Inpatient Facility Coding & Compliance Alert

Hint: Watch for new requirements regarding provider eligibility and more

Keeping abreast of Joint Commission standards for accreditation and certification is imperative for every facility. Now you have another Commission area to watch, as the agency is aligning its standards to match the newly revised CMS requirements for Medicare Conditions of Participation (CoPs). The Commission released new prepublication requirements for hospitals and critical access hospitals on Aug. 21, 2014, with an effective date of Sept. 29, 2014. 

The changes:  The Joint commission now requires the psychiatric and rehabilitation units in critical access hospitals also to abide by the hospital CoPs. The Joint Commission standards have been changed to include:

• The requirements of a practitioner who is not on the medical staff  rolls but  is ordering outpatient services, governing body consultation with the medical staff, and medical staff structure for multihospital systems.
• Requirement to define staff qualifications and have medical staff bylaws addressing self governance and accountability. 
• Requirement that hospitals should have a written policy and protect the rights of patients and residents who work for or on behalf of the LTCHs. 

Moreover, quite a few requirements have been added for hospitals that have swing beds used for long term care. As per these prepublication requirements, this means that the Joint Commission could survey policies related to hospitals using the swing beds as part of deemed status surveys.

CMS published information on CoPs in the Federal Register on May 12, 2014. For more information, see “Conditions Of Participation: Watch These 4 Areas Surveyors Are Targeting” on page 1 of this issue. You can also read the Joint commission prepublication at: http://www.jointcommission.org/assets/1/6/HAP_Burden_Reduction_Aug2014.pdf.