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Hospital & Critical Access Hospital (CAH) Changes to Promote Innovation, Flexibility, and Improvement in Patient care – Proposed Rule

From: Federal Register CMS-3295-P; 6/16/16

CMS Fact Sheet Article:

CMS Issues Proposed Rule that Prohibits Discrimination, Reduces Hospital-Acquired Conditions, and Promotes Antibiotic Stewardship in Hospitals


Today, the Centers for Medicare & Medicaid Services (CMS) announced that it is proposing to update the requirements that hospitals and critical access hospitals (CAHs) must meet to participate in Medicare and Medicaid. The proposed changes to the requirements, formally called the Conditions of Participation, would modernize and revise the requirements to reflect current standards of practice and support improvements in quality of care by:

  • Reducing readmissions;
  • Reducing barriers to care;
  • Reducing the incidence of hospital-acquired conditions (including healthcare-associated infections);
  • Improving the use of antibiotics (including the potential for reduced antibiotic resistance);
  • Addressing workforce shortage issues; and
  • Improving patient protections.

For more information, please visit: There is a 60 day comment period on the proposed rule.

Proposed changes to hospital and CAH requirements

Under the proposed rule, hospitals and CAHs would be required to:

  • Have hospital-wide infection prevention and control and antibiotic stewardship programs for the surveillance, prevention, and control of healthcare-associated infections and other infectious diseases, and for the appropriate use of antibiotics;
  • Designate leaders of the infection prevention and control program and the antibiotic stewardship program respectively, who are qualified through education, training, experience, or certification.  This requirement allows for flexibility in staffing in order to suit the needs of each hospital or CAH; and
  • Establish and implement a policy prohibiting discrimination on the basis of race, color, religion, national origin, sex (including gender identity), sexual orientation, age, or disability;

The proposed rule would make several clarifications and revisions to the current requirements:

  • Would change the term “licensed independent practitioner” to simply “licensed practitioner” so that hospitals may use physician assistants to the extent of their educational preparation and scope of practice, as determined by state law;
  • Would require that a hospital’s Quality Assessment and Performance Improvement (QAPI) program incorporate quality indicator data related to hospital readmissions and hospital-acquired conditions;
  • For nursing services, would allow a hospital to establish a policy that would specify which outpatient departments would not be required to have a registered nurse physically present as well as the alternative staffing plans that would be established under such a policy;
  • Would require that each patient’s medical record contain information to justify all admissions and continued hospitalizations, support the diagnoses, describe the patient’s progress and responses to medications and services, and document all inpatient stays and outpatient visits to reflect all services provided to the patient; and
  • Would require that all patient medical records document discharge and transfer summaries, including any patient discharge instructions.
  • Clarifies that patients should be able to access their medical records in a form and format requested by the patient, whether electronically or in a hard copy format, if readily producible in that form and format.

Additional proposed changes for CAHs include:

  • The elimination of the CAH disclosure of ownership requirement in order to remove a redundancy in regulations;
  • A requirement that individual patient nutritional needs be met in accordance with recognized dietary practices and the orders of the practitioner responsible for the care of the patients, or by a qualified dietitian or qualified nutrition professional as authorized by the medical staff in accordance with State law governing dietitians and nutrition professionals. This may allow dietitians and nutrition professionals to work to their full scope of practice (this provision aligns with requirements already in place for non-CAH hospitals); and
  • A requirement that a CAH develop, implement, maintain, and evaluate its own QAPI program in order to monitor and improve patient care.

Hospital & Critical Access Hospital (CAH) Changes to Promote Innovation, Flexibility, and Improvement in Patient care – Proposed Rule

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Revisions to State Operations Manual (SOM), Appendix W for CAHs

From: CMS Transmittal 138 (Pub. 100-07) – 4/7/15

Summary of Changes:

Appendix W, Survey Protocol, Regulations and Interpretive Guidance for Critical Access Hospitals (CAHs) and Swing Beds in CAHs, is being revised to reflect recent regulation changes.  We are also taking this opportunity to make clarifications and updates to existing guidance.

Read more: Revisions to State Operations Manual (SOM), Appendix W for CAHs

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CMS Issues Final Rules on Hospital Conditions of Participation

Federal Register – CMS-3244-F; FR 5/16/12 – Final rules

The Centers for Medicare and Medicaid Services (CMS) May 10 issued a final rule, “Reform of Hospital and Critical Access Hospital Conditions of Participation” (CoPs). The revisions to the CoPs are part of the government’s response to Executive Order 13563, “Improving Regulations and Regulatory Review.” The changes include:

  • One governing body will be allowed to oversee multiple hospitals in a multi-hospital system, and a member or members of the hospital’s medical staff must be included on the governing body;
  • Hospitals will have the flexibility to include other practitioners as eligible candidates for the medical staff with hospital privileges to practice in the hospital in accordance with state law;
  • Elimination of the requirement for authentication of verbal orders within 48 hours; authentication timeframes will be established according to state law; and
  • All orders, including verbal orders, must be dated, timed, and authenticated by either the ordering practitioner or another practitioner who is responsible for the care of the patient.

CMS Issues Final Rules on Hospital Conditions of Participation

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