CMS Manual System - Centers for Medicare & Medicaid Services

CMS Manual System

Pub. 100-07 State Operations Provider Certification

Transmittal 84

Department of Health & Human Services (DHHS) Centers for Medicare & Medicaid Services (CMS)

Date: June 7, 2013

SUBJECT: Revised Appendix A, Interpretive Guidelines for Hospitals, Appendix L, Interpretive Guidelines for Ambulatory Surgical Centers and Appendix W, Interpretive Guidelines for Critical Access Hospitals.

I. SUMMARY OF CHANGES: Changes are made to reflect revised regulations adopted for hospitals in 42 CFR Part 482, ambulatory surgical centers in 42 CFR Part 416, and critical access hospitals in 42 CFR Part 485, Subpart F.

NOTES:

Appendix A ?482.23(c) Standard: Nursing Services/Tag A-0404 deleted (content combined with Tag A-0405) ?482.42(a) Standard: Infection Control/Tag A-0750 deleted (content removed through regulation)

Appendix L ?416.44(a)(3) Standard: Environment/Tag Q-0103 deleted (referenced regulation was deleted as redundant in the revised regulation)

NEW/REVISED MATERIAL - EFFECTIVE DATE*: June 7, 2013 IMPLEMENTATION DATE: June 7, 2013

The revision date and transmittal number apply to the red italicized material only. Any other material was previously published and remains unchanged. However, if this revision contains a table of contents, you will receive the new/revised information only, and not the entire table of contents.

II. CHANGES IN MANUAL INSTRUCTIONS: (R = REVISED, N = NEW, D = DELETED)

R/N/D R R R R R

N

CHAPTER/SECTION/SUBSECTION/TITLE Appendix A Table of Contents Appendix A/?482.12 Condition: Governing Body/Tag A-0043 Appendix A/?482.13(b) Standard: Exercise of Rights/Tag A-0131 Appendix A/?482.13(c) Standard: Privacy and Safety/Tag A-0143 Appendix A/?482.13(d) Standard: Confidentiality of patient records/Tag A-0147 Appendix A/?482.13(g) Standard: Death Reporting Requirements/Tag A-

0213

R

Appendix A/?482.13(g) Standard: Death Reporting Requirements/Tag A-

0214

R

Appendix A/?482.22(b) Standard: Medical Staff Organization and

Accountability/Tag A-0347

R

Appendix A/?482.22(c) Standard: Medical Staff Bylaws/Tag A-0358

R

Appendix A/?482.23(b) Standard: Staffing and Delivery of Care/Tag A-

0396

D

Appendix A/?482.23(c) Standard: Preparation and Administration of

Drugs/Tag A-0404

R

Appendix A/?482.23(c) Standard: Preparation and Administration of

Drugs/Tag A-0405

R

Appendix A/?482.23(c) Standard: Preparation and Administration of

Drugs/Tag A-0406

R

Appendix A/?482.23(c) Standard: Preparation and Administration of

Drugs/Tag A-0407

R

Appendix A/?482.23(c) Standard: Preparation and Administration of

Drugs/Tag A-0408

R

Appendix A/?482.23(c) Standard: Preparation and Administration of

Drugs/Tag A-0409

R

Appendix A/?482.23(c) Standard: Preparation and Administration of

Drugs/Tag A-0410

N

Appendix A/?482.23(c) Standard: Preparation and Administration of

Drugs/Tag A-0412

N

Appendix A/?482.23(c) Standard: Preparation and Administration of

Drugs/Tag A-0413

R

Appendix A/?482.24(b) Standard: Form and Retention of Record/Tag A-

0441

R

Appendix A/?482.24(c) Standard: Form and Retention of Record /Tag A-

0454

R

Appendix A/?482.24(c) Standard: Form and Retention of Record /Tag A-

0457

R

Appendix A/?482.24(c) Standard: Form and Retention of Record /Tag A-

0458

R

Appendix A/?482.24(c) Standard: Form and Retention of Record /Tag A-

0461

R

Appendix A/?482.24(c) Standard: Form and Retention of Record /Tag A-

0463

R

Appendix A/?482.24(c) Standard: Form and Retention of Record /Tag A-

0464

R

Appendix A/?482.24(c) Standard: Form and Retention of Record /Tag A-

0465

R

Appendix A/?482.24(c) Standard: Form and Retention of Record /Tag A-

0466

R

Appendix A/?482.24(c) Standard: Form and Retention of Record /Tag A-

0467

R

Appendix A/?482.24(c) Standard: Form and Retention of Record /Tag A-

0468

R

Appendix A/?482.24(c) Standard: Form and Retention of Record /Tag A-

0469

R

Appendix A/?482.25(b) Standard: Delivery of Services/Tag A-0508

R

Appendix A/?482.42(a) Standard: Organization and Policies/Tag A-0748

R

Appendix A/?482.42(a) Standard: Organization and Policies /Tag A-0749

D

Appendix A/?482.42(a) Standard: Organization and Policies /Tag A-0750

R

Appendix A/?482.42(b) Standard: Responsibilities of Chief Executive

Officer, Medical Staff, and Director of Nursing Services/Tag A-0756

R

Appendix A/?482.54 Condition: Outpatient Services/Tag A-1076

R

Appendix A/?482.54(b) Standard: Organization/Tag A-1079

N

Appendix A/?482.54 Condition: Outpatient Services (standard-level Tag)

/Tag A-1080

N

Exhibit XX Hospital Restraint/Seclusion Death Report Worksheet

R

Appendix L Table of Contents

R

Appendix L ASC Survey Protocol

R

Appendix L/?416.2 Definitions/Tag Q-0002

R

Appendix L/?416.43 Condition: Quality Assessment and Performance

Improvement/Tag Q-0080

D

Appendix L/?416.44(a)(3) Standard: Physical Environment/Q-0103

R

Appendix L/?416.44(b) Standard: Safety from Fire/Tag Q-0104

R

Appendix L/?416.44(c) Standard: Emergency Equipment/Tag Q-0105

R

Appendix L/?416.45(b) Standard: Reappraisals/Tag Q-0122

R

Appendix L/?416.47 Condition: Medical Records/Tag Q-0160

R

Appendix L/?416.47(b) Standard: Form and Content of Record/Tag Q-

0162

N

Appendix L/?416.50 Condition: Patient Rights/Tag Q-0219

R

Appendix L/?416.50 Condition: Patient Rights (standard-level Tag)/Tag

Q-0220

R

Appendix L/?416.50(a) Standard: Notice of Rights/Tag Q-0221

R

Appendix L/?416.50(b) Standard: Disclosure of Physician Financial

Interest or Ownership/Tag Q-0223

R

Appendix L/?416.50(c) Standard: Advance Directives/Tag Q-0224

R

Appendix L/?416.50(d) Standard: Submission and Investigation of

Grievances/Tag Q-0225

R

Appendix L/?416.50(d) Standard: Submission and Investigation of

Grievances/Tag Q-0226

R

Appendix L/?416.50(e) Standard: Exercise of Rights and Respect for

Property and Person/Tag Q-0227

R

Appendix L/?416.50(e) Standard: Exercise of Rights and Respect for

Property and Person/Tag Q-0228

R

Appendix L/?416.50(e) Standard: Exercise of Rights and Respect for

Property and Person/Tag Q-0229

R

Appendix L/?416.50(e) Standard: Exercise of Rights and Respect for

Property and Person/Tag Q-0230

R

Appendix L/?416.50(f) Standard: Privacy and Safety/Tag Q-0231

R

Appendix L/?416.50(f) Standard: Privacy and Safety /Tag Q-0232

R

Appendix L/?416.50(f) Standard: Privacy and Safety /Tag Q-0233

R

Appendix L/?416.50(g) Standard: Confidentiality of Clinical Records/Tag

Q-0234

R

Appendix L/?416.51(b) Standard: Infection Control Program/Tag Q-0245

R

Exhibit 351 ASC Infection Control Worksheet

R

Appendix W Table of Contents

R

Appendix W/?485.608(a) Standard: Compliance with Federal Laws and

Regulations/Tag C-0151

R

Appendix W/?485.610 Condition: Status and Location/Tag C-0160

R

Appendix W/?485.610(c) Standard: Location Relative to Other Facilities

or Necessary Provider Certification/Tag C-0165

R

Appendix W/?485.623(a) Standard: Construction/Tag C-0221

R

Appendix W/?485.635(b) Standard: Patient Services/Tag C-0273

R

Appendix W/?485.635(b) Standard: Patient Services /Tag C-0281

R

Appendix W/?485.635(b) Standard: Patient Services /Tag C-0282

R

Appendix W/?485.635(b) Standard: Patient Services /Tag C-0283

R

Appendix W/?485.635(b) Standard: Patient Services /Tag C-0284

R

Appendix W/?485.639 Condition: Surgical Services/Tag C-0320

III. FUNDING: No additional funding will be provided by CMS; contractor activities are to be carried out within their FY 2013 operating budgets.

IV. ATTACHMENTS:

Business Requirements X Manual Instruction

Confidential Requirements One-Time Notification Recurring Update Notification

State Operations Manual

Appendix A - Survey Protocol, Regulations and Interpretive Guidelines for Hospitals

Table of Contents (Rev.84, Issued: 06-07-13)

Exhibit XX Hospital Restraint/Seclusion Death Report Worksheet

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