Provisions of the Final Notice. A. Differences Between CHAP’s Standards and Requirements for Accreditation and Medicare Conditions and Survey Requirements We compared CHAP’s hospice accreditation requirements and survey process with the Medicare CoPs of part 418, and the survey and certification process requirements of parts 488 and 489. Our review and evaluation of CHAP’s hospice application, which were conducted as described in section III of this final notice, yielded the following areas where, as of the date of this notice, CHAP has completed revising its standards and certification processes in order to ensure that hospices accredited by CHAP meet the requirements at: • § 418.64(d)(2), to ensure the dietary needs of patients are met. • § 418.76(b)(1), to ensure training is conducted by a registered nurse, or a licensed practical nurse under the supervision of a registered nurse. • § 418.76(b)(3)(xiii), to ensure that any other task that the hospice may choose to have an aide perform must be included in the content of the hospice aide classroom and supervised practical training. • § 418.76(d)(1), to ensure that in- service training is supervised by a registered nurse. • § 418.76(h)(3)(iv) and (v), to address the requirement that the supervising nurse must assess an aide’s ability to demonstrate initial and continued satisfactory performance in meeting outcome criteria for the hospice’s infection control policy and procedures and for reporting changes in the patient’s conditions. • § 418.76(k)(3), to address the requirement for homemakers to report concerns to the member of the interdisciplinary group who is responsible for coordinating homemaker services. • § 418.104, to address the requirement allowing medical records to be maintained electronically. • § 418.110(d)(3), to address the requirement that provisions of the adopted edition of the Life Safety Code do not apply in a state if CMS finds that a fire and safety code imposed by state law adequately protects patients in hospices. • § 418.113, to ensure compliance with all applicable federal, state, and local emergency preparedness requirements. • § 488.5(a)(7) through (9), to ensure that new surveyors receive the required initial orientation training, and that all new surveyors receive an evaluation of performance, in accordance with CHAP policies. • § 488.5(a)(12), to ensure that complaint surveys are conducted in a manner that meets or exceeds the processes and investigation practices of CMS; that the rationale for the decision...
Provisions of the Final Notice. A. Differences Between DNV GL’s Standards and Requirements for Accreditation and Medicare’s Conditions and Survey Requirements We compared DNV GL’s CAH requirements and survey process with the Medicare conditions of participation and survey process as outlined in the State Operations Manual (SOM). Our review and evaluation of DNV GL’s CAH accreditation program application, which were conducted as described in section III of this final notice, yielded the following: • To meet the requirements at § 412.25(d), DNV GL revised its standards to address the number of excluded units permitted. • To meet the requirements at § 412.27(c)(2)(vii), DNV GL revised its standards to include the requirement for an inventory of the inpatient’s assets in a descriptive fashion and ensured that consistent language is used in the crosswalk and manual. • To meet the requirements at § 412.27(d)(3), DNV GL revised its standards to more fully address nursing services requirements. • To meet the requirements § 412.27(d)(4), DNV GL revised its standards to address ‘‘service objectives’’ for psychological services. • To meet the requirements at § 412.27(d)(6)(ii), DNV GL revised its standards to address the number of ‘‘qualified therapists, support personnel and consultants’’ needed to provide comprehensive therapeutic activities consistent with each inpatient’s active treatment program. • To meet the requirements at § 412.29(h), DNV GL revised its standards to ensure a plan of treatment for each inpatient that is established, reviewed, and revised as needed by a physician in consultation with other professional personnel who provide services to the patient. • To meet the requirements at § 482.12(c)(1)(iv), DNV GL revised its standards related to a doctor of optometry. • To meet the requirements at § 482.12(c)(2), DNV GL revised its standards to address the regulatory language, ‘‘patients are admitted to the hospital only on the recommendation of a licensed practitioner.’’ • To meet the requirements at § 482.13(h)(1), DNV GL revised its standards to more fully address the requirement to inform each patient (or ‘‘support person, where appropriate’’) of his or her visitation rights, including any clinical restriction or limitation on such rights, when he or she is informed of his or her rights under this section, and ensured consistent language is used in its manual and crosswalk. • To meet the requirements at § 482.21(e)(1), DNV GL revised its standards to ensure that an ongoing qualit...
