CMS Manual System

CMS Manual System

Pub. 100-07 State Operations Provider Certification

Transmittal 37

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

Date: October 17, 2008

SUBJECT: Revise Appendix A, "Interpretive Guidelines for Hospitals"

I. SUMMARY OF CHANGES: Appendix A is being revised to reflect amended regulations and survey and certification policy issuances concerning the Conditions of Participation for Hospitals, 42 CFR Part 482. It also contains new guidance related to the Patients' Rights Final Rule, 42 CFR 482.13(e), (f), and (g), published in the Federal Register December 8, 2006 (71 FR 71378). In addition, Regulatory text that appears in brackets was included in a previous tag, but is repeated for clarity and accuracy in representing the regulatory citation.

NEW/REVISED MATERIAL - EFFECTIVE DATE*: Upon Issuance IMPLEMENTATION DATE: Upon Issuance

Disclaimer for manual changes only: 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: (N/A if manual not updated.) (R = REVISED, N = NEW, D = DELETED) ? (Only One Per Row.)

R/N/D R R R R

N R R R

N R R R

CHAPTER/SECTION/SUBSECTION/TITLE Appendix A Table of Contents Appendix A/?482.13/Condition of Participation: Patient's Rights Appendix A/?482.13(e)/Restraint or Seclusion Appendix A/?482.13(f)/Standard: Restraint or Seclusion: Staff Training Requirements Appendix A/?482.13(g)/Standard: Death Reporting Requirements Appendix A/ ?482.26(a)/Standard: Radiologic Services Appendix A/?482.27(a)/Standard: Adequacy of Laboratory Services Appendix A/?482.27(b)/Standard: Potentially Infectious Blood and Blood Components Appendix A/?482.27(c)/Standard: General Blood Safety Issues Appendix A/?482.52(c)/Standard: State Exemption Appendix A/?482.57/Condition of Participation: Respiratory Care Services Appendix A/?482.11/Condition of Participation: Compliance With Federal, State and Local Laws

R

Appendix A/?482.11(a)

R

Appendix A/?482.11(b)

R

Appendix A/?482.11(c)

R

Appendix A/?482.12/Condition of Participation: Governing Body

R

Appendix A/?482.12(a)/Standard: Medical Staff

R

Appendix A/?482.12(b)/Standard: Chief Executive Officer

R

Appendix A/?482.12(c)/Standard: Care of Patients

R

Appendix A/?482.12(d)/Standard: Institutional Plan and Budget

R

Appendix A/?482.12(e)/Standard: Contracted Services

R

Appendix A/?482.12(f)/Standard: Emergency Services

R

Appendix A/?482.13/Condition of Participation: Patient's Rights

R

Appendix A/?482.13(a)/Standard: Notice of Rights

R

Appendix A/?482.13(b)/Standard: Exercise of Rights

R

Appendix A/?482.13(c)/Standard: Privacy and Safety

R

Appendix A/?482.13(d)/Standard: Confidentiality of Patient Records

R

Appendix A/?482.13(e)/Standard: Restraint or Seclusion

R

Appendix A/?482.13(f)/Standard: Restraint or Seclusion: Staff Training

Requirements

N

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

R

Appendix A/?482.21/Condition of Participation: Quality Assessment and

Performance Improvement Program

R

Appendix A/?482.21(a)/Standard: Program Scope

R

Appendix A/?482.21(b)/Standard: Program Data

R

Appendix A/?482.21(c)/Standard: Program Activities

R

Appendix A/?482.21(d)/Standard: Performance Improvement Projects

R

Appendix A/?482.21(e)/Standard: Executive Responsibilities

R

Appendix A/?482.22/Condition of Participation: Medical staff

R

Appendix A/?482.22(a)/Standard: Composition of the Medical Staff

R

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

Accountability

R

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

R

Appendix A/482.22(d)/Standard: Autopsies

R

Appendix A/?482.23/Condition of Participation: Nursing Services

R

Appendix A/?482.23(a)/Standard: Organization

R

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

R

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

R

Appendix A/?482.24/Condition of Participation: Medical Record Services

R

Appendix A/?482.24(a)/Standard: Organization and Staffing

R

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

R

Appendix A/?482.24(c)/Standard: Content of Record

R

Appendix A/?482.25/Condition of Participation: Pharmaceutical Services

R

Appendix A/?482.25(a)/Standard: Pharmacy Management and Administration

R

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

R

Appendix A/?482.26/Condition of Participation: Radiologic Services

R

Appendix A/?482.26(a)/Standard: Radiologic Services

R

Appendix A/?482.26(b)/Standard: Safety for Patients and Personnel

R

Appendix A/?482.27/Condition of Participation: Laboratory Services

R

Appendix A/?482.27(a)/Standard: Adequacy of Laboratory Services

R

Appendix A/?482.27(b)/Standard: Potentially Infectious Blood and Blood

Components

N

Appendix A/?482.27(c)/Standard: General Blood Safety Issues

R

Appendix A/?482.28/Condition of Participation: Food and Dietetic Services

R

Appendix A/?482.28(a)/Standard: Organization

R

Appendix A/?482.28(b)/Standard: Diets

R

Appendix A/?482.30/Condition of Participation: Utilization Review

R

Appendix A/?482.30(a)/Standard: Applicability

R

Appendix A/?482.30(b)/Standard: Composition of Utilization Review

Committee

R

Appendix A/?482.30(c)/Standard: Scope and Frequency of Review

R

Appendix A/?482.30(d)/Standard: Determination Regarding Admissions or

Continued Stays

R

Appendix A/?482.30(e)/Standard: Extended Stay Review

R

Appendix A/?482.30(f)/Standard: Review of Professional Services

R

Appendix A/?482.41/Condition of Participation: Physical Environment

R

Appendix A/?482.41(a)/Standard: Buildings

R

Appendix A/?482.41(b)/Standard: Life Safety From Fire

R

Appendix A/?482.41(c)/Standard: Facilities

R

Appendix A/?482.42/Condition of Participation: Infection Control

R

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

R

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

Medical Staff, and Director of Nursing Services

R

Appendix A/?482.43 /Condition of Participation: Discharge Planning

R

Appendix A/?482.43(a)/Standard: Identification of Patients in Need of

Discharge Planning

R

Appendix A/?482.43(b)/Standard: Discharge Planning Evaluation

R

Appendix A/?482.43(c)/Standard: Discharge Plan

R

Appendix A/?482.43(d)/Standard: Transfer or Referral

R

Appendix A/?483.43(e)/Standard: Reassessment

R

Appendix A/?482.45/Condition of Participation: Organ, Tissue, and Eye

Procurement

R

Appendix A/?482.45(a)/Standard: Organ Procurement Responsibilities

R

Appendix A/?482.45(b)/Standard: Organ Transplantation Responsibilities

R

Appendix A/?482.51/Condition of Participation: Surgical Services

R

Appendix A/?482.51(a)/Standard: Organization and Staffing

R

Appendix A/?482.52/Condition of Participation: Anesthesia Services

R

Appendix A/?482.52(a)/Standard: Organization and Staffing

R

Appendix A/?482.52(b)/Standard: Delivery of Services

R

Appendix A/?482.56/Condition of Participation: Rehabilitation Services

R

Appendix A/?482.56(a)/Standard: Organization and Staffing

R

Appendix A/?482.56(b)/Standard: Delivery of Services

R

Appendix A/?482.57/Condition of Participation: Respiratory Care Services

R

Appendix A/?482.57(a)/Standard: Organization and Staffing

R

Appendix A/?482.57(b)/Standard: Delivery of Services

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

IV. ATTACHMENTS:

Business Requirements X Manual Instruction

Confidential Requirements One-Time Notification Recurring Update Notification

*Unless otherwise specified, the effective date is the date of service.

State Operations Manual

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

Table of Contents

(Rev. 37, I0-17-08)

Survey Protocol Introduction

Task 1 - Off-Site Survey Preparation Task 2 - Entrance Activities Task 3 - Information Gathering/Investigation Task 4 - Preliminary Decision Making and Analysis of Findings Task 5 - Exit Conference Task 6 ? Post-Survey Activities Psychiatric Hospital Survey Module Psychiatric Unit Survey Module Rehabilitation Hospital Survey Module Inpatient Rehabilitation Unit Survey Module Hospital Swing-Bed Survey Module

Regulations and Interpretive Guidelines ?482.2 Provision of Emergency Services by Nonparticipating Hospitals ?482.11 Condition of Participation: Compliance with Federal, State and Local Laws ?482.12 Condition of Participation: Governing Body ?482.12(a) Standard: Medical Staff ?482.12(b) Standard: Chief Executive Officer ?482.12(c) Standard: Care of Patients ?482.12(d) Standard: Institutional Plan and Budget ?482.12(e) Standard: Contracted Services ?482.12(f) Standard: Emergency Services ?482.13 Condition of Participation: Patient's Rights

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