2000 CMS General

2001 CMS Highlights  [Info]

2005  42 CFR Part 482 - [Info]  Hospitals are required to be in compliance with the Federal requirements set forth in the Medicare Conditions of Participation (CoP) in order to receive Medicare/Medicaid payment. The goal of a hospital survey is to determine if the hospital is in compliance with the CoP set forth at 42 CFR Part 482 which contains the minimum health and safety requirements that hospitals must meet to participate in the Medicare and Medicaid program. The CMS State Operations Manual (SOM) provides CMS policy regarding survey and certification activities.  Specifics are provided in State Operations Manual (SOM) Appendix A and Appendix AA below.  See also SL6 - Why does CMS continue to perform surveys if a hospital has deemed status?

2010 Programs & Information (P&I)

2010.10 About CMS

• Contact CMS
  • Toll-Free: 877-267-2323 (Employee directory available x5)
  • Local: 410-786-3000
• CMS Leadership:  Overview,  
  • Center for Medicaid and State Operations,
  • Office of Clinical Standards and Quality
  • CMS Regional Offices
• Hospital Center
• Regional Offices
  • Consortia
    

    Consortium/Business Line	Consortium Administrator (CA)	CA Location	Senior Management Official
    Consortium for Medicare Health Plans Operations (CMHPO)	James T.Kerr	New York	Boston New York Philadelphia
    Consortium for Financial Management and Fee for Service Operations (CFMFFSO)	Nanette Foster Reilly	Kansas City	Kansas City Denver San Francisco
    Consortium for Medicaid and Children's Health Operations (CMCHO)	Jackie Garner	Chicago	Chicago Seattle
    Consortium for Quality Improvement and Survey & Certification Operations (CQISCO)	Randy Farris, M.D.	Dallas	Atlanta Dalla

•  
  • Regional Offices
    • Boston Regional Office [PDF, 56KB]
    • New York Regional Office [PDF, 60KB]
    • Philadelphia Regional Office [PDF, 56KB]
    • Atlanta Regional Office [PDF, 62KB]
    • Chicago Regional Office [PDF, 54KB]
    • Dallas Regional Office [PDF, 59KB]
    • Kansas City Regional Office [PDF, 59KB]
    • Denver Regional Office [PDF, 60KB]
    • San Francisco Regional Office [PDF, 56KB]
    • Seattle Regional Office [PDF, 53KB]

2010.20 Medicare

• Provider Enrollment & Certification
  • Survey & Certification - General Information
    •  
  • Survey & Certification - Certification & Compliance
    • Hospitals
    • Intermediate Care Facilities for the Mentally Retarded (ICFs/MR)
    • Psychiatric Residential Treatment Facility Providers
    • Psychiatric Hospitals
    • Outpatient Rehabilitation Providers
    • Inpatient Rehabilitation Facilities
    • Comprehensive Outpatient Rehabilitation Facilities
    •  
  • Survey & Certification - Emergency Preparedness
  • Survey & Certification - Enforcement
  • Survey & Certification - Guidance to Laws & Regulations
  • Survey & Certification - Promising Practices Project
  • Survey & Certification - Surveyor Training
• Overview - Deeming Authority
  • S&C-09-02: Approval of Deeming Authority of Det Norske Veritas Healthcare, Inc. for Hospitals

2010.30 Medicaid
2010.40 SCHIP
2010.50 Regulations, Guidance & Standards 

• Guidance
  • Manuals
  • Rulings
  • Transmittals
    • Transmittal # R78SOMA: (PDF):  Revised Appendix A, Interpretive Guidelines for Hospitals, and Revised Appendix W, Interpretive Guidelines for Critical Access Hospitals (CAHs),  New guidance is provided to reflect regulatory changes concerning the provision of telemedicine services in Hospitals and CAHs.  Issue date 12/22/2011
• Health Insurance Portability and Accountability Act (HIPAA1106)
  • The HIPAA Law and Related Information1106
  • Privacy and Security Standards1106s
    • Summary of the HIPAA Privacy Rule1106
      • Treatment & Payment & Health Care Operations FAQs1106
        • May mental health practitioners or other specialists provide therapy to patients in a group setting where other patients and family members are present?1106
    • Summary of the HIPAA Security Rule1106
  • HIPAA - General Information
• Legislation
  • Clinical Laboratory Improvement Amendments (CLIA)
  • Emergency Medical Treatment & Labor Act (EMTALA)
• Regulations & Policies
  • Quarterly Provider Updates - Regulations
  • Regulations.gov:  Search for a regulation such as a CMS proposed rule, final rule or Federal Register (FR) notice. Submit a comment on a regulation or on another comment.
  • Policy & Memos to States and Regions  (PMSR)  Search here for S&C Letters

•  

2010.60 Research, Statistics, Data, & Systems

2010.70 Outreach & Education

• HIV and AIDS Resources
• Open Door Forums
  • Hospitals Open Door Forum
  • Physicians, Nurses and Allied Health Professionals Open Door Forum
• RSS Feeds and Podcasts

2010.80 Resources & Tools

• Frequently Asked Questions (FAQ) 
• Relevant Fact Sheets
  • 8/4/08:  202-690-6145: CMS IMPROVES PATIENT SAFETY FOR MEDICARE AND MEDICAID BY ADDRESSING NEVER EVENTS
•  Federal Resgister  (FR)
  • Current & other 2009 Issues 

 2080  Relevant Rulings (F= Final, P = Proposed):

• CMS-3244-P  HTML1201, PDF1201 10/24/11 Reform of Hospital CoP (incl 48-hr Authentication of Verbal Orders, Substitute Authentication Exemption)
• Medicare and Medicaid Programs; Approval of the Joint Commission for Deeming Authority for Psychiatric Hospitals (2/15/11)  This notice announces  decision to approve the Joint Commission for recognition as a national accreditation program for psychiatric hospitals seeking to participate in the Medicare or Medicaid programs. This initial 4-year approval is effective February 25, 2011, through February 25, 2015.
• CMS-3228-F HTML , PDF , SUMMARY 11/19/10  Medicare and Medicaid Programs: Changes to the Hospital and Critical Access Hospital Conditions of Participation To Ensure Visitation Rights for All Patients
• CMS-3227-P  {QPU}  (PDF)   HTML1110 , PDF1110 , SUMMARY1110 5/26/10 Credentialing and Privileging of Telemedicine Physicians and Practitioners,
• CMS-1390-F  {QPU}  (PDF)  8/19/08 - Changes to the Hospital Inpatient Prospective Payment Systems and Fiscal Year 2009 Rates [More details @ 2001 Highlights]

• CMS-3018-F  {QPU}  (PDF)  12/8/06  [SHCCinfo] - Hospital Conditions of Participation: Patient's Rights (including S&R)  [More details @ 2001 Highlights]

• CMS-3122-F  {QPU}  (PDF) 11/27/06  [SHCC Info] - Hospital Conditions of Participation: Requirements for History and Physical Examinations; Authentication of Verbal Orders; Securing Medications…  [More details @ 2001 Highlights]

• CMS-4105-F  {QPU}  (PDF)  11/27/06  [SHCCinfo ] - Notification Procedures for Hospital Discharges  [More details @ 2001 Highlights] 

2100 Appendix A  (A Tags - Gen Hospital) {PDF1107}    {Revision -  Survey and Cert Letter 11-32 (PDF, 200KB) }

2101 - HIghlights  [Info]

2102 - §482.2 Provision of Emergency Services by Nonparticipating Hospitals       

2111 - §482.11    Compliance with Federal, State and Local Laws

2112 - §482.12    Governing Body

HCPro Credentialing Resource Center:  2004:2008 GB Crosswalk (PDF)

2113 - §482.13    Patients’ Rights

• S&C-08-23 [Info] (PDF)  05/30/2008: SOM Chapter 5/Release of Person-Identifiable Data Related to Restraint/Seclusion Deaths…  [More details @ 2101 Highlights]

• S&C -8-18 [Info] (PDF)  (04/11/2008) Restraint/Seclusion Interpretive Guidelines & Updated SOM Appendix A  [More details @ 2101 Highlights]

• S&C -07-22  [Info] (PDF)   (06/22/2007) Clarification of 'Physical Restraints' as Applied to the Requirements for LTC Facilities  [More details @ 2101 Highlights]

• S&C-06-31 [Info] (PDF)   (09/29/2006) Hospital Death Reporting Requirements Related to Behavior Management Restraint and Seclusion  [More details @ 2101 Highlights]

• CMS-3018-F  {QPU}  (PDF)  12/8/06  [SHCCinfo] - Hospital Conditions of Participation: Patient's Rights (including S&R)  [More details @ 2001 Highlights]

2121 - §482.21    Quality Assmt/Performance Improvement

2122 - §482.22    Medical Staff

• Transmittal # R78SOMA: (PDF):  Revised Appendix A, Interpretive Guidelines for Hospitals, and Revised Appendix W, Interpretive Guidelines for Critical Access Hospitals (CAHs),  New guidance is provided to reflect regulatory changes concerning the provision of telemedicine services in Hospitals and CAHs.  Issue date 12/22/2011
• Credentialing and Privileging of Telemedicine Physicians and Practitioners
• Revised Interpretive Guidelines for Hospital Conditions of Participation     Posted 02/08/2008
• CMS-3244-P  HTML1201, PDF1201 10/24/11 Reform of Hospital CoP (incl 48-hr Authentication of Verbal Orders, Substitute Authentication Exemption)
• Verbal Orders: CMS-3122-F  {Info}
• CMS Requirements for Hospital Medical Staff Privileging - 2004:  S&C-05-04 (PDF)
• HCPro Credentialing Resource Center:  2004:2008 MS Crosswalk (PDF)

2123 - §482.23    Nursing Services

• Medication Administration: S&C-112-05 (Revised 12.02.11) - End of 30-min rule, intro of 'Time-Critical' medications.  See FAQ
• Verbal Orders: CMS-3122-F  {Info}

2124 - §482.24    Medical Record Services

•  Revised Interpretive Guidelines for Hospital Conditions of Participation     Posted 02/08/2008

• Verbal Orders/ Authentication: CMS-3122-F  {Info}

• S&C-09-10 (PDF) :  “Standing Orders” in Hospitals

2125 - §482.25    Pharmaceutical Services

• Securing Medications: CMS-3122-F  {Info}

2126 - §482.26    Radiological Services

2127 - §482.27    Laboratory Services

• Clinical Laboratory Improvement Amendments (CLIA)
• CLIA Waivers1001 , CLIA - Tests waived by FDA from January 2000 to present1001

2128 - §482.28    Food and Dietetic Services

2130 - §482.30    Utilization Review

2141 - §482.41    Physical Environment

•  S&C-11-05-LSC:  [Info] (PDF)   (02/18/2011): Update of Hospital and CAH component facilities classifications as new or existing Health Care, Ambulatory Health Care, Business, or other occupancies, as allowed by provisions of the LSC. 

2142 - §482.42    Infection Control

• Revisions to the Hospital Interpretive Guidelines for Infection Control     Posted 11/21/2007

2143 - §482.43    Discharge Planning

• Discharge Notification: CMS-4105-F  {Info}

2145 - §482.45    Organ, Tissue and Eye Procurement

2151 - §482.51    Surgical Services

2152 - §482.52    Anesthesia Services

2153 - §482.53    Nuclear Medicine Services

2154 - §482.54    Outpatient Services

2155 - §482.55    Emergency Services

2156 - §482.56    Rehabilitation Services

2157 - §482.57    Respiratory Services

2200 Appendix AA (B Tags - Psych Hospital)  {PDF1107}

2201 - Highlights  [Info]

2260 - §482.60 Condition of Participation: Special Provisions Applying to Psychiatric Hospitals

2261 - §482.61 Condition of Participation: Special Medical Record Requirements for Psychiatric Hospitals

• 2261.01 - §482.61(a) Standard:  Development of Assessment/Diagnostic Data
  • Neurological examination  [FAQ]
• 2261.02 - §482.61(b) Standard:  Psychiatric Evaluation
• 2261.03 - §482.61(c) Standard:  Treatment Plan
• 2261.04 - §482.61(d) Standard:  Recording Progress
  • What is Active Treatment? (PDF)
• 2261.05 - §482.61(e) Standard:  Discharge Planning and Discharge Summary

2262 - §482.62 Condition of Participation: Special Staff Requirements for Psychiatric Hospitals

• 2262.01 - §482.62(a) Standard: Personnel
• 2262.0b - §482.62(b) Standard:  Director of Inpatient Psychiatric Services; Medical Staff
• 2262.03 - §482.62(c) Standard Availability of Medical Personnel
• 2262.04 - §482.62(d) Standard:  Nursing Services
• 2262.05 - §482.62(e) Standard Psychological Services
• 2262.06 - §482.62(f) Standard: Social Services
• 2262.07 - §482.62(g) Standard: Therapeutic Activities

2300 Appendix Q (Immediate Jeopardy)  {PDF}

2301 - Highlights  [Info]

2310 - Immediate Jeopardy

2320 - Introduction, Definitions, Principles

2330 - Immediate Jeopardy Triggers
2340 - Procedures, Implementation, Documentation

2350 - Enforcement
2360 - References

• 2360.10 - Attachment A
• 2360.20 - Attachment B
• 2360.30 - 483(b) Requirements: Abuse
• 2360.40 - 485.723 Condition: Physical Environment
• 2360.50 - 485.723(a) Standard Safety of Patients
• 2360.60 - 485.723(b) Standard: Maintenance of
• 2360.70 - Equipment/Buildings/Grounds
  
• 2360.80 - Attachment C - Overview - Recommended Key Components of Systemic Approach to Prevent Abuse and Neglect

2400 Appendix V (Emergency Cases/EMTALA)  {PDF}

2400  General Information (HTML)

2401 - Highlights  [Info] 

• IHA/DMH:  Recommendations to Improve the Assessment, Treatment, and Transfer of Psychiatric Patients to State-Operated Hospitals” [HTML] {PDF} - includes postion paper and hospital monitoring forms

2410  Part I- Investigative Procedures

I. General Information

•  EMTALA (Info)

II. Principal Focus of Investigation

III. Task 1 - Entrance Conference

IV. Task 2 - Case Selection Methodology

V. Task 3- Record Review

VI. Task 4- Interviews

VII. Task 5-Exit Conference

VIII. Task 6- Professional Medical Review

IX. Task 7- Assessment of Compliance and Completion of the Deficiency Report

X. Additional Survey Report Documentation

2420 Part II - Interpretive Guidelines - Responsibilities of Medicare Participating Hospitals in Emergency Cases

§489.20 Basic Section 1866 Commitments Relevant to Section 1867 Responsibilities

§489.24(j) Availability of On-Call physicians

§489.24 Special Responsibilities of Medicare Hospitals in Emergency Cases

§489.24(a) General

§489.24(b)

•  Definition of 'stabilized' - {HTML}, {PDF}

§489.24(c) Use of Dedicated Emergency Department for Nonemergency Services

§489.24(d) Necessary Stabilizing Treatment for Emergency Medical Conditions

§489.24(e) Restricting Transfer Until the Individual Is Stabilized

§489.24(f) Recipient Hospital Responsibilities