2015 new standards to old standards -...

HFAP Acute Care Hospital Manual

Crosswalk of 2015 HFAP Standards against 2014 v 3 HFAP Standards

2015 Standard CMS2015 Standard

TitleRevised New

2014 v 3

StandardComments

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 Not Applicable

01.00.06

Articles of

Incorporation &

Documentation of

Actions

01.00.07Governing Body

ResponsibilitiesX Clarification

01.01.00 §482.12

Condition of

Participation:

Governing Body

X 01.00.05 CMS Updates

01.01.01

§482.12(a)

§482.12(a)(1)Categories Eligible

for AppointmentX 01.00.08 CMS Updates

01.01.02 §482.12(a)(2)Medical Staff

Appointment01.00.09

Chapter 1 Administration of the Organization




TitleRevised New

2014 v 3

StandardComments

01.01.03 §482.12(a)(3)

Provision of

Medical Staff

Bylaws

01.00.10

01.01.04 §482.12(a)(4)

Approval of

Medical Staff

Bylaws

01.00.11

01.01.05 §482.12(a)(5)Medical Staff

Quality of Care01.00.12

01.01.06 §482.12(a)(6)

Selection Criteria

forAppointment to

the Staff

01.00.13

01.01.07 §482.12(a)(7)Required Criteria

for Appointment01.00.14

01.01.08§482.12(a)(8)

§482.12(a)(9)

Telemedicine

Agreements with

Distant Site

Hospitals or

Distant Site

Entities

X01.00.15

01.00.16CMS Updates


01.00.16

Telemedicine

Agreements

with Distant

Sites

Retired

01.01.10 §482.12(a)(10)

Governing Body

Consults

Periodically with

the Medical Staff

X CMS Updates

01.01.11 §482.12(b) CEO Appointment 01.00.17





TitleRevised New

2014 v 3

StandardComments

01.01.12

§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)

Care of Patients

01.00.18

Licensed

Practitioner

Care

Requirements

01.01.13 §482.12(c)(2)State Privilege

Requirements01.00.19

01.01.14 §482.12(c)(3)Physician

Availability01.00.20

01.01.15 §482.12(c)(4)Medical Staff

Oversight01.00.21

01.01.16

§482.12(d)

§482.12(d)(1)

§482.12(d)(2)

§482.12(d)(3)

§482.12(d)(4)

Institutional Plan &

Budget01.00.22

01.01.17 §482.12(d)(5) Plan Submission 01.00.23

01.01.18 §482.12(d)(6)Plan Review &

Update01.00.24

01.01.19

§482.12(d)(7)

§482.12(d)(7)(i)

§482.12(d)(7)(ii)Plan Preparation 01.00.25

01.01.20

Oversight of the

Physical

Environment

X 01.00.26 Clarification

01.01.21Oversight of the

QAPI Plan01.00.27





TitleRevised New

2014 v 3

StandardComments

01.01.22 §482.12(e)Contracted

ServicesX 01.00.28 CMS Updates

01.01.23 §482.12(e)(1)Contractor Quality

Monitoring01.00.29

01.01.24 §482.12(e)(2)List of Contracted

Services01.00.30

01.01.25

Policy, Procedure

Review, &

Approval

01.00.31

01.01.26

Medically‐related

Patient Care

Services


01.02.01 §482.12(f)Emergency

ServicesX 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





TitleRevised New

2014 v 3

StandardComments

02.00.01

02.00.01

Allied Health

Practitioner

Categories

Chapter 2 is

retired.

Refer to Chapter

3 for standard

relating to non‐

physician

practitioners.

02.00.02

02.00.02

Credentialing

Procedures &

Scope of

Practice

Retired

02.00.03

02.00.03Federal

& State

Regulations

Regarding

Privileges

Retired

02.00.04 For Future Use

02.00.05

02.00.05

Supervision of

Allied Health

Practitioners

Retired

02.00.06

02.00.06

Quality

Assessment

Performance

Improvement

Retired

02.00.07

02.00.07

Allied Health

Professional

Membership

Retired

Chapter 2 Allied Health Practitioners




TitleRevised New

2014 v 3

StandardComments

03.00.00 §482.22

Condition of

Participation:

Medical Staff

X CMS update

03.00.01 §482.22(a)

Eligibility and

Process for

Appointment To

The Medical Staff

XComposition of

the Medical

Staff

CMS update

03.00.02 §482.22(a)(1) Periodic Appraisal

of MembersX CMS update



03.00.05

Responsibilities of

Credentialed

Professionals

03.00.06 §482.22(a)(2)

Recommendation

for Appointment

to Governance

X CMS update

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 Hospital

Agreement

X CMS update

03.00.09

§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 Agreement

X CMS update

Chapter 3 Medical Staff




TitleRevised New

2014 v 3

StandardComments

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)(ii);

§482.22(b)(3)(iii)

Medical Staff

Responsiblities to

the Governing

Body

X CMS update

03.00.11§482.22(b)(4)

Unified and

Integrated

Medical Staff

X CMS update

03.00.12§482.22(b)(4)(i)

Voting

Requirements for

Separately

Certified Hopsitals

X CMS update

03.00.13§482.22(b)(4)(ii)

Medical Staff:

Bylaws of the

Unifed Medical

Staff

X CMS update

03.00.14§482.22(b)(4)(iii)

Medical Staff:

Unique

Circumstances

X CMS update

03.00.15§482.22(b)(4)(iv)

Medical Staff:

Policies of the

Unified Medical

Staff

X CMS update

03.01.01 §482.22(c) Medical Staff

Bylaws

03.01.02 §482.22 (c)(1)

Medical Staff

Bylaws: Approval

by Governance

03.01.03 §482.22(c)(2)

Medical Staff

Bylaws:

Categories, Duties,

& Responsiblities

of the Medical

Staff





TitleRevised New

2014 v 3

StandardComments

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,

Reapplication, &

Criteria for

Membership

03.01.07

§482.22(c)(5);

§482.22(c)(5)(i)

Medical Staff

Bylaws: History &

Physical

Requirement

XScoring

clarification

03.01.08 §482.22(c)(5)(ii)

Medical Staff

Bylaws: History &

Physical Prior to

Admission

XScoring

clarification

03.01.09 §482.22(c)(6)

Medical Staff

Bylaws: Granting

of Privileges

X CMS update

03.01.10

Medical Staff

Policies &

Procedures

03.01.11

Medical Staff

Bylaws: Periodic

Review

X Clarification

03.01.12

Uniform

Application of

Membership

Criteria






TitleRevised New

2014 v 3

StandardComments

03.01.14

Non‐

discrimination in

Application for

Membership

Criteria

03.01.15

Required

Application ‐

Reapplication

Information for

Review

X


03.01.17Emergency

Privileges

03.01.18Temporary

Privileges

03.01.19Suspension of

Privileges

03.01.20Fair Hearing

ProcessX

03.01.21

Medical Staff

Bylaws:

Definition of a

Clinical

Emergency


03.01.23

Medical Staff

Bylaws: Meeting

Frequency &

Attendance

03.01.24

Medical Staff

Bylaws: Clinical

Department

Structure





TitleRevised New

2014 v 3

StandardComments

03.02.01 §482.22(d) Autopsies X Clarification

Not numberedRequired

CommitteesClarification

03.03.01Medical Executive

Committee (MEC)

03.03.02Medical Executive

Committee ScopeX Clarification

03.04.00 §482.30

Condition of

Participation:

Utilization Review


03.04.01 §482.30(a) Applicability X 03.04.02 Clarification

03.04.02

§482.30(b)

§482.30(b)(1)

§482.30(b)(1)(i)

§482.30(b)(1)(ii)

§482.30(b)(1)(ii)(A)

§482.30(b)(1)(ii)(B)

§482.30(b)(2)

§482.30(b)(3)

§482.30(b)(3)(i)

§482.30(b)(3)(ii)

Composition of

the Utilization

Review

Committee

03.04.03

03.04.03 §482.30(c) UR Review

Requirements

03.04.04

Scope and

Frequency Of

Review

03.04.04 §482.30(d)

Determination

Regarding

Admissions or

Cotinued Stays

03.04.05





TitleRevised New

2014 v 3

StandardComments

03.04.05 §482.30(e)

Utilization Review

Scope in Non‐PPS

Hospitals ‐

Extended Stay

Review


03.04.06 §482.30(f)

Review of

Professional

Services


03.04.07

The Utilization

Review

Committee

Meeting

Frequency &

Attendance

03.04.08

03.05.01

Utilization of

Osteopathic

Methods &

Concepts

Committee

(OMCC)

03.05.02 OMCC Functions

03.05.03

OMCC

Documentation &

Meeting

Frequency &

Attendance

Requirements

03.06.01

Credentials

Committee

(function)

03.06.02

Credentials

Committee

Responsibility

03.06.03Credentials







TitleRevised New

2014 v 3

StandardComments


03.06.06Incomplete

Applications


03.06.08

Time Frame for

Processing of

Applications

03.06.09

Meeting

Frequency and

Attendance



Joint Advisory

Committee

Responsibility

Retired


Joint Advisory

Committee

Meeting

Frequency &

Attendance

Retired


03.10.01Mortality Review


03.10.02

Mortality Review

Committee

Responsibility‐

Appropriateness

of Care

X Clarification





TitleRevised New

2014 v 3

StandardComments

03.10.03

Mortality Review

Committee

Responsibility‐

Attending

Physician

Involvement

X Clarification

03.10.04Mortality Chart

Review X Clarification

03.10.05Mortality Review

EducationX

Mortality

Review

Education

Retired

03.10.06

Mortality Review

Committee

Meeting

Frequency &

Attendance

X Clarification


03.12.01

Availability of

Professional

Literature


03.14.01Transfusion

Committee

Responsibilities

03.14.02

Scope of the

Transfusion

Review

Committee

03.14.03Performance

ImprovementX Clarification

03.15.01

Ongoing

Professional

Practice

Evaluation (OPPE)

X Clarification





TitleRevised New

2014 v 3

StandardComments

03.15.02

Focused

Professional

Practice

Evaluation (FPPE)





TitleRevised New

2014 v 3

StandardComments

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 Revised

Chapter 4 Human Resources Management




TitleRevised New

2014 v 3

StandardComments

Chapter 5




TitleRevised New

2014 v 3

StandardComments

Chapter 6




TitleRevised New

2014 v 3

StandardComments

07.00.00 §482.42

Condition of

Participation:

Infection Control

Format

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 Incident Log 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



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 X Clarification

Chapter 7 Infection Control




TitleRevised New

2014 v 3

StandardComments

07.01.12State & Local

Reporting

07.01.13Committee/

Function Structure

07.01.14Infection Control

PlanX Clarification

07.01.15Reporting

Requirements

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

X Clarification

07.01.20Surgical Site

InfectionsX NQF reference

07.01.21Hand‐washing

GuidelinesX NQF reference

07.01.22Environmental

SurveillanceX Clarification

07.01.23 Employee Health X Clarification

07.01.24Employee Health

PoliciesX Clarification





TitleRevised New

2014 v 3

StandardComments

07.01.25Employee Health‐

Influenza VaccineX NQF reference

07.01.26 Annual Report X Clarification

07.02.00 Central Supply

07.02.01Decontamination

& Sterilization

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





TitleRevised New

2014 v 3

StandardComments

07.02.11

Environment

Requirements in

Decontamination

Rooms

07.02.12

Immediate Use

Steam

Sterilization (IUSS)

in Surgical

Settings

XClarification from

CMS

07.03.00 Housekeeping X Clarification

07.03.01Cleaning Products

InventoryX Clarification

07.03.02High Risk Cleaning

ProceduresX Clarification

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





TitleRevised New

2014 v 3

StandardComments


07.04.03Clean Linen

Storage

07.05.01 Pest Control

07.05.02Extermination

Program





TitleRevised New

2014 v 3

StandardComments

08.00.01 Inventory

08.00.02Supplies for

Patient Care

08.00.03Safe Storage of

SuppliesX Format

08.00.04Policies on Supply

AvailabilityX Format

08.00.05Special Storage

Requirements

08.00.06 Product Recall

Chapter 8 Materials Management




TitleRevised New

2014 v 3

StandardComments

09.00.01Emergency

Operations PlanX Clarification

09.00.02

Emergency

Hazard

Vulnerability

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

09.02.01Emergency

ExercisesX Clarification

09.02.02Emergency

Education

Chapter 9 Emergency Management




TitleRevised New

2014 v 3

StandardComments

10.00.00 §482.24

Condition of

Participation:

Medical Record

Services

10.00.01 Re‐numbered

10.00.01 §482.24(a)Organization &

Staffing10.00.02

10.00.02 §482.24(b)Retention of

Medical RecordsX 10.00.03 Clarification

10.00.03 §482.24(b)(1)

Record Security &

Retention

Requirements

10.00.04

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

10.00.05 §482.24(b)(3)

Security of

Medical

Information

X 10.00.06 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 &

CompleteX Format

10.01.04 §482.24(c)(2)

Dating, Timing, &

Authentication of

Orders

X CMS Update

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 (Health Information) Services




TitleRevised New

2014 v 3

StandardComments

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)Consultative

ReportsX

Retitled:

Required

Consultations

10.01.11 Not Applicable X

Required

Consultations ‐

Categories

Retired

10.01.12Consultation

Requirements

10.01.13 Not Applicable XIndications for

ConsultationRetired

10.01.14 Not Applicable X Second Opinions Retired

10.01.15 §482.24(c)(4)(iv)Documentation of

ComplicationsX

Required

Documentation 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





TitleRevised New

2014 v 3

StandardComments

10.01.20§485.641(a)(1)(ii)

Multi‐disciplinary

Medical Record

Review & Audit

Requirements

X Clarification

10.01.21

Patient

Assessments ‐

Content &

Authentication

Patient Safety

Initiative

10.01.22Patient / Family

Education

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





TitleRevised New

2014 v 3

StandardComments

10.01.31 Obstetric Patients X Clarification

10.01.32

Actions Taken to

Improve Glycemic

Control

Patient Safety

Initiative

10.01.33Discharge

Summary

10.02.01

Medical Records

Committee ‐

Scope

10.02.02

Medical Records

Committee ‐

Responsibility

10.02.03

Medical Records

Committee ‐

Written Reports

10.02.04Record Use or

Format Changes


10.02.06

Policies on

Confidentiality &

Release of

Records

10.02.07

Medical Records

Committee ‐

Meeting

Frequency &

Attendance

Requirements

X Format





TitleRevised New

2014 v 3

StandardComments

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

Chairperson

X Clarification

11.01.05 Safety Officer


Teams

Appointed for

Specific Safety

Areas

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

11.01.10

Eyewash Stations

and Emergency

Showers

X

Chapter 11 Physical Environment




TitleRevised New

2014 v 3

StandardComments

11.02.01 Building Security

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

& SDSX

Changed from

"MSDS"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





TitleRevised New

2014 v 3

StandardComments

11.04.03 Fire Drill ‐ Critique X Clarification

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

11.04.06Fire Response ‐

Staff TrainingX 11.08.01 Clarification

11.05.01

Medical

Equipment &

Sytems:

Maintenance

X Clarification

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

11.06.03 Not ApplicableGenerator

Inspection

Moved to

13.05.04





TitleRevised New

2014 v 3

StandardComments


Generator

Monthly Load

Test

Moved to

13.05.05

11.06.05 Not ApplicableGenerator 3‐

Year Load Test

Moved to

13.05.06


Automatic

Transfer Switch

Test

Moved to

13.05.07

11.06.07 Potable Water X Clarification


Generator

Monthly Load

Test

Moved to

13.05.08

11.06.09

Plant Equipment

& Systems:

Maintenance

11.06.10Plant Equipment

Inventory


Medical Gas

Systems &

Equipment ‐

Maintenance

Moved to

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





TitleRevised New

2014 v 3

StandardComments


Americans with

Disabilities Act

(ADA)

Retired


Occupational

Safety & Health

Act (OSHA)

Retired

11.07.06

Assessing Risk

Prior to

Construction

11.07.07

Monitoring the

Physical

Environment

11.08.01Fire Response ‐

Staff TrainingMoved to 11.04.06





TitleRevised New

2014 v 3

StandardComments

12.00.00 §482.21

Condition of

Participation:

Quality Assurance

Performance

Improvement

X 12.00.01

12.00.01

§482.21(a)(1)

§482.21(a)(2)

§482.21(b)

§482.21(b)(1)

§482.21(b)(2)

§482.21(b)(2)(i)

§482.21(b)(3)

Data Collection &

Analysis: Program

Scope

X

12.00.03

12.00.09

12.00.10

12.00.12

CMS Updates

12.00.02

§482.21(b)(2)(ii)

§482.21(c)

§482.21(c)(1)

§482.21(c)(1)(i)

§482.21(c)(1)(ii)

§482.21(c)(1)(iii)

§482.21(c)(3)

Quality

Improvement

Program Activities

X

12.00.10

12.00.11

12.00.13

12.00.15

12.01.01

12.01.02

12.01.03

12.01.04

12.01.05

12.01.06

12.01.09

CMS Updates

12.00.03

§482.21(a)(1)

§482.21(a)(2)

§482.21(c)(2)

§482.21(e)(3)

Patient Safety,

Medical Errors &

Adverse Events

X

12.00.03

12.00.09

12.00.14

12.00.21

CMS Updates

12.00.04

§482.21(d)

§482.21(d)(1)

§482.21(d)(2)

§482.21(d)(3)

§482.21(d)(4)

Performance

Improvement

Projects

X

12.00.16

12.00.17

12.00.18

12.00.19

CMS Updates

12.00.05

§482.21(e)

§482.21(e)(1)

§482.21(e)(2)

§482.21(e)(5)

Executive

Responsibility for

the Hosptial‐wide

Quality Program

X12.00.04

12.00.21Clarification

Chapter 12 Quality Assurance Performance Improvement




TitleRevised New

2014 v 3

StandardComments

12.00.06 §482.21(e)(4)

Executive

Responsibility for

Providing

Adequate

Resources

X

12.00.02

12.00.04

12.00.05

12.00.06

12.00.08

12.00.21

Clarification

12.00.07 §482.21

Standard: Quality

Assessment

Performance

Improvement

X CMS Updates

12.01.01

Quality

Management

Position

12.00.02

12.01.02

Quality

Committee /

Function

12.00.05

12.01.03

Meetings &

Documentation of

Activities

12.00.06

12.01.04Annual Quality

ReportX 12.00.07 Clarification

12.01.05Education

ProgramX 12.00.08 Clarification

12.01.06

HFAP Clinical

Quality

Measurement

Program

12.00.20





TitleRevised New

2014 v 3

StandardComments

12.01.07Reporting to the

Board of TrusteesX 12.01.08 Clarification

12.02.01 Culture of Safety 12.00.22

12.02.02Adverse Event

Review ProcessX 12.00.23 Clarification

12.02.03

Communication to

the Patient of an

Adverse Event

12.01.10Patient Safety

Initiative

12.02.04Support of

Caregivers12.01.11

Patient Safety

Initiative





TitleRevised New

2014 v 3

StandardComments

13.00.01

§482.41(b)(1)(i)

§482.41(b)(1)(ii)

§482.41(b)(3)

Life Safety Code

ComplianceX

13.00.02

Alternative Life

Safety Measures ‐

Policy

X Clarification

13.00.03

Alternative Life

Safety Measures ‐

Implementation

X

13.00.04

Notification of

Emergency

Response Forces

X Clarification

13.00.05

Facility

Demographic

Information (FDI)

X Clarification

13.00.06

Testing &

Inspection ‐

Definition of Time

13.00.07

Testing &

Inspection ‐

Documentation

X Clarification

13.00.08 Interior Finish X

13.01.01Corridor Door

LatchingX Clarification

13.01.02 Door Locks X Clarification

13.01.03 Corridor Width X Clarification

13.01.04 Suites

13.01.05 Exit Signs X Clarification

13.01.06 Exit Discharge X Clarification

13.01.07Corridor

ProjectionsX Clarification

Chapter 13 Life Safety Code




TitleRevised New

2014 v 3

StandardComments

13.01.08Path of Egress

ObstructionsX Clarification

13.01.09Travel Distance to

ExitsX 13.03.09 Clarification

13.01.10 Exit Enclosures X 13.06.04 Clarification

13.02.01Fire Alarm System

‐ InstallationX Clarification

13.02.02Fire Alarm System

‐ Testing

13.02.03

Fire Alarm

Systems ‐

Transmitting

Signal

X Clarification

13.02.04

Fire Alarm

Systems ‐

Technician

Qualifications

X Clarification

13.03.01

Water‐Based Fire

Protection System

‐ Installation

X Clarification

13.03.02

Water‐Based Fire

Protection System

‐ Testing &

Inspection

X Clarification

13.03.03

Water‐Based Fire

Protection System

‐ Control Valves,

Piping and

Hangers

X Renamed

13.03.04Fire Pumps ‐

Weekly Test

13.03.05Fire Pumps ‐

Annual Test





TitleRevised New

2014 v 3

StandardComments

13.03.06

Alternative Fire

Suppression

systems ‐

Installation &

Testing

13.03.07

Water‐Based

Standpipes &

Hoses ‐ Inspection

& Testing

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

X Clarification

13.04.05 Construction Type X Clarification

13.04.06Separated

Occupancies

13.04.07Fire Rated Door

Assemblies





TitleRevised New

2014 v 3

StandardComments

13.04.08 Hazardous Areas X Clarification

13.04.09 Ceilings

13.04.10 Corridor Walls

13.05.01 Fireplaces X Clarification

13.05.02 Elevator Recall X Clarification

13.05.03Trash & Linen

Chutes

13.05.04Generator

Inspection11.06.03

13.05.05Generator Montly

Load Test11.06.04

13.05.06Generator 3‐Year

Load Test11.06.05

13.05.07

Automatic

Transfer Switch

Test

11.06.06

13.05.08Medical Gas

Shutoff Valves

13.05.09 Utility Systems X

13.05.10

Medical Gas

Systems &

Equipment:

Maintenance

11.06.11

13.05.11Cooking Hoods

CleaningX

13.06.01 Decorations





TitleRevised New

2014 v 3

StandardComments

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

X

13.07.01 §482.41(b)(2)CMS Waiver of

Life Safety Code

13.07.02

Fire Safety

Evaluation System

(FSES)

X Clarification





TitleRevised New

2014 v 3

StandardComments

14.00.00 §482.45

Condition of

Participation:

Organ, Tissue, and

Eye Procurement

14.00.01

14.00.01§482.45(a)

§482.45(a)(1)

Organ/Tissue

Donation and

Transplantation

14.00.02

14.00.02 §486.316(e)OPO Waiver

Requests14.00.03

14.00.03§482.45(a)(2) Tissue and Eye

Bank Agreements14.00.04

14.00.04§482.45(a)(3) Informed Consent


14.00.05 §482.45(a)(3)Designated

RequestorsX 14.00.06 Clarification

14.00.06 §482.45(a)(4)Sensitivity

Training14.00.07

14.00.07 §482.45(a)(5)OPO

Responsibilities14.00.08

14.00.08

§482.45(b)(1);

§482.45(b);

§482.45(b)(2)

Organ Transplant

Facilities14.00.09

14.00.09 §482.45(b)(3)Data Collection

and Reporting14.00.10

Chapter 14 Organ Procurement




TitleRevised New

2014 v 3

StandardComments

14.00.10§482.24(b)(3);

§486.306(o)

Confidentiality of

Patient Records14.00.11

Chapter 14 Organ Procurement




TitleRevised New

2014 v 3

StandardComments

15.00.00 §482.13

Condition of

Participation:

Patient Rights

15.01.00 Not Applicable Patient Rights Refer to 15.01.02


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




TitleRevised New

2014 v 3

StandardComments

15.01.09

§482.13(b)(1)

§482.13(b)(3)

§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(b)(2)§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


Patient Self‐

Determination

(Advance

Directives)

Refer to 15.01.12

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


Suspected

Abuse / Neglect

Patients

Refer to 15.01.18





TitleRevised New

2014 v 3

StandardComments


15.01.21§482.13(d)

§482.13(d)(1)

Confidentiality of

Patient RecordsX

Previous title:

"Confidentiality of

Patient Records:

Confidentiality of

Medical Records"

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

Records

15.01.23 Not ApplicableRestraint or

Seclusion

Moved to

15.02.00


15.01.25 §482.13(h) Visitation Rights

15.01.26§482.13(h)(1)

§482.13(h)(2)

Patient Visitation

RightsX

Previous Title:

Visitation Rights

‐ Clinical

Restrictions


Visitation Rights

‐ Patient

Determination

Incorporated into

15.01.26

15.01.28§482.13(h)(3)

§482.13(h)(4)

Visitation Rights ‐

Discrimination


Visitation Rights

‐ Fair

Application of

Process

Incorporated into

15.01.28

15.02.00 §482.13(e)Restraint or

Seclusion15.02.00

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





TitleRevised New

2014 v 3

StandardComments

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

Seclusion

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)

§482.13(e)(8)(i)(A)

§482.13(e)(8)(i)(B)

§482.13(e)(8)(i)(C)

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

15.02.18 §482.13(e)(11) Physician Training





TitleRevised New

2014 v 3

StandardComments

15.02.19

§482.13(e)(12)(i)

§482.13(e)(12)(i)(A)

§482.13(e)(12)(i)(B)

One Hour Face‐to‐

Face

15.02.20

§482.13(e)(12)(ii)

§482.13(e)(12)(ii)(A)

§482.13(e)(12)(ii)(B)

§482.13(e)(12)(ii)(C)

§482.13(e)(12)(ii)(D)

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

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





TitleRevised New

2014 v 3

StandardComments

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

15.02.40 Not Applicable Restraint Data Retired

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)(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





TitleRevised New

2014 v 3

StandardComments

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


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






TitleRevised New

2014 v 3

StandardComments

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









15.03.23 §482.43(d)Transfer or

Referral

15.03.24 §482.43(e)Discharge Plan

ReassessmentX Clarification


15.03.26Discharge

InstructionsX Clarification

15.03.27Discharge

Checklist





TitleRevised New

2014 v 3

StandardComments

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 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

Nonemployee

Staff

Chapter 16 Nursing Department




TitleRevised New

2014 v 3

StandardComments




16.01.01

§482.23(c)

§482.23(c)(1)

§482.23(c)(1)(i)

§482.23(c)(2)

Preparation and

Administration of

Drugs

X Format


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






TitleRevised New

2014 v 3

StandardComments

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

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

Hospital Issued

Medications:

Medications

Brought into the

Hospital

X Clarification



16.02.02 Patients at RiskPatient Safety

Initiative

16.02.03Standards

Availability





TitleRevised New

2014 v 3

StandardComments

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

TestingX Clarification

17.00.07 §482.57(b)(3) Services Provided X CMS Update

17.00.08 §482.57(b)(4)Respiratory Care

Services Orders

17.00.09Therapeutic

Medical Gases

17.00.10

Adverse Drug

Reactions &

Medical Error

Reporting


17.00.12Equipment

Availability

17.00.13 Assessment

Chapter 17 Respiratory Care




TitleRevised New

2014 v 3

StandardComments

18.00.01

Organizational

Structure: Scope

of Service

X

18.00.08

18.00.10

21.00.01

21.00.08

21.00.09

Combined

Chapter 18 and

Chapter 21

18.00.02 Location X 18.00.02 Clarification

18.00.03Physical

EnvironmentX

18.00.09


18.00.04Instrumentation

AvailabilityX

18.00.06


18.00.05Standards of

PracticeX 18.00.01 Clarification

18.00.06 Staffing X 21.00.04 Clarification

18.00.07Supervision of

CareX 18.00.05 Clarification

18.00.08Moderate

SedationX 21.00.03 Clarification

18.00.09

Moderate

Sedation:

Monitoring the

Patient


18.00.10

Moderate

Sedation:

Assisting with the

Procedure


18.00.11Preoperative

AssessmentX 18.00.07 Clarification

18.00.12Post‐Procedure

ReportX

18.00.13


18.00.13

Outpatient

Discharge

Requirements

X18.00.11


18.00.14Discharge

InstructionsX

18.00.12


18.00.15Outpatient Follow‐

up CallsX

18.00.14


Chapter 18 Cardiovascular Services, Interventional Radiology, and Endoscopic Services




TitleRevised New

2014 v 3

StandardComments

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 for Patients

and PersonnelX 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 X CMS Update

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




TitleRevised New

2014 v 3

StandardComments

19.00.14Order

Requirement

19.00.15

§482.26(d)

§482.26(d)(1)

§482.26(d)(2)

Record

MaintenanceX CMS Update

19.00.16

"Report

Authentication" has

been combined with

19.00.15

Retired

19.00.17Qualified

Physicians

19.00.18 Contrast MediaPatient Safety

Initiative

19.00.19

"Retention of

Records" has been

combined with

19.00.15

Retired

19.00.20Labeling of

Radiographs

Patient Safety

Initiative

Chapter 19 Diagnostic Radiology and Radiation Therapy Services




TitleRevised New

2014 v 3

StandardComments

20.00.00 §482.55

Condition of

Participation:

Emergency

Services

20.00.01 Re‐numbered

20.00.01§482.55(a);

§482.55(a)(1)

Medical Staff

LeadershipX 20.00.02 Clarification

20.00.02 §482.55(a)(2) Integration 20.00.03 Clarification

20.00.03 §482.55(a)(3)Policies &

ProceduresX 20.00.04 Clarification

20.00.04Required Policies

& ProceduresX 20.00.05

20.00.05§482.55(b);

§482.55(b)(1)Personnel X 20.00.06 Clarification

20.00.06 482.55(b)(2)

Personnel:

Staffing & Staff

Qualifications

20.00.07

20.00.07 Staff Training X 20.00.08 Clarification

20.00.08 Records X 20.00.09 Clarification

20.00.09Emergency Room

LogX 20.00.10 Clarification

20.00.10

Change in

Treatment Plan

Log


Chapter 20 Emergency Services




TitleRevised New

2014 v 3

StandardComments

18.00.01 21.00.01

Combined

Chapter 18 and

Chapter 21

Retired 21.00.02

18.00.08 21.00.03

18.00.06 21.00.04

Retired 21.00.05

18.00.04 21.00.06

18.00.03 21.00.07

18.00.01 21.00.08

18.00.01 21.00.09

18.00.13 21.00.10

18.00.14 21.00.11

18.00.15 21.00.12

Chapter 21 Endoscopic Services




TitleRevised New

2014 v 3

StandardComments

22.00.00 §482.27

Condition of

Participation:

Laboratory

Services

X Clarification

22.00.01 §482.27(a)

Accreditation /

Certification of

Laboratory

22.00.02 §482.27(a)(1)

Emergency

Service

Availability

22.00.03 §482.27(a)(2)

Laboratory

Services

Description

X Clarification

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

22.00.05 §482.27(a)(4)Required Tissue

Examination

22.01.01 §482.27(b)

Potentialy

Infectious Blood

and Blood

Components

X Clarification

22.01.02

Exposure

Resulting in HIV

Conversion

22.01.03

§482.27(c)

§482.27(c)(1)

§482.27(c)(2)

General Blood

Safety Issues

22.02.01Point of Care

Testing

Chapter 22 Laboratory Services




TitleRevised New

2014 v 3

StandardComments

23.00.00 §482.53

Condition of

Participation:

Nuclear Medicine

Services

X CMS Update

23.00.01

§482.53(a)

§482.53(a)(1)

§482.53(a)(2)

Organization &

StaffingX CMS Update

23.00.02"Medical Director"

has been combined

with 23.00.01Retired

23.00.03

"Personnel

Requirements" has

been combined with

23.00.01

Retired

23.00.04§482.53(b)

§482.53(b)(2) Delivery of Service X

"Policy &

Procedure

Requirements"

CMS Update

23.00.05 §482.53(b)(1)

In‐House

Prepration of

Radio

pharmaceuticals

X CMS Update

23.00.06

"Storage & Disposal

of Waste" has been

combined with

23.00.04

Retired

23.00.07Shielding

RequirementsX

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

Chapter 23 Nuclear Medicine Services




TitleRevised New

2014 v 3

StandardComments

23.00.11

§482.53(c)

§482.53(c)(1)

§482.53(c)(2)

Facilities X

"Safe Handling

of Reagents &

Equipment

Maintenance"

CMS Update

23.00.12Equipment

SafetyRetired

23.00.13

Handling &

Disposal of

Radium Elements

23.00.14

Approval of

Policies &

Procedures

23.00.15Order

Requirements

23.00.16

§482.53(d)

§482.53(d)(1)

§482.53(d)(2)

Medical Record

RequirementsX CMS Update

23.00.17

"Record

Retention

Requirements"

combined with

23.00.16

Retired

23.00.18

"Qualified

Practitioners"

combined with

23.00.16

Retired

23.00.19 §482.53(d)(3)Documentation

RequirementsX CMS Update

23.00.20 §482.53(d)(4)Qualified Ordering

PractitionersX CMS Update

23.00.21 §482.53Standard: Nuclear

MedicineX CMS Update

Chapter 23 Nuclear Medicine Services




TitleRevised New

2014 v 3

StandardComments

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


Nutritional

Screening

Assessments

Incorporated with

24.00.06

24.00.06 §482.28(b)

§482.28(b)(1)

Diets: Menus

Must Meet the

Needs of Patients

X 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

X Clarification

Chapter 24 Nutritional Services




TitleRevised New

2014 v 3

StandardComments

24.00.10

Nutrition

Counseling and

Education

24.00.11Outcomes

Management

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 Not ApplicableVending

MachinesRetired

24.01.06 Not Applicable Ice Machines Retired





TitleRevised New

2014 v 3

StandardComments

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

24.01.13 Traffic Control

24.01.14

Food Storage and

Preparation in

Remote Areas





TitleRevised New

2014 v 3

StandardComments

24.01.15Local Health

Standards

24.01.16 Infection Control





TitleRevised New

2014 v 3

StandardComments

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)

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

Chapter 25 Pharmacy Services / Medication Use




TitleRevised New

2014 v 3

StandardComments

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

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





TitleRevised New

2014 v 3

StandardComments

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

25.01.18 Labeling





TitleRevised New

2014 v 3

StandardComments

25.01.19Standardization of

Labeling

Patient Safety

Initiative

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





TitleRevised New

2014 v 3

StandardComments

25.01.29 Documentation

25.01.30Antithrombotic

Therapy

Patient Safety

Initiative

25.02.01

Preparation &

Administration of

Drugs

Patient Safety

Initiative

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





TitleRevised New

2014 v 3

StandardComments

26.00.00 §482.56

Condition of

Participation:

Rehabilitation

Services

26.01.00

This chapter

applies to

inpatient general

rehabilitation

services.

For DPU

Rehabilitation

Units, refer to

Chapter 33

26.00.01 §482.56(a)Organization &

Staffing26.01.01

26.00.02 §482.56(a)(1) Leadership 26.01.03

26.00.03 §482.56(a)(2)Staff

Qualifications26.01.04

26.00.04Minimum Staffing


26.00.05 Therapy Orders X 26.01.06 Clarification

26.00.06 §482.56(b)Delivery of

ServicesX 26.01.07 CMS Updates

26.00.07 §482.56(b)(1)Rehabilitation

Orders26.01.08

26.00.08 §482.56(b)(2)Standards of

Practice26.01.09

26.00.09 Organizational

PlanX

26.01.10

Combine with

Plan of Care

Revised

26.00.10Initial

Assessments26.01.12

Chapter 26 Physical Rehabilitation Services




TitleRevised New

2014 v 3

StandardComments

26.00.11Treatment Plan /

Plan of CareX 26.01.13 Clarification

26.00.12 Treatment Goals 26.01.14


Education26.01.15

26.00.14 Reassessment 26.01.16

26.00.16

Quality Assurance

Performance

Improvement

(QAPI)

26.01.17

Chapter 26 Physical Rehabilitation Services




TitleRevised New

2014 v 3

StandardComments

§482.60

Condition of

Participation:

Psychiatric

Hospitals

27.00.00

Chapter 27

Psychiatric

Hospitals has

been retired.

For DPU

Psychiatric Units,

refer to Chapter

34

§482.60(a) Clinical Focus 27.00.01 Retired

§482.60(b)

Compliance with

Hospital

Requirements

27.00.02 Retired

§482.60(c)Medical Records

Requirements27.00.03 Retired

§482.60(d)Staffing


§482.61

Condition of

Participation:

Special Medical

27.01.01 Retired

§482.61(a)

Development of

Assessment /

Diagnostic Data

27.01.02 Retired

§482.61(a)(1)Patient Legal

Status27.01.03 Retired

§482.61(a)(2)Admitting

Diagnosis27.01.04 Retired

§482.61(a)(3)Patient Reason for

Admission27.01.05 Retired

§482.61(a)(4)

Psychosocial

History /

Assessment

27.01.06 Retired

§482.61(a)(5)Neurological

Examination27.01.07 Retired

Chapter 27 Psychiatric Services




TitleRevised New

2014 v 3

StandardComments

Confidentiality of

Information27.01.08 Retired

§482.61(b)Psychiatric

Evaluation27.01.09 Retired

§482.61(b)(1)Timeframe for

Completion27.01.10 Retired

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

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

§482.61(b)(4)Reason for

Admission27.01.13 Retired

§482.61(b)(5)Behavioral

Assessment27.01.14 Retired

§482.61(b)(6)Cognitive

Assessment27.01.15 Retired

§482.61(b)(7)Inventory of

Strengths27.01.16 Retired

§482.61(c) Treatment Plan 27.01.17 Retired

§482.61(c)(1)Treatment Plan ‐

Individualized27.01.18 Retired

Treatment Plan ‐

Documentation27.01.19 Retired

§482.61(c)(1)Treatment Plan

Foundation27.01.20 Retired

§482.61(c)(1)(i)

Treatment Plan

Contents ‐

Diagnosis

27.01.21 Retired

§482.61(c)(1)(ii)Treatment Plan

Contents ‐ Goals27.01.22 Retired

§482.61(c)(1)(iii)

Treatment Plan

Contents ‐

Treatment

Modalities

27.01.23 Retired

§482.61(c)(1)(iv)

Treatment Plan

Contents ‐

Individual Staff

Responsibilities

27.01.24 Retired

§482.61(c)(1)(v)

Treatment Plan

Contents ‐

Justification of

Diagnosis

27.01.25 Retired

§482.61(c)(2)Documentation of

Active Treatment27.01.26 Retired





TitleRevised New

2014 v 3

StandardComments

§482.61(d) Progress Notes 27.01.27 Retired

§482.61(d)Frequency of

Progress Notes27.01.28 Retired

§482.61(e)

Discharge

Planning &

Summary

27.01.29 Retired

§482.62

Condition of

Participation:

Special Staffing

Requirements for

Psychiatric

Hospitals

27.02.00 Retired

§482.62(a)(1)Staffing








§482.62(b) Clinical Director 27.02.05 Retired

§482.62(b) Medical Staff 27.02.06 Retired

§482.62(b)(1)Medical Director

Qualifications27.02.07 Retired

§482.62(b)(2)Medical Director

Responsibilities27.02.08 Retired

§482.62(c)Availability of

Medical Personnel27.02.09 Retired

§482.62(d) Nursing Services 27.02.10 Retired

§482.62(d)(1)

Director of

Nursing

Qualifications

27.02.11 Retired

§482.62(d)(2) Staffing 27.02.12 Retired

§482.62(e)Psychological

Services27.02.13 Retired

§482.62(f) Social Services 27.02.14 Retired

§482.62(f)

Social Service

Staff Standards of

Practice

27.02.15 Retired

§482.62(f)(1)

Social Services

Director

Qualifications

27.02.16 Retired

§482.62(f)(2)

Social Services

Staff

Responsibilities

27.02.17 Retired

§482.62(g)Therapeutic

Activities Program27.02.18 Retired





TitleRevised New

2014 v 3

StandardComments

§482.62(g)(1)Activities Program

Focus27.02.19 Retired

§482.62(g)(2)Activities Program

Staffing27.02.20 Retired

Scope &

Description of

Available Services

27.02.21 Retired

Physical Facilities 27.03.01 Retired

Treatment

Environment27.03.02 Retired

Patient Bedrooms ‐

Safety and

Security

27.03.03 Retired

Sleeping

Accommodations27.03.04 Retired

Personal Property 27.03.05 Retired

Laundry 27.03.06 Retired

Patient Hygiene

Needs27.03.07 Retired

Treatment Space 27.03.08 Retired

Barrier‐Free 27.03.09 Retired

Patient Rights 27.04.01 Retired

Convulsive

Therapy27.05.01 Retired

Convulsive

Therapy ‐ Use

with Children

27.05.02 Retired

Administrative

Policy27.05.03 Retired

Psychosurgery 27.05.04 RetiredReferral for

Specialized

Services

27.05.05 Retired

Aversive

Conditioning27.05.06 Retired

27.06.01

Refer to Chapter

34 For Distinct

Part Unit ‐

Psychiatric Unit





TitleRevised New

2014 v 3

StandardComments

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

28.00.07

Patient Placement

Criteria

for Level II –

Intensive

Outpatient

28.00.08

Patient Placement

Criteria

for Level III –

Residential

/ Inpatient

28.00.09

Patient Placement

Criteria

for Level IV –

Medically

28.00.10

Opioid

Maintenance

Therapy (OMT)

28.00.11Treatment

Modalities

28.00.12

Treatment of Co‐

Occurring

Substance

Abuse and Mental

Health

28.00.13

Treatment

Protocols –

Alcohol

28.00.14

Treatment

Protocols – Use

of FDA Approved

Medications in

Chapter 28 Substance Abuse Services




TitleRevised New

2014 v 3

StandardComments

28.00.15

Treatment

Protocols – Use

of FDA Approved

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

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





TitleRevised New

2014 v 3

StandardComments

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

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


28.03.01

Confidentiality of

Substance Abuse

Patient

Records

28.03.02

Consent for

Disclosure of

Information

28.03.03Notice of Privacy

Practices





TitleRevised New

2014 v 3

StandardComments

28.04.01

Quality

Assessment /

Performance

Improvement

(QAPI)





TitleRevised New

2014 v 3

StandardComments

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

29.00.16

Policies ‐

Subspecialty

Patient Needs

Chapter 29 Special Care Units




TitleRevised New

2014 v 3

StandardComments

30.00.00 §482.51

Condition of

Participation:

Surgical Services

Format

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 Clarification

30.00.04 §482.51(a)(3) Circulating Nurses X Clarification

30.00.05 §482.51(a)(4) Surgical Privileges X Clarification


30.00.06

Medical Staff

Rules &

Regulations

30.00.07 First Assistants

30.00.08Physician

AvailabilityX Clarification

30.00.09 §482.51(b)Standards of

PracticeX Clarification

30.00.10 §482.51(b)(1) History & Physical X Clarification

Chapter 30 Surgical Services




TitleRevised New

2014 v 3

StandardComments

30.00.11§482.51(b)(2)

§482.24(c)(2)(v)Informed Consent X

Patient Safety

Initiative

30.00.12 §482.51(b)(3)Required

EquipmentX Clarification

30.00.13

Supply and

Instrumentation

Availability &

Sterilization

X Clarification

30.00.14Operative Site

Verification

Patient Safety

Initiative

30.00.15 Not Applicable30.00.15 Risk

AssessmentRetired

30.00.16Pneumatic

Tourniquets

Patient Safety

Initiative

30.00.17 §482.51(b)(4)Postoperative

CareX Clarification

30.00.18 §482.51(b)(5)Operating Room

RegisterX Clarification

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

30.00.20Pathology Review

Exemptions





TitleRevised New

2014 v 3

StandardComments

30.00.21

Label Medications

& Solutions on the

Sterile Field

Patient Safety

Initiative


30.00.22

Postoperative

Medical Care

30.01.00 §482.52

Condition of

Participation:

Anesthesia

Services


30.01.01 §482.52(a)Scope of Service:

Anesthesia30.01.02

30.01.02§482.52(c)(2)

§482.52(c)(2)

Anesthesia

ProvidersX 30.01.03 Clarification

30.01.03

Moderate

Sedation

(Conscious

Sedation)

30.01.04

30.01.04 §482.52(b) Required Policies X 30.01.05 Clarification

30.01.05 §482.52(b)(1)Preanesthesia

Evaluation30.01.06





TitleRevised New

2014 v 3

StandardComments

30.01.06 §482.52(b)(2)Intraoperative

Anesthesia RecordX 30.01.07 Clarification

30.01.07 §482.52(b)(3)Postanesthesia

AssessmentX 30.01.08 Clarification

30.01.08 Equipment Safety 30.01.09


Medical Staff

Rules &

Regulations

Availability ‐

Postanesthesia


30.02.03Nursing Care:

Postanesthesia

30.02.04

Nursing Care

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 &

Instrumentation

Availability &






TitleRevised New

2014 v 3

StandardComments



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

30.03.02

Outpatient

Discharge

Instructions

X Clarification

30.03.03Post‐procedure

Follow‐up CallX Clarification





TitleRevised New

2014 v 3

StandardComments

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

31.00.12 §482.54

Standard Level:

Outpatient

Services

X CMS Update

Chapter 31 Outpatient Services




TitleRevised New

2014 v 3

StandardComments

32.00.00 §482.58

Special

Requirements for

Hospital Providers

of Long‐Term Care

Services ("Swing‐

Beds")

X CMS Update

32.00.01

§482.58(a)

§482.58(a)(1)

§482.58(a)(2)

§482.58(a)(3)

§482.58(a)(4)

Eligibility X Clarification

32.00.02 Not Applicable Bed Size

32.00.03 Not Applicable Hospital

Location

32.00.04 Not Applicable Nursing Waiver


No Termination

of Swing Bed

Approval

32.00.06 §482.58(b)Skilled Nursing

Facility ServicesX Clarification

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

X

Chapter 32 Swing Beds




TitleRevised New

2014 v 3

StandardComments

32.01.05 §483.10(b)(8) Advance

DirectivesX

32.01.06

§483.10(d)

§483.10(d)(1) Personal Physician

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

and TreatmentX Clarification

32.01.08 §483.10(d)(3)Participation in

CareX Clarification

32.01.09

§483.10(e)

§483.10(e)(1)

§483.10(e)(2)

§483.10(e)(3)(i)(ii)

Personal Privacy

and

Confidentiality

X Clarification

32.01.10

§483.10 (h)

§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)(2)Mail

32.01.12

§483.10(j)

§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 PropertyPersonal

Possessions

32.01.14 §483.10(m) Married Couples

32.01.15

§483.12(a)

§483.12(a)(1)Transfer and

Discharge





TitleRevised New

2014 v 3

StandardComments

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

NoticeX Clarification

32.01.21 §483.12(a)(7)

Orientation for

Transfer or

Discharge

32.01.22Exercise of

RightsRetired

32.02.01

§483.13

§483.13(a) Restraints

32.02.02 §483.13(b) Abuse





TitleRevised New

2014 v 3

StandardComments

32.02.03

§483.13(c)

§483.13(c)(1)(i)Staff Treatment of

Residents

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)(iii)

Screening of Staff X Clarification

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 Clarification

32.03.03Activities

Director Retired

32.03.04

§483.15(g)

§483.15(g)(1) Social Services X Clarification

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 Clarification





TitleRevised New

2014 v 3

StandardComments

32.03.06

§483.20(l)

§483.20(l)(1)

§483.20(l)(2)

§483.20(l)(3)

Discharge

SummaryX Clarification

32.04.01

§483.45

§483.45(a)

§483.45(a)(1)

§483.45(a)(2)

Specialized

Rehabilitative

Services:

Provision of

Services

X Clarification

32.04.02 §483.45(b)

Rehabilitative

Service Orders:

Qualifications

X Clarification

32.05.01 §483.55 Dental Services

32.05.02

§483.55(a)(1)

§483.55(a)(2)

Skilled Nursing

Facility:

Patient Liability

for Dental Care

X Clarification

32.05.03

§483.55(a)(3)

§483.55(a)(3)(i)

§483.55(a)(3)(ii)

§483.55(a)(4)

Skilled Nursing

Facility:

Resident Dental

Appointments

X Clarification

32.05.04

§483.55(b)

§483.55(b)(1)

§483.55(b)(1)(i)

§483.55(b)(1)(ii)

Nursing Facilities:

Provision of

Dental Services

X Clarification

32.05.05

§483.55(b)(2)

§483.55(b)(2)(i)

§483.55(b)(2)(ii)

§483.55(b)(3)

Nursing Facilities:

Appointments and

Referrals

X Clarification





TitleRevised New

2014 v 3

StandardComments

Distinct Part

Rehabilitation

Unit / Prospective

Payment System

Excluded Unit

26.00.01

33.00.01 §412.25(a)(1)

PPS Excluded

Hospital Units:

Basis for Exclusion

26.00.02

33.00.02 §412.25(a)(2)

PPS Excluded

Hospital Units:

Admission Criteria


33.00.03 §412.25(a)(3)

PPS Excluded

Hospital Units:

Separate Medical

Records


33.00.04 §412.25(a)(4)

PPS Excluded

Hospital Units:

Availability of

Clinical Records &

Information


33.00.05 §412.25(a)(5)

PPS Excluded

Hospital Units:

State Licensure

Requirements


33.00.06 §412.25(a)(6)

PPS Excluded

Hospital Units:

Utilization Review

Requirements

26.00.07

33.00.07 §412.25(a)(7)

PPS Excluded

Hospital Units:

Distinct Unit

Structure


Chapter 33 Distinct Part Unit ‐ Physical Rehabilitation Services




TitleRevised New

2014 v 3

StandardComments

33.00.08 §412.25(a)(8)

PPS Excluded

Hospital Units:

Fiscal

Intermediary

X CMS Update

33.00.09 §412.25(a)(9)

PPS Excluded

Hospital Units:

Separate Cost

Center

X CMS Update

33.00.10 §412.25(a)(10)

PPS Excluded

Hospital Units:

Allocate Costs

X CMS Update

33.00.11 §412.25(a)(11)

PPS Excluded

Hospital Units:

Statistical Data

X CMS Update

33.00.12 §412.25(a)(12)

PPS Excluded

Hospital Units:

Cost Report

X CMS Update

33.00.13 §412.25(a)(13)

PPS Excluded

Hospital Units:

Requirements on

the First Day of

the First Cost

Reporting Period

X CMS Update

33.00.14 §412.25(b)

PPS Excluded

Hospital Units:

Change in the Size

of Excluded Units


33.00.15

§412.25(c)(1)

§412.25(c)(2)

PPS Excluded

Hospital Units:

Change in Status

of Hospital Units


33.00.16 §412.25(d)

PPS Excluded

Hospital Units:

Number of

Excluded Units






TitleRevised New

2014 v 3

StandardComments

33.00.17

§412.25(e)

§412.25(e)(1) Satellite Facility:

Define X CMS Update

33.00.18

§412.25(e)(2)

§412.25(e)(2)(i)

§412.25(e)(2)(ii)

§412.25(e)(2)(ii)(A)

§412.25(e)(2)(ii)(B)

Satellite Facility:

CriteriaX CMS Update

33.00.19 §412.25(e)(2)(iii)(A)

Satellite Facility:

Separate

Governing Body

X CMS Update

33.00.20 §412.25(e)(2)(iii)(B)

Satellite Facility:

Admission and

Discharge Records

X CMS Update

33.00.21 §412.25(e)(2)(iii)(C)

Satellite Facility:

Beds are

Physically

Separate

X CMS Update

33.00.22 §412.25(e)(2)(iii)(D)

Satellite Facility:

Fiscal

Intermediary

X CMS Update

33.00.23 §412.25(e)(2)(iii)(E)

Satellite Facility:

Separate Cost

Center

X CMS Update

33.00.24 §412.25(e)(2)(iii)(F)

Satellite Facility:

Accounting

System

X CMS Update

33.00.25 §412.25(e)(2)(iii)(G)

Satellite Facility:

Hospital Cost

Report

X CMS Update





TitleRevised New

2014 v 3

StandardComments

33.00.26 §412.25(e)(3)Satellite Facility:

ExceptionX CMS Update

33.00.27

§ 412.25(e)(4)

§ 412.25(e)(4)(i)

§ 412.25(e)(4)(ii)

Satellite Facility:

Increase /

Decrease the

Square Footage or

Decrease the

Number of Beds

X CMS Update

33.00.28

§412.25(e)(5)

§412.25(e)(5)(i)

§412.25(e)(5)(ii)

Satellite Facility:

Structure Changes

After October 1,

2006

X CMS Update

33.00.29 §4 12.25(e)(6)

Satellite Facility:

Inpatient

Rehabilitation

Facility

X CMS Update

33.00.30 § 412.25(f)

Changes in

Classification of

Hospital Units

X CMS Update

33.01.00 §412.29

Inpatient

Rehabilitation

Facility (IRF):

Classification

Criteria for

Payment

X Clarification

33.01.01 §412.29(a)

Inpatient

Rehabilitation

Facility (IRF):

Provider

Agreement






TitleRevised New

2014 v 3

StandardComments

33.01.02

§412.29(b)

§412.29(b)(1)

§412.29(b)(1)(i)

§412.29(b)(1)(ii)

§412.29(b)(2)

§412.29(b)(2)(i)

§412.29(b)(2)(ii)

§412.29(b)(2)(iii)

§412.29(b)(2)(iv)

§412.29(b)(2)(v)

§412.29(b)(2)(vi)

§412.29(b)(2)(vii)

§412.29(b)(2)(viii)

§412.29(b)(2)(ix)

§412.29(b)(2)(x)

§412.29(b)(2)(xi)

§412.29(b)(2)(xii)

§412.29(b)(2)(xiii)

§412.29(b)(2)(xiii)(A)

§412.29(b)(2)(xiii)(B)

§412.29(b)(2)(xiii)(C)

Inpatient

Rehabilitation

Facility (IRF):

Requirement to

Serve Inpatient

Population

X CMS Update

33.01.03

§412.29(c)

§412.29(c)(1)

§412.29(c)(2)

§412.29(c)(3)

§412.29(c)(4)

Inpatient

Rehabilitation

Facility (IRF):

Written

Certification for

New IRFs

X CMS Update

33.01.04 §412.29(d)

Inpatient

Rehabilitation

Facility (IRF):

Preadmission

Screening


33.01.05 §412.29(e)Medical

Supervision X CMS Update

33.01.06 §412.29(f)Personnel

QualificationsX 26.00.11 CMS Update





TitleRevised New

2014 v 3

StandardComments

33.01.07 §412.29(g)

Medical Director

of

Rehabilitation –

Qualifications


33.01.08 §412.29(h) Plan of Treatment X 26.00.12 Clarification

33.01.09 §412.29(i) Coordinated Inter‐

disciplinary Team

Approach


33.01.10 §412.29(j) Retroactive

AdjustmentsX CMS Update

33.02.01Multi‐disciplinary

Team26.00.14

33.02.02Physician

Responsibility26.00.16

33.02.03 Nursing Care 26.00.17

33.02.04Organizational

Plan26.00.18

33.02.05Collaborative

Goals26.00.19


Education26.00.20

33.02.07

Quality

Assessment

Performance

Improvement

26.00.22





TitleRevised New

2014 v 3

StandardComments

Distinct Part

Psychiatric Unit /

Propsective

Payment System

Excluded Unit

X 27.06.00 Clarifications

34.00.01

§412.25

§412.25(a)

§412.25(a)(1)

§412.25(a)(1)(i)

§412.25(a)(1)(ii)

§412.25(a)(1)(iii)

PPS Excluded

Hospital Units:

Excluded Hospital

Units


34.00.02 §412.25(a)(2)

PPS Excluded

Hospital Units:

Admission Criteria


34.00.03 §412.25(a)(3)

PPS Excluded

Hospital Units:

Separate Medical

Records


34.00.04 §412.25(a)(4)

PPS Excluded

Hospital Units:

Availablity of

Clinical Records &

Information


34.00.05 §412.25(a)(5)

PPS Excluded

Hospital Units:

State Licensure

Requirements


34.00.06 §412.25(a)(6)

PPS Excluded

Hospital Units:

Utilization Review

Requirements

27.06.06

34.00.07 §412.25(a)(7)

PPS Excluded

Hospital Units:

Distinct Unit

Structure


Chapter 34 Distinct Part Unit ‐ Psychiatric Services




TitleRevised New

2014 v 3

StandardComments

34.00.08 §412.25(a)(8)

PPS Excluded

Hospital Units:

Fiscal

Intermediary

X CMS Updates

34.00.09 §412.25(a)(9)

PPS Excluded

Hospital Units:

Separate Cost

Center

X CMS Updates

34.00.10 §412.25(a)(10)

PPS Excluded

Hospital Units:

Allocate Costs

X CMS Updates

34.00.11 §412.25(a)(11)

PPS Excluded

Hospital Units:

Statistical Data

X CMS Updates

34.00.12 §412.25(a)(12)

PPS Excluded

Hospital Units:

Cost Report

X CMS Updates

34.00.13 §412.25(a)(13)

PPS Excluded

Hospital Units:

Requirements on

the First Day of

the First Cost

Reporting Period

X CMS Updates

34.00.14 §412.25(b)

PPS Excluded

Hospital Units:

Change in Size

X CMS Updates

34.00.15

§412.25(c)

§412.25(c)(1)

§412.25(c)(2)

PPS Excluded

Hospital Units:

Change in Status

X CMS Updates

34.00.16 §412.25(d)

PPS Excluded

Hospital Units:

Number of

Excluded Units

X CMS Updates





TitleRevised New

2014 v 3

StandardComments

34.00.17§412.25(e)

§412.25(e)(1)

Satellite Facilities:

DefineX CMS Updates

34.00.18

§412.25(e)(2)

§412.25(e)(2)(i)

§412.25(e)(2)(ii)

§412.25(e)(2)(ii)(A)

§412.25(e)(2)(ii)(B)

Satellite Facility:

CriteriaX CMS Updates

34.00.19 §412.25(e)(2)(iii)(A)

Satellite Facility:

Separate

Governing Body

X CMS Updates

34.00.20 §412.25(e)(2)(iii)(B)

Satellite Facility:

Admission and

Discharge Records

X CMS Updates

34.00.21 §412.25(e)(2)(iii)(C)

Satellite Facility:

Beds are

Physically

Separate

X CMS Updates

34.00.22 §412.25(e)(2)(iii)(D)

Satellite Facility:

Fiscal

Intermediary

X CMS Updates

34.00.23 §412.25(e)(2)(iii)(E)

Satellite Facility:

Separate Cost

Center

X CMS Updates

34.00.24 §412.25(e)(2)(iii)(F)

Satellite Facility:

Accounting

System

X CMS Updates





TitleRevised New

2014 v 3

StandardComments

34.00.25 §412.25(e)(2)(iii)(G)

Satellite Facility:

Hospital Cost

Report

X CMS Updates

34.00.26 §412.25(e)(3)Satellite Facility:

ExceptionX CMS Updates

34.00.27

§412.25(e)(4)

§412.25(e)(4)(i)

§412.25(e)(4)(ii)

Satellite Facility:

Increase /

Decrease Square

Footage or

Decrease Beds

X CMS Updates

34.00.28

§412.25(e)(5)

§412.25(e)(5)(i)

§412.25(e)(5)(ii)

Satellite Facility:

Structural

Changes After

October 1, 2006

X CMS Updates

34.00.29 § 412.25(e)(6)

Satellite Facility:

Inpatient

Psychiatric Unit

X CMS Updates

34.00.30 §412.25(f)

Changes in

Classification of

Hospital Units

X CMS Updates

34.01.01

PPS Excluded

Psychiatric Units:

Additional

Requirements

27.06.08

34.01.02 §412.27(a)

PPS Excluded

Psychiatric Units:

Admission Criteria






TitleRevised New

2014 v 3

StandardComments

34.01.03 §412.27(b)

PPS Excluded

Psychiatric Units:

Scope of Service


34.01.04 §412.27(c)

PPS Excluded

Psychiatric Units:

Treatment Plan


34.01.05 §412.27(c)(1)

PPS Excluded

Psychiatric Units:

Development of

Assessment /

Diagnostic Data


34.01.06 §412.27(c)(1)(i)

PPS Excluded

Psychiatric Units:

Legal Status

27.06.13

34.01.07 §412.27(c)(1)(ii)

PPS Excluded

Psychiatric Units:

Admission

Diagnosis


34.01.08 §412.27(c)(1)(iii)

PPS Excluded

Psychiatric Units:

Patient Reason for

Admission


34.01.09 §412.27(c)(1)(iv)

PPS Excluded

Psychiatric Units:

Social History and

Assessment


34.01.10 §412.27(c)(1)(v)

PPS Excluded

Psychiatric Units:

Neurological

Examination

27.06.17





TitleRevised New

2014 v 3

StandardComments

34.01.11 §412.27(c)(2)

PPS Excluded

Psychiatric Units:

Psychiatric

Evaluation

27.06.18

34.01.12 §412.27(c)(2)(i)

PPS Excluded

Psychiatric Units:

Psychiatric

Evaluation ‐

Timeframe


34.01.13 §412.27(c)(2)(ii)

PPS Excluded

Psychiatric Units:

Psychiatric

Evaluation ‐

Medical History

27.06.20

34.01.14 §412.27(c)(2)(iii)

PPS Excluded

Psychiatric Units:

Psychiatric

Evaluation ‐

Mental Status

27.06.21

34.01.15 §412.27(c)(2)(iv)

PPS Excluded

Psychiatric Units:

Psychiatric

Evaluation ‐ Onset

of Illness

27.06.22

34.01.16 412.27(c)(2)(v)

PPS Excluded

Psychiatric Units:

Psychiatric

Evaluation ‐

Description of

Attitudes and

Behaviors

27.06.23





TitleRevised New

2014 v 3

StandardComments

34.01.17 §412.27(c)(2)(vi)

PPS Excluded

Psychiatric Units:

Psychiatric

Evaluation ‐

Cognition

27.06.24

34.01.18 §412.27(c)(2)(vii)

PPS Excluded

Psychiatric Units:

Psychiatric

Evaluation ‐ Assets

27.06.25

34.01.19 §412.27(c)(3)(i)

PPS Excluded

Psychiatric Units:

Treatment Plan

X 27.06.26

34.01.20 §412.27(c)(3)(ii)

PPS Excluded

Psychiatric Units:

Documentation of

Active Treatment


34.01.21 §412.27(c)(4)

PPS Excluded

Psychiatric Units:

Progress Notes

Requirements


34.01.22 §412.27(c)(5)

PPS Excluded

Psychiatric Units:

Discharge

Planning and

Discharge

Summary


34.01.23 §412.27(d)(1)(i)

PPS Excluded

Psychiatric Units:

Staffing

Requirements

27.06.30 CMS Updates





TitleRevised New

2014 v 3

StandardComments

34.01.24 §412.27(d)(1)(ii)

PPS Excluded

Psychiatric Units:

Staffing

Requirements


34.01.25 §412.27(d)(1)(iii)

PPS Excluded

Psychiatric Units:

Staffing

Requirements


34.01.26 §412.27(d)(1)(iv)

PPS Excluded

Psychiatric Units:

Staffing

Requirements


34.01.27 §412.27(d)(2)

PPS Excluded

Psychiatric Units:

Director of

Inpatient

Psychiatric

Services: Medical

Staff


34.01.28 §412.27(d)(2)(i)

PPS Excluded

Psychiatric Units:

Medical Director

Qualifications


34.01.29 §412.27(d)(2)(ii)

PPS Excluded

Psychiatric Units: Medical Director

Responsibilities


34.01.30 §412.27(d)(3)

PPS Excluded

Psychiatric Units:

Nursing Services






TitleRevised New

2014 v 3

StandardComments

34.01.31 §412.27(d)(3)(i)

PPS Excluded

Psychiatric Units:

Nursing Services

Leadership


34.01.32 §412.27(d)(3)(ii)

PPS Excluded

Psychiatric Units:

Staffing

27.06.39

34.01.33 §412.27(d)(4)

PPS Excluded

Psychiatric Units:

Psychological

Services


34.01.34 §412.27(d)(5)

PPS Excluded

Psychiatric Units:

Social Services


34.01.35 §412.27(d)(6)

PPS Excluded

Psychiatric Units:

Therapeutic

Activities

27.06.42

34.01.36 §412.27(d)(6)(i)

PPS Excluded

Psychiatric Units:

Program Scope


34.01.37 §412.27(d)(6)(ii)

PPS Excluded

Psychiatric Units:

Program Staffing


34.02.01

Scope &

Description of

Available Services






TitleRevised New

2014 v 3

StandardComments

34.02.02 Physical Facilities 27.06.46

34.02.03

Patient Bedrooms ‐

Safety and

Security


34.02.04Patient Hygiene

Needs27.06.48

34.02.05Handicapped

AccessiblityX 27.06.49 Clarifications

34.02.06Confidentiality of

InformationX 27.06.50 Clarifications


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