.00.00 §482.26

Condition of

Participation:

Radiological

Services

X CMS Update

19.00.01 §482.26(a) Scope of Service X CMS Update

19.00.02 §482.26(b) Safety of Services X

Safety for

Patients and

Personnel

CMS Update

19.00.03 §482.26(b)(1) Shielding X CMS Update

19.00.04 §482.26(b)(2)Equipment

InspectionsX CMS Update

19.00.05 §482.26(b)(3) Exposure Meters X CMS Update

19.00.06 §482.26(b)(4) Orders X CMS Update

19.00.07Physicist

Inspections

19.00.08Equipment Output

Monitoring

19.00.09

Approval of

Policies &

Procedures

19.00.10 §482.26(c) Personnel

19.00.11 §482.26(c)(1)Medical

SupervisionX CMS Update

19.00.12Personnel

Requirements

19.00.13 §482.26(c)(2)Qualified

PersonnelX CMS Update

Chapter 19 Diagnostic Radiology and Radiation Therapy Services Page 58



2014 v 3

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CMS Acute Care

Hospital CfR

2014 v 3 Standard


19.00.14Order

Requirement

19.00.15 §482.26(d)Record

MaintenanceX CMS Update

19.00.16 §482.26(d)(1)Report

AuthenticationX

Combined with

19.00.15

19.00.17Qualified

Physicians

19.00.18 Contrast MediaPatient Safety

Initiative

19.00.19 §482.26(d)(2)Retention of

RecordsX

Combined with

19.00.15

19.00.20Labeling of

Radiographs

Patient Safety

Initiative

Chapter 19 Diagnostic Radiology and Radiation Therapy Services Page 59



2014 v 3

Standard

CMS Acute Care

Hospital CfR

2014 v 3 Standard


20.00.01 §482.55

Condition of

Participation:

Emergency

Services

X

02.00.00;

02.00.01;

06.00.06

20.00.02§482.55(a);

§482.55(a)(1)

Medical Staff

LeadershipX

20.00.03 §482.55(a)(2) Integration X

20.00.04 §482.55(a)(3)Policies &

ProceduresX

06.00.00;

06.00.01;

06.00.02;

06.00.03;

06.00.04


& ProceduresX 02.01.00

20.00.06§482.55(b);

§482.55(b)(1)Personnel X

20.00.07 482.55(b)(2)

Personnel:

Staffing & Staff

Qualifications

X 02.00.07

20.00.08 Staff Training X 02.01.01

20.00.09 Records X 02.01.02

20.00.10Emergency Room

LogX 02.01.03

20.00.11

Change in

Treatment Plan

Log

X 02.01.04

20.00.13 §482.12(f)(3)

Provision of

Emergency

Services in Off‐

Campus

Departments

X

Chapter 20 Emergency Services Page 60



2014 v 3

Standard

CMS Acute Care

Hospital CfR

2014 v 3 Standard


20.00.14

(20.00.17)

Personnel‐Medical

Screening

Examinations by a

Registered Nurse

X 02.00.07

20.00.15Personnel ‐

Registered NurseX 02.00.07

20.00.16

Coordination with

Emergency

Response Systems

X 02.00.08

20.00.17

Equipment,

Supplies, &

Medication

X

02.00.02;

02.00.03;

02.00.04;

06.01.00

20.00.18Blood & Blood

ProductsX

02.00.05;

02.00.06

Chapter 20 Emergency Services Page 61



2014 v 3

Standard

CMS Acute Care

Hospital CfR

2014 v 3 Standard


21.00.01Endoscopic

ServicesX 18.00.01

21.00.02

Medical Staff

Rules &

Regulations

X Retired

21.00.03Moderate

SedationX 18.00.08

21.00.04Staffing

RequirementsX 18.00.09


21.00.06Clean

EnvironmentX 18.00.04

21.00.07Physical

Environment X 18.00.03

21.00.08 Patient Eligibility X 18.00.01

21.00.09 Outpatient X 18.00.01

21.00.10

Outpatient

Discharge

Requirements

X 18.00.13

21.00.11

Outpatient

Discharge

Instructions

X 18.00.14

21.00.12Outpatient Follow‐

upX 18.00.15

Chapter 21 Endoscopic Services Page 62



2014 v 3

Standard

CMS Acute Care

Hospital CfR

2014 v 3 Standard


22.00.00 Laboratory

ServicesX

Condition of

Participation:

Laboratory

Services

Clarification

22.00.01 §482.27

Contion of

Participation:

Scope of Services

22.00.00

22.00.02 §482.27(a)

Accreditation/

Certification of

Laboratory

Services

22.00.01

22.00.03 §482.27(a)(1)

Emergency

Service

Availability

22.00.02

22.00.04 §482.27(a)(2)

Laboratory

Services

Description


22.00.05 §482.27(a)(3) Tissue Specimens X 22.00.04 Clarification

22.00.06 §482.27(a)(4)Required Tissue

Examination22.00.05

22.01.01 §482.27(b)

Potentially

Infectious Blood &

Blood

Components

X Clarification

22.01.02

Exposure

Resulting in HIV

Conversion

22.01.03§482.27(c)(1)

§482.27(c)(2)

General Blood

Safety Issues

22.02.01Point of Care

Testing

Chapter 22 Laboratory Services Page 63



2014 v 3

Standard

CMS Acute Care

Hospital CfR

2014 v 3 Standard


23.00.00 §482.53

Condition of

Participation:

Nuclear Medicine

Services

X CMS Update

23.00.01§482.53(a)

Organization &

StaffingX CMS Update

23.00.02 §482.53(a)(1) Medical Director XCombined with

23.00.01CMS Update

23.00.03 §482.53(a)(2)Personnel

Requirement X

Combined with

23.00.01CMS Update

23.00.04§482.53(b)

§482.53(b)(1)

Policy and

Procedure

Requirements

X

Re‐titled to

"Delivery of

Service"

CMS Update

23.00.05 §482.53(b)(1)

In‐House

Preparation of

Radio

pharmaceuticals

X CMS Update

23.00.06 §482.53(b)(2)Storage and

Disposal of WasteX

Combined with

23.00.01CMS Update

23.00.07Shielding

Requirements

23.00.08Monitoring of

ExposureX Clarification

23.00.09

Nuclear

Regulatory

Commission

Licensure

23.00.10 §482.53(b)(3) Laboratory Testing X CMS Update

23.00.11 §482.53(c)

Safe Handling of

Reagents and

Equipment

Maintenance

XRe‐titled to

"Facilities"CMS Update

Chapter 23 Nuclear Medicine Services Page 64



2014 v 3

Standard

CMS Acute Care

Hospital CfR

2014 v 3 Standard


23.00.12§482.53(c)(1)

§482.53(c)(2)Equipment Safety X

Combined with

23.00.11CMS Update

23.00.13

Handling and

Disposal of

Radium Elements

23.00.14

Approval of

Policies and

Procedures

23.00.15Order

Requirements

23.00.16 §482.53(d)Medical Record

RequirementsX CMS Update

23.00.17 §482.53(d)(1)Record Retention

RequirementsX

Combined with

23.00.16CMS Update

23.00.18 §482.53(d)(2)Qualified

PractitionersX

Combined with

23.00.16CMS Update

23.00.19 §482.53(d)(3)Documentation

RequirementsX CMS Update

23.00.20 §482.53(d)(4)Qualified Ordering

PractitionersX CMS Update

Chapter 23 Nuclear Medicine Services Page 65



2014 v 3

Standard

CMS Acute Care

Hospital CfR

2014 v 3 Standard


24.00.00 §482.28

Condition of

Participation:

Food and Dietetic

Services

X Clarification

24.00.01 §482.28(a) Organization

24.00.02

§482.28(a)(1)

§482.28(a)(1)(i)

§482.28(a)(1)(ii)

§482.28(a)(1)(iii)

Food and Dietetic

ServicesX Clarification

24.00.03 §482.28(a)(2) Dietitian Services X Clarification

24.00.04 §482.28(a)(3)Staffing

QualificationsX Clarification

24.00.05§482.28(b)

Nutritional

Screening

Assessments

X Retired

24.00.06 §482.28(b)(1)Patient Nutritional

NeedsX Clarification

24.00.07 §482.28(b)(2) Diet Orders X Clarification

24.00.08 §482.28(b)(3) Diet Manual X Clarification

24.00.09

Access to

Professional and

Evidence‐Based

Dietetics Practice

Resources

24.00.10

Nutrition

Counseling and

Education

24.00.11Outcomes

Management

Chapter 24 Nutritional Services Page 66



2014 v 3

Standard

CMS Acute Care

Hospital CfR

2014 v 3 Standard


24.00.12Emergency

Preparedness Plan

24.01.01

Food Service

Department ‐

General

Requirements

24.01.02

Policy

Requirement ‐

Tube Feedings

24.01.03

Policy

Requirement ‐

Food Preparation

and Storage in

Patient Care Areas

24.01.04

Preparation and

Storage of

Formula and

Breastmilk

X Clarification

24.01.05 Vending Machines X Retired

24.01.06 Ice Machines X Retired

24.01.07 Trash Disposal

24.01.08Physical

Environment

24.01.09

Lighting,

Ventilation, and

Temperature

Control

24.01.10 Staff Education

24.01.11Staff Hygiene and

Health

24.01.12 China and Utensils




2014 v 3

Standard

CMS Acute Care

Hospital CfR

2014 v 3 Standard


24.01.13 Traffic Control

24.01.14

Food Storage and

Preparation in

Remote Areas

24.01.15Local Health

Standards

24.01.16 Infection Control




2014 v 3

Standard

CMS Acute Care

Hospital CfR

2014 v 3 Standard


25.00.00 §482.25

Conditon of

Participation:

Pharmaceutical

Services

25.00.01 Licensure

25.00.02Permits &

Certifications

25.00.03 Scope of Service

25.00.04 §482.25(a)(1)

Pharmacy

Management &

Administration

X Clarification

25.00.05 §482.25(a)(1) Management

25.00.06 §482.25(a)(2) Staffing X Clarification

25.00.07 §482.25(a)(3) Scheduled Drugs

25.00.08Space

Requirements

25.01.01 §482.25(b)

Medication

Control &

Distribution

X Clarification

25.01.02 §482.25(b)(1)

Supervision of

Pharmacy

Activities

X Clarification

25.01.03§482.25(b)(2)(i) Security of

Medications

25.01.04 §482.25(b)(2)(ii)Controlled

Substances

Chapter 25 Pharmacy Services / Medication Use Page 69



2014 v 3

Standard

CMS Acute Care

Hospital CfR

2014 v 3 Standard


25.01.05 §482.25(b)(2)(iii)

Access to

Controlled

Substances

25.01.06 Pharmacy Security

25.01.07 §482.25(b)(3)

Inventory

Management

System

25.01.08 §482.25(b)(4) Pharmacy Access X Clarification

25.01.09 §482.25(b)(5)Automatic Stop

Medication Order

25.01.10 §482.25(b)(6)

Drug Reactions,

Administration

Errors, &

Incompatibilities

X Clarification

25.01.11 §482.25(b)(7)

Reporting of

Controlled Drug

Loss and/or Abuse

X Clarification

25.01.12 §482.25(b)(8)Informational

ResourcesX Clarification

25.01.13 §482.25(b)(9) Formulary System X Clarification

25.01.14Integrity of

MedicationsX Clarification

25.01.15

Consultations/

Resource

Availability

25.01.16Medication

Protocols

25.01.17Home

Medications X Clarification




2014 v 3

Standard

CMS Acute Care

Hospital CfR

2014 v 3 Standard


25.01.18 Labeling

25.01.19Standardization of

Labeling

25.01.20High‐Alert

Medications

Patient Safety

Initiative

25.01.21Dispensing

Methods

Patient Safety

Initiative

25.01.22

Preparation of

Intravenous Drugs

& Fluids

25.01.23 Sample Drugs

25.01.24Patient

Medication Profile

25.01.25 Profile ReviewPatient Safety

Initiative

25.01.26Drug

Administration

25.01.27

Label Medications

& Solutions on the

Sterile Field

Patient Safety

Initiative

25.01.28Investigational

Drugs

25.01.29 Documentation

25.01.30Antithrombotic

Therapy

Patient Safety

Initiative

25.02.01

Preparation &

Administration of

Drugs

Patient Safety

Initiative




2014 v 3

Standard

CMS Acute Care

Hospital CfR

2014 v 3 Standard


25.02.02

Medication

Preparation

Environment

Patient Safety

Initiative

25.02.03Medication

Reconciliation

Patient Safety

Initiative

25.03.01Performance

Improvement

25.03.02Data Collection &

Monitoring

25.03.03Medication Use

Review

25.03.04 Data Reporting

25.03.05Annual Report on

Medication Use

25.03.06

Performance

Improvement in

Medication Use

Patient Safety

Initiative




2014 v 3

Standard

CMS Acute Care

Hospital CfR

2014 v 3 Standard


26.00.00Rehabilitation

Unit Services

Moved to

Chapter 33:

Distinct Part Unit

26.00.01Rehabilitation

Unit Services

26.00.02 §412.25(a)(1)Excluded Hospital

Units33.00.01

26.00.03 §412.25(a)(2) Admission Criteria X 33.00.02 Clarification

26.00.04 §412.25(a)(3)Separate Medical

RecordsX 33.00.03 Clarification

26.00.05 §412.25(a)(4)

Availability of

Clinical Records &

Information


26.00.06 §412.25(a)(5)State Licensure

RequirementsX 33.00.05 Clarification

26.00.07 §412.25(a)(6)Utilization Review


26.00.08 §412.25(a)(7)Distinct Unit

StructureX 33.00.07 Clarification

26.00.09§412.29

§412.29(a)

Provider

AgreementX

33.01.00


26.00.10 §412.29(b)Preadmission

ScreeningX 33.01.04 CMS Update

26.00.11 §412.29(c)

Medical

Supervision &

Personnel

Qualifications


26.00.12 §412.29(d) Plan of Treatment X 33.01.08 CMS Update

Chapter 26 DPU Distinct Part Unit ‐ Physical Rehabilitation Services Page 73



2014 v 3

Standard

CMS Acute Care

Hospital CfR

2014 v 3 Standard


26.00.13 §412.29(e)

Coordinated

Multidisciplinary

Team Approach


26.00.14Multidiciplinary

Team33.02.01

26.00.15 §412.29(f)Director ‐


26.00.16Physician

Responsibility33.02.02

26.00.17 Nursing Care 33.02.03

26.00.18Organizational

Plan33.02.04

26.00.19Collaborative

Goals33.02.05

26.00.20Patient / Family

Education33.02.06

26.00.21

Quality

Assessment

Performance

Improvement

33.02.07

26.00.22 §412.25(b) Change in Size X 33.00.14 Clarification

26.00.23§412.25(c)(1)

§412.25(c)(2)Change in Status X 33.00.15 Clarification

26.00.24 §412.25(d)Number of

Excluded UnitsX 33.00.16 Clarification

Chapter 26 DPU Distinct Part Unit ‐ Physical Rehabilitation Services Page 74



2014 v 3

Standard

CMS Acute Care

Hospital CfR

2014 v 3 Standard


26.01.00 §482.56

Condition of

Participation:

Rehabilitation

Services

26.00.00

Renumbered;

standards are

separated for

General

Rehabilitation

Services

26.01.01 §482.56(a)Organization &

StaffingX 26.00.01 Clarification

26.01.03 §482.56(a)(1) Leadership 26.00.02

26.01.04 §482.56(a)(2)Staff

Qualifications26.00.03

26.01.05Minimum Staffing


26.01.06 Therapy Orders X 26.00.05 Clarification

26.01.07 §482.56(b)Delivery of

ServicesX 26.00.06 Clarification

26.01.08 §482.56(b)(1)Rehabilitation

Orders26.00.07

26.01.09 §482.56(b)(2)Standards of

PracticeX 26.00.08 Clarification

26.01.10 Plan of Care X

26.00.09

Organizational

Plan

26.01.11

Program

Objective &

Standards of

Practice

XCombine with


26.01.12Initial

Assessments26.00.10

26.01.13Treatment Plan /

Plan of CareX 26.00.11 Clarification

Chapter 26 Physical Rehabilitation Services Page 75



2014 v 3

Standard

CMS Acute Care

Hospital CfR

2014 v 3 Standard


26.01.14 Treatment Goals 26.00.12

26.01.15 Patient Education 26.00.13

26.01.16 Reassessment 26.00.14

26.01.17

Quality Assurance

Performance

Improvement

(QAPI)

26.00.15

Chapter 26 Physical Rehabilitation Services Page 76



2014 v 3

Standard

CMS Acute Care

Hospital CfR

2014 v 3 Standard


27.00.00 §482.60

Condition of

Participation:

Psychiatric

Hospitals

X

THESE

REQUIREMENTS

DO NOT APPLY TO

ACUTE CARE

HOSPITALS

27.00.01 §482.60(a) Clinical Focus X

27.00.02 §482.60(b)

Compliance with

Hospital

Requirements

X

27.00.03 §482.60(c)Medical Records

RequirementsX

27.00.04 §482.60(d)Staffing

RequirementsX

27.01.01 §482.61

Condition of

Participation:

Special Medical

Records

Requirements for

Psychiatric

Hospitals

X

27.01.02 §482.61(a)

Development of

Assessment /

Diagnostic Data

X

27.01.03 §482.61(a)(1)Patient Legal

StatusX

27.01.04 §482.61(a)(2)Admitting

DiagnosisX

27.01.05 §482.61(a)(3)Patient Reason for

AdmissionX

27.01.06 §482.61(a)(4)

Psychosocial

History /

Assessment

X

27.01.07 §482.61(a)(5)Neurological

ExaminationX

Chapter 27 A Psychiatric Hospital Page 77



2014 v 3

Standard

CMS Acute Care

Hospital CfR

2014 v 3 Standard


27.01.08Confidentiality of

InformationX

27.01.09 §482.61(b)Psychiatric

EvaluationX

27.01.10 §482.61(b)(1)Timeframe for

CompletionX

27.01.11 §482.61(b)(2) Medical History X

27.01.12 §482.61(b)(3) Mental Status X

27.01.13 §482.61(b)(4)Reason for

AdmissionX

27.01.14 §482.61(b)(5)Behavioral

AssessmentX

27.01.15 §482.61(b)(6)Cognitive

AssessmentX

27.01.16 §482.61(b)(7)Inventory of

StrengthsX

27.01.17 §482.61(c) Treatment Plan X

27.01.18 §482.61(c)(1)Treatment Plan ‐

IndividualizedX

27.01.19Treatment Plan ‐

DocumentationX

27.01.20 §482.61(c)(1)Treatment Plan

FoundationX

27.01.21 §482.61(c)(1)(i)

Treatment Plan

Contents ‐

Diagnosis

X




2014 v 3

Standard

CMS Acute Care

Hospital CfR

2014 v 3 Standard


27.01.22 §482.61(c)(1)(ii)Treatment Plan

Contents ‐ GoalsX

27.01.23 §482.61(c)(1)(iii)

Treatment Plan

Contents ‐

Treatment

Modalities

X

27.01.24 §482.61(c)(1)(iv)

Treatment Plan

Contents ‐

Individual Staff

Responsibilities

X

27.01.25 §482.61(c)(1)(v)

Treatment Plan

Contents ‐

Justification of

Diagnosis

X

27.01.26 §482.61(c)(2)Documentation of

Active TreatmentX

27.01.27 §482.61(d) Progress Notes X

27.01.28 §482.61(d)Frequency of

Progress NotesX

27.01.29 §482.61(e)

Discharge

Planning &

Summary

X

27.02.00 §482.62

Condition of

Participation:

Special Staffing

Requirements for

Psychiatric

Hospitals

X

27.02.01 §482.62(a)(1)Staffing

RequirementsX




2014 v 3

Standard

CMS Acute Care

Hospital CfR

2014 v 3 Standard


27.02.02 §482.62(a)(2)Staffing

RequirementsX

27.02.03 §482.62(a)(3)Staffing

RequirementsX

27.02.04 §482.62(a)(4)Staffing

RequirementsX

27.02.05 §482.62(b) Clinical Director X

27.02.06 §482.62(b) Medical Staff X

27.02.07 §482.62(b)(1)Medical Director

QualificationsX

27.02.08 §482.62(b)(2)Medical Director

ResponsibilitiesX

27.02.09 §482.62(c)Availability of

Medical PersonnelX

27.02.10 §482.62(d) Nursing Services X

27.02.11 §482.62(d)(1)

Director of

Nursing

Qualifications

X

27.02.12 §482.62(d)(2) Staffing X

27.02.13 §482.62(e)Psychological

ServicesX

27.02.14 §482.62(f) Social Services




2014 v 3

Standard

CMS Acute Care

Hospital CfR

2014 v 3 Standard


27.02.15 §482.62(f)

Social Service

Staff Standards of

Practice

X

27.02.16 §482.62(f)(1)

Social Services

Director

Qualifications

X

27.02.17 §482.62(f)(2)

Social Services

Staff

Responsibilities

X

27.02.18 §482.62(g)Therapeutic

Activities ProgramX

27.02.19 §482.62(g)(1)Activities Program

FocusX

27.02.20 §482.62(g)(2)Activities Program

StaffingX

27.02.21

Scope &

Description of

Available Services

X

27.03.01 Physical Facilities X

27.03.02Treatment

EnvironmentX

27.03.03

Patient Bedrooms ‐

Safety and

Security

X

27.03.04Sleeping

AccommodationsX

27.03.05 Personal Property X




2014 v 3

Standard

CMS Acute Care

Hospital CfR

2014 v 3 Standard


27.03.06 Laundry X

27.03.07Patient Hygiene

NeedsX

27.03.08 Treatment Space X

27.03.09 Barrier‐Free X

27.04.01 Patient Rights X

27.05.01Convulsive

TherapyX

27.05.02

Convulsive

Therapy ‐ Use

with Children

X

27.05.03Administrative

PolicyX

27.05.04 Psychosurgery X

27.05.05

Referral for

Specialized

Services

X

27.05.06Aversive

ConditioningX




2014 v 3

Standard

CMS Acute Care

Hospital CfR

2014 v 3 Standard


27.06.00 §412.25(a)

Distinct Part

Psychiatric Unit /

Propsective

Payment System

Excluded Unit

Distinct Part

Psychiatric Unit

/ Propsective

Payment

System

Excluded Unit

27.06.01

§412.25(a)

§412.25(a)(1)

§412.25(a)(1)(i)

§412.25(a)(1)(ii)

§412.25(a)(1)(iii)

Excluded Hospital

Units34.00.01

27.06.02 412.25(a)(2) Admission Criteria 34.00.02

27.06.03 412.25(a)(3)Separate Medical

Records34.00.03

27.06.04 412.25(a)(4)

Availablity of

Clinical Records &

Information

34.00.04

27.06.05 412.25(a)(5)State Licensure


27.06.06 412.25(a)(6)Utilization Review


27.06.07 412.25(a)(7)Distinct Unit

Structure34.00.07

27.06.08

Excluded

Psychiatric Units:

Additional

Requirements

34.01.01

27.06.09 412.27(a) Admission Criteria 34.01.02

27.06.10 412.27(b) Scope of Service 34.01.03

Chapter 27 Distinct Part Psychiatric Unit / PPS Excluded Unit Page 83



2014 v 3

Standard

CMS Acute Care

Hospital CfR

2014 v 3 Standard


27.06.11 412.27(c) Treatment Plan 34.01.04

27.06.12 412.27(c)(1)

Development of

Assessment /

Diagnostic Data

34.01.05

27.06.13 412.27(c)(1)(i) Legal Status 34.01.06

27.06.14 412.27(c)(1)(ii)Admission

Diagnosis34.01.07

27.06.15 412.27(c)(1)(iii)Patient Reason for

Admission34.01.08

27.06.16 412.27(c)(1)(iv)Social History and

Assessment34.01.09

27.06.17 412.27(c)(1)(v)Neurological

Examination34.01.10

27.06.18 412.27(c)(2)Psychiatric

Evaluation34.01.11

27.06.19 412.27(c)(2)(i)

Psychiatric

Evaluation ‐

Timeframe

34.01.12

27.06.20 412.27(c)(2)(ii)

Psychiatric

Evaluation ‐

Medical History

34.01.13

27.06.21 412.27(c)(2)(iii)

Psychiatric

Evaluation ‐

Mental Status

34.01.14

27.06.22 412.27(c)(2)(iv)

Psychiatric

Evaluation ‐ Onset

of Illness

34.01.15




2014 v 3

Standard

CMS Acute Care

Hospital CfR

2014 v 3 Standard


27.06.23 412.27(c)(2)(v)

Psychiatric

Evaluation ‐

Description of

Attitudes and

Behaviors

34.01.16

27.06.24 412.27(c)(2)(vi)

Psychiatric

Evaluation ‐

Cognition

34.01.17

27.06.25 412.27(c)(2)(vii)Psychiatric

Evaluation ‐ Assets34.01.18

27.06.26 §412.27(c)(3)(i) Treatment Plan 34.01.19

27.06.27 §412.27(c)(3)(ii)Documentation of

Active Treatment34.01.20

27.06.28 §412.27(c)(4)Progress Notes


27.06.29 §412.27(c)(5)

Discharge

Planning and

Discharge

Summary

34.01.22

27.06.30 §412.27(d)(1)(i)Staffing


27.06.31 §412.27(d)(1)(ii)Staffing


27.06.32 §412.27(d)(1)(iii)Staffing


27.06.33 §412.27(d)(1)(iv)Staffing





2014 v 3

Standard

CMS Acute Care

Hospital CfR

2014 v 3 Standard


27.06.34 §412.27(d)(2)

Director of

Inpatient

Psychiatric

Services: Medical

Staff

34.01.27

27.06.35 §412.27(d)(2)(i)Medical Director

Qualifications34.01.28

27.06.36 §412.27(d)(2)(ii)Medical Director

Responsibilities34.01.29

27.06.37 §412.27(d)(3) Nursing Services 34.01.30

27.06.38 §412.27(d)(3)(i)Nursing Services

Leadership34.01.31

27.06.39 §412.27(d)(3)(ii) Staffing 34.01.32

27.06.40 §412.27(d)(4)Psychological

Services34.01.33

27.06.41 §412.27(d)(5) Social Services 34.01.34

27.06.42 §412.27(d)(6)Therapeutic

Activities34.01.35

27.06.43 §412.27(d)(6)(i) Program Scope 34.01.36

27.06.44 §412.27(d)(6)(ii) Program Staffing 34.01.37

27.06.45

Scope and

Description of

Available Services

34.02.01

27.06.46 Physical Facilities 34.02.02




2014 v 3

Standard

CMS Acute Care

Hospital CfR

2014 v 3 Standard


27.06.47

Patient Bedrooms ‐

Safety and

Security

34.02.03

27.06.48Patient Hygiene

Needs34.02.04

27.06.49Handicapped

Accessiblity34.02.05

27.06.50Confidentiality of

Information34.02.06




2014 v 3

Standard

CMS Acute Care

Hospital CfR

2014 v 3 Standard


28.00.01Organizational

Chart

28.00.02

Scope and

Description of

Services

28.00.03

The Continuum of

Substance Abuse

Services

28.00.04Criteria for Client

Placement

28.00.05

Patient Placement

Criteria

for Level 0.5 –

Early

Intervention

28.00.06

Patient Placement

Criteria for Level I ‐

Outpatient

Treatment

28.00.07

Patient Placement

Criteria

for Level II –

Intensive

Outpatient

Treatment /

Partial

Hospitalization

28.00.08

Patient Placement

Criteria

for Level III –

Residential

/ Inpatient

Treatment

Chapter 28 Substance Abuse Services Page 88



2014 v 3

Standard

CMS Acute Care

Hospital CfR

2014 v 3 Standard


28.00.09

Patient Placement

Criteria

for Level IV –

Medically

Managed

Intensive

Inpatient

Treatment

28.00.10

Opioid

Maintenance

Therapy (OMT)

28.00.11Treatment

Modalities

28.00.12

Treatment of Co‐

Occurring

Substance

Abuse and Mental

Health

Disorders

28.00.13

Treatment

Protocols –

Alcohol

Withdrawal

28.00.14

Treatment

Protocols – Use

of FDA Approved

Medications in

Treatment

of Alcohol Abuse

Disorders

28.00.15

Treatment

Protocols – Use

of FDA Approved

Medications in

Treatment

of Opiate

Addiction




2014 v 3

Standard

CMS Acute Care

Hospital CfR

2014 v 3 Standard


28.00.16

Medical Staff

Qualifications for

Administration of

Buprenorphine

28.00.17 Informed Consent

28.00.18 Activities Program

28.00.19

Referral and

Access to

Special Services

28.00.20

Family

Psychosocial

Assessment

28.00.21Personal

Belongings

28.00.22Policies and

Procedures

28.00.23

Common Areas

and Space

Requirements

28.00.24

Work Space and

Therapeutic

Equipment

Requirements

28.00.25Client Access to

Staff

28.00.26After Hours

Resources

28.00.27 Patient Rights

28.00.28 Written Consent




2014 v 3

Standard

CMS Acute Care

Hospital CfR

2014 v 3 Standard


28.00.29

Referral and

Access to

Special Services

28.00.30

Required

Emergency

Services

28.00.31Intermediate Plan

of Care

28.00.32Outpatient Follow‐

up Care

28.01.01 Medical Staff

28.01.02

Availability of

Medical

Personnel

28.01.03

Staff Knowledge

of Client

Legal Rights and

the

Criminal Judicial

System

28.01.04

§482.62;

§482.62(a);

§482.62(a)(1);

§482.62(a)(2);

§482.62(a)(3);

§482.62(a)(4)

Staffing

Qualifications

28.01.05

Competencies of

Addiction

Counselors and

Specialists

28.01.06

Coordination of

Social

Services

28.01.07

Case / Care

Manager ‐

Qualifications




2014 v 3

Standard

CMS Acute Care

Hospital CfR

2014 v 3 Standard


28.02.01Medical Record

Requirements

28.02.02

History

Assessment

Requirements

28.02.03

Physical

Assessment

Requirements

28.02.04

Individualized

Treatment

Plan

28.02.05 §482.61(c)(2)

Documentation of

Active

Treatment

28.02.06§482.61(c)(2)

(vii)

Discharge

Summary

28.02.07Statement of

Ability

28.02.08 For Future Use

28.03.01

Confidentiality of

Substance Abuse

Patient

Records

28.03.02

Consent for

Disclosure of

Information

28.03.03Notice of Privacy

Practices

28.04.01

Quality

Assessment /

Performance

Improvement

(QAPI)




2014 v 3

Standard

CMS Acute Care

Hospital CfR

2014 v 3 Standard


29.00.01 Special Care Unit

29.00.02 Medical Care

29.00.03 Nursing Care

29.00.04 Admission Criteria

29.00.05 Discharge Criteria

29.00.06Prioritization of

Care

29.00.07 Staff Orientation

29.00.08Physical

Environment



29.00.11Equipment ‐

Training

29.00.12Equipment ‐

Required

29.00.13 Supply Storage

29.00.14Required Policies

and Procedures

29.00.15

Policy ‐

Collaborative

Development

Chapter 29 Special Care Unit Page 93



2014 v 3

Standard

CMS Acute Care

Hospital CfR

2014 v 3 Standard


29.00.16

Policies ‐

Subspecialty

Patient Needs

Chapter 29 Special Care Unit Page 94



2014 v 3

Standard

CMS Acute Care

Hospital CfR

2014 v 3 Standard


30.00.00 §482.51

Condition of

Participation:

Surgical Services

30.00.01 §482.51(a)Organizational

Structure

30.00.02 §482.51(a)(1) Leadership

30.00.03 §482.51(a)(2) Scrub Nurses X CMS Update

30.00.04 §482.51(a)(3) Circulating Nurses X CMS Update

30.00.05 §482.51(a)(4) Surgical Privileges X CMS Update

30.00.06

Medical Staff

Rules &

Regulations

X Retired

30.00.07 First Assistants

30.00.08Physician

AvailabilityX Clarification

30.00.09 §482.51(b)Standards of

PracticeX CMS Update

30.00.10 §482.51(b)(1) History & Physical X CMS Update

30.00.11 §482.51(b)(2) Informed Consent XPatient Safety

Initiative

30.00.12 §482.51(b)(3)Required

EquipmentX Clarification

Chapter 30 Surgical Services Page 95



2014 v 3

Standard

CMS Acute Care

Hospital CfR

2014 v 3 Standard


30.00.13

Supply &

Instrumentation

Availability &

Flash Sterilization

X IUSS Update

30.00.14Operative Site

Verification

Patient Safety

Initiative

30.00.15 Risk Assessment X Retired

30.00.16Pneumatic

Tourniquets

Patient Safety

Initiative

30.00.17 §482.51(b)(4)Postoperative

CareX CMS Update

30.00.18 §482.51(b)(5)Operating Room

RegisterX CMS Update

30.00.19 §482.51(b)(6) Operative Report X Clarification

30.00.20Pathology Review

Exemptions

30.00.21

Label Medications

& Solutions on the

Sterile Field

Patient Safety

Initiative

30.00.22Postoperative

Medical CareX Retired

30.01.00Anesthesia

ServicesX Retired

30.01.01 §482.52

Condition of

Participation:

Medical

Leadership ‐

Anesthesia

Services





2014 v 3

Standard

CMS Acute Care

Hospital CfR

2014 v 3 Standard


30.01.02 §482.52(a)Scope of Service ‐

Anesthesia30.01.01

30.01.03

§482.52(a)

§482.52(a)(2)

§482.52(a)(3)

§482.52(a)(4)

§482.52(a)(5)

§482.52(c)(1)§482.52(c)(2)

Anesthesia

ProvidersX 30.01.02 CMS Update

30.01.04

Moderate

Sedation

(Conscious

Sedation)

30.01.03

30.01.05 §482.52(b) Required Policies X 30.01.04 CMS Update

30.01.06 §482.52(b)(1)Preanesthesia

EvaluationX 30.01.05 Clarification

30.01.07 §482.52(b)(2)Intra‐operative

Anesthesia RecordX 30.01.06 Clarification

30.01.08 §482.52(b)(3)Post‐anesthesia

AssessmentX 30.01.07 Clarification

30.01.09 Equipment Safety 30.01.08

30.02.01

Medical Staff

Rules &

Regulations ‐

Regulations

Availability ‐

Postanesthesia

X Retired


30.02.03Nursing Care ‐

Postanesthesia




2014 v 3

Standard

CMS Acute Care

Hospital CfR

2014 v 3 Standard


30.02.04

Registered Nurse

Supervision ‐

Postanesthesia

Recovery

30.02.05

Staff Orientation

& Training ‐

Postanesthesia

Recovery

30.02.06 §482.51(b)(3)Required

EquipmentX Clarification

30.02.07

Supply &

Equipment

Availability




30.02.11

Policy ‐ Bypass of

Postanesthesia

Recovery Service

30.02.12Recovery in Non‐

PACU Locations

30.02.13 Discharge Criteria

30.02.14Documentation

Requirements

30.02.15Staffing

Requirements

30.03.01

Outpatient

Discharge

Requirement

X Clarification




2014 v 3

Standard

CMS Acute Care

Hospital CfR

2014 v 3 Standard


30.03.02

Outpatient

Discharge

Instructions

X Clarification

30.03.03Post‐Procedure

Follow‐up CallX Clarification




2014 v 3

Standard

CMS Acute Care

Hospital CfR

2014 v 3 Standard


31.00.00§482.54

Condition of

Participation:

Outpatient

Services

X CMS Update

31.00.01 §482.54(a)Integration of

Services

31.00.02§482.54(b)(1)

§482.54(b)(2) Personnel X CMS Update

31.00.03Documentation in

Patient Records

31.00.04Patient

Satisfaction

31.00.05 Activity Logs

31.00.06After‐Hours

Resources

31.00.07 Referrals



31.00.10 Storage

31.00.11

§482.54(c)

§482.54(c)(1)

§482.54(c)(2)

§482.54(c)(3)

§482.54(c)(4)

Orders for

Outpatient

Services

X CMS Update

Chapter 31 Outpatient Services Page 100



2014 v 3

Standard

CMS Acute Care

Hospital CfR

2014 v 3 Standard


32.00.00 §482.58

Special

Requirements for

CAH Providers of

Long‐Term Care

Services ("Swing‐

Beds").

X CMS Updates

32.00.01

§482.58(a)

§482.58(a)(1)

§482.58(a)(2)

§482.58(a)(3)

§482.58(a)(4)

Eligibility X CMS Updates

32.00.02 Bed Size XCombined with

32.00.01CMS Updates

32.00.03 Hospital Location XCombined with

32.00.01CMS Updates

32.00.04 Nursing Waiver XCombined with

32.00.01CMS Updates

32.00.05

No Termination of

Swing Bed

Approval

XCombined with

32.00.01CMS Updates

32.00.06 §482.58(b)Skilled Nursing

Facility ServicesX CMS Updates

32.01.01 §483.10 Resident Rights

32.01.02 §483.10(b)(3)Notice of Rights

and Services

32.01.03 §483.10(b)(4)Right to Refuse

Treatment

32.01.04§483.10(b)(5)

§483.10(b)(6)

Medicaid &

Medicare

Notification

Chapter 32 Swing Beds Page 101



2014 v 3

Standard

CMS Acute Care

Hospital CfR

2014 v 3 Standard


32.01.05 §483.10(b)(8) Advance

Directives

32.01.06§483.10(d)

§483.10(d)(1) Personal Physician

32.01.07 §483.10(d)(2)Informed of Care

and Treatment

32.01.08 §483.10(d)(3)Participation in

Care

32.01.09

§483.10(e)

§483.10(e)(1)

§483.10(e)(2)

§483.10(e)(3)

§483.10(e)(3)(i)

§483.10(e)(3)(ii)

Personal Privacy

and

Confidentiality

X CMS Update

32.01.10

§483.10(h)(1);

§483.10(h)(2)

§483.10(h)(2)(i);

§483.10(h)(2)(ii)

§483.10(h)(2)(iii)

§483.10(h)(2)(iv)

Work

32.01.11

§483.10(i)

§483.10(i)(1)

§483.10(i)(ii)

Mail

32.01.12

§483.10(j)(1)

§483.10(j)(1)(vii)

§483.10(j)(1)(viii)

Access and

Visitation Rights

32.01.13 §483.10(l)Personal

Possessions

32.01.14 §483.10(m) Married Couples

32.01.15

§483.12(a)

§483.12(a)(1)Transfer and

Discharge




2014 v 3

Standard

CMS Acute Care

Hospital CfR

2014 v 3 Standard


32.01.16

§483.12(a)(2)

§483.12(a)(2)(i)

§483.12(a)(2)(ii)

§483.12(a)(2)(iii)

§483.12(a)(2)(iv)

§483.12(a)(2)(v)

§483.12(a)(2)(vi)

Transfer &

Discharge

Requirements

32.01.17

§483.12(a)(3)

§483.12(a)(3)(i)

§483.12(a)(3)(ii)Documentation

32.01.18

§483.12(a)(4)

§483.12(a)(4)(i)

§483.12(a)(4)(ii)

§483.12(a)(4)(iii)

Notice Before

Transfer

32.01.19

§483.12(a)(5)

§483.12(a)(5)(i)

§483.12(a)(5)(ii)

§483.12(a)(5)(ii)(A)

§483.12(a)(5)(ii)(B)

§483.12(a)(5)(ii)(C)

§483.12(a)(5)(ii)(D)

§483.12(a)(5)(ii)(E)

Timing of the

Notice

32.01.20

§483.12(a)(6)

§483.12(a)(6)(i)

§483.12(a)(6)(ii)

§483.12(a)(6)(iii)

§483.12(a)(6)(iv)

§483.12(a)(6)(v)

§483.12(a)(6)(vi)

§483.12(a)(6)(vii)

Contents of the

Notice

32.01.21 §483.12(a)(7)

Orientation for

Transfer or

Discharge

32.01.22

§483.10(a)(1)

§483.10(a)(2)

§483.10(a)(3)

§483.10(a)(4)

Exercise of Rights




2014 v 3

Standard

CMS Acute Care

Hospital CfR

2014 v 3 Standard


32.02.01

§483.13

§483.13(a)Restraints X 11.03.00

32.02.02 §483.13(b) Abuse X 11.03.01

32.02.03

§483.13(c)

§483.13(c)(1)(i)Staff Treatment of

ResidentsX

11.03.02;

11.03.03

32.02.04

§483.13(c)(1)(ii)

§483.13(c)(1)(ii)(A)

§483.13(c)(1)(ii)(B)

§483.13(c)(1)(ii)(B)(i

ii)

Screening of Staff

32.02.05 §483.13(c)(2)

Reporting of

Patient

Mistreatment,

Neglect, or Abuse

32.02.06 §483.13(c)(3) Investigation of

Alleged Abuse

32.02.07 §483.13(c)(4) Reporting of

Investigations


32.03.02

§483.15(f)

§483.15(f)(1)

§483.15(f)(2)

§483.15(f)(2)(i)

§483.15(f)(2)(i)(A)

§483.15(f)(2)(i)(B)

§483.15(f)(2)(ii)

§483.15(f)(2)(iii)

§483.15(f)(2)(iv)

Activities X CMS Update

32.03.03 Activities Director XCombined into

32.03.02

32.03.04

§483.15(g)

§483.15(g)(1) Social Services X CMS Update




2014 v 3

Standard

CMS Acute Care

Hospital CfR

2014 v 3 Standard


32.03.05

§483.15(g)(2)

§483.15(g)(3)

§483.15(g)(3)(i)

§483.15(g)(3)(ii)Qualifications of

Social WorkerX CMS Update

32.03.06

§483.20(l)

§483.20(l)(1)

§483.20(l)(2)

§483.20(l)(3)

Discharge

SummaryX CMS Update

32.04.01

§483.45

§483.45(a)

§483.45(a)(1)

§483.45(a)(2)

Specialized

Rehabilitative

Services

X

Retitled,

"Specialized

Rehabilitative

Services:

Provision of

Services"

CMS Update

32.04.02 §483.45(b)Rehabilitative

Service OrdersX

Retitled:

"Rehabilitative

Service Orders:

Qualifications"

Clarification

32.05.01 §483.55 Dental Services

32.05.02§483.55(a)(1)

§483.55(a)(2)

Patient Liability

for Dental Care

Retitled: "Skilled

Nursing Facility:

Patient Liability

for Dental Care"

32.05.03

§483.55(a)(3)

§483.55(a)(3)(i)

§483.55(a)(3)(ii)

§483.55(a)(4)

Resident Dental

Appointment

Retitled: "Skilled

Nursing Facility:

Resident Dental

Appointments"




2014 v 3

Standard

CMS Acute Care

Hospital CfR

2014 v 3 Standard


32.05.04

§483.55(b)

§483.55(b)(1)

§483.55(b)(1)(i)

§483.55(b)(1)(ii)

Provision of

Dental Services

Retitled:

"Nursing

Facilities:

Provision of

Dental

Services"

32.05.05

§483.55(b)(2)

§483.55(b)(2)(i)

§483.55(b)(2)(ii)

§483.55(b)(3)

Appointments and

Referrals

Retitled:

"Nursing

Facilities:

Appointments

and Referrals"


Documents

2015 Old Standards to New Standards 031415 - HFAPhfap.org/.../10/055_2015_Old_Standards_to_New_Standards.pdf · HFAP Acute Care Hospital Manual Crosswalk of 2014 v 3 Standards against