Are you a hospital using Joint Commission accreditation for deemed status with the US Centers for Medicare & Medicaid? If so, are you ready for a CMS survey\u2014every day, at any time? According to federal policy, for 60 days after a Joint Commission survey, any organization that uses accreditation for deemed status is at risk for a validation survey from the US Centers for Medicare & Medicaid Services (CMS). In fact, CMS may elect, at any time, to conduct its own additional evaluation of a hospital with deemed status through a complaint or potential immediate jeopardy investigation. When CMS or the Department of Health arrives at your facility, you need to be prepared. The 2024 Joint Commission and CMS Crosswalk: Comparing Hospital Standards and CoPs offers easy access to the full\u2014and current as of January 1, 2024\u2014language of the Medicare hospital Conditions of Participation (CoPs) and demonstrates their equivalency with the Joint Commission\u2019s hospital standards. A reverse crosswalk, listing Joint Commission requirements with equivalent CoP numbers, shows equivalencies in the opposite direction. This allows staff to easily see how the two sets of requirements relate to each other, whether they are more familiar with the Medicare CoPs or the Joint Commission standards. Regulatory staff and accreditation managers can use the crosswalks in this guide to identify how your organization’s policies, procedures, and practices support one or more Joint Commission standards and demonstrate compliance with equivalent CMS regulations\u2014or identify gaps. Hospitals and psychiatric hospitals preparing for a deemed status survey from The Joint Commission need resources to ensure they are compliant with both sets of requirements and are ready for survey. Although accredited hospitals are able to access two of the four crosswalks in this book on E-dition\u00ae, this guide goes a step further, providing the reverse crosswalks as well as critical information about CMS and deemed status. Plus, the book’s sidebars and tables provide additional information on Joint Commission accreditation for deemed status, CMS-related updates, and how both organizations survey for compliance. Key Topics: Medicare hospital CoPs and equivalent Joint Commission standards as of January 1, 2024 Eligibility requirements for Joint Commission hospital accreditation for deemed status recognition by CMS Description of deemed status and what that means for a hospital Highlights of all the revisions to CMS regulations in the new edition Tips to maintain compliance without duplicating effort<\/p>\n
| PDF Pages<\/th>\n | PDF Title<\/th>\n<\/tr>\n | ||||||
|---|---|---|---|---|---|---|---|
| 3<\/td>\n | Contents <\/td>\n<\/tr>\n | ||||||
| 5<\/td>\n | Introduction Purpose of this Book Overview of Contents <\/td>\n<\/tr>\n | ||||||
| 7<\/td>\n | What’s New How to Use this Crosswalks <\/td>\n<\/tr>\n | ||||||
| 8<\/td>\n | Potential Limitations with the Crosswalks <\/td>\n<\/tr>\n | ||||||
| 11<\/td>\n | Part 1: Understanding Deemed Status <\/td>\n<\/tr>\n | ||||||
| 13<\/td>\n | What is Deemed Status? <\/td>\n<\/tr>\n | ||||||
| 18<\/td>\n | How Does My Hospital Achieve Joint Commission Accreditation for Deemed Status Purposes? <\/td>\n<\/tr>\n | ||||||
| 25<\/td>\n | What is Intracycle Monitoring <\/td>\n<\/tr>\n | ||||||
| 26<\/td>\n | How Do We Know What Requirements to Meet? <\/td>\n<\/tr>\n | ||||||
| 27<\/td>\n | What is an 1135 Waiver? When Might My Organization Need an 1135 Waiver? What Are Blanket Waivers? <\/td>\n<\/tr>\n | ||||||
| 29<\/td>\n | How Does My Organization Request an 1135 Waiver? What Happens If a Joint Commission Surveyor Identifies Noncompliance? <\/td>\n<\/tr>\n | ||||||
| 36<\/td>\n | How Will We Learn About Our Joint Commission Survery Findings? <\/td>\n<\/tr>\n | ||||||
| 37<\/td>\n | How Will CMS Be Notified of Our Joint Commission Survey Results? <\/td>\n<\/tr>\n | ||||||
| 41<\/td>\n | What is a CMS Validation Survey? <\/td>\n<\/tr>\n | ||||||
| 45<\/td>\n | Part 2: 2024 Joint Commission and CMS Hospital Crosswalk <\/td>\n<\/tr>\n | ||||||
| 47<\/td>\n | \u00a7482.1 Basics and Scope \u00a7482.11 CoP: Compliance with Federal, State \nand Local Laws <\/td>\n<\/tr>\n | ||||||
| 50<\/td>\n | \u00a7482.12 CoP: Governing Body <\/td>\n<\/tr>\n | ||||||
| 70<\/td>\n | \u00a7482.13 CoP: Patient\u2019s Rights <\/td>\n<\/tr>\n | ||||||
| 111<\/td>\n | \u00a7482.15 CoP: Emergency Preparedness <\/td>\n<\/tr>\n | ||||||
| 153<\/td>\n | \u00a7482.21 CoP: Quality Assessment and Performance Improvement Program <\/td>\n<\/tr>\n | ||||||
| 174<\/td>\n | \u00a7482.22 CoP: Medical Staff <\/td>\n<\/tr>\n | ||||||
| 205<\/td>\n | \u00a7482.23 CoP: Nursing Services <\/td>\n<\/tr>\n | ||||||
| 230<\/td>\n | \u00a7482.24 CoP: Medical Record Services <\/td>\n<\/tr>\n | ||||||
| 255<\/td>\n | \u00a7482.25 CoP: Pharmaceutical Services <\/td>\n<\/tr>\n | ||||||
| 265<\/td>\n | \u00a7482.26 CoP: Radiologic Services <\/td>\n<\/tr>\n | ||||||
| 277<\/td>\n | \u00a7482.27 CoP: Laboratory Services <\/td>\n<\/tr>\n | ||||||
| 293<\/td>\n | \u00a7482.28 CoP: Food and Dietetic Services <\/td>\n<\/tr>\n | ||||||
| 301<\/td>\n | \u00a7482.30 CoP: Utilization Review <\/td>\n<\/tr>\n | ||||||
| 329<\/td>\n | \u00a7482.41 CoP: Physical Environment <\/td>\n<\/tr>\n | ||||||
| 387<\/td>\n | \u00a7482.42 CoP: Infection Prevention and Control and Antibiotic Stewardship Programs <\/td>\n<\/tr>\n | ||||||
| 408<\/td>\n | \u00a7482.43 CoP: Discharge Planning <\/td>\n<\/tr>\n | ||||||
| 416<\/td>\n | \u00a7482.45 CoP: Organ, Tissue and Eye Procurement <\/td>\n<\/tr>\n | ||||||
| 420<\/td>\n | \u00a7482.51 CoP: Surgical Services <\/td>\n<\/tr>\n | ||||||
| 434<\/td>\n | \u00a7482.52 CoP: Anesthesia Services <\/td>\n<\/tr>\n | ||||||
| 444<\/td>\n | \u00a7482.53 CoP: Nuclear Medicine Services <\/td>\n<\/tr>\n | ||||||
| 453<\/td>\n | \u00a7482.54 CoP: Outpatient Services <\/td>\n<\/tr>\n | ||||||
| 461<\/td>\n | \u00a7482.55 CoP: Emergency Services <\/td>\n<\/tr>\n | ||||||
| 466<\/td>\n | \u00a7482.56 CoP: Rehabilitation Services <\/td>\n<\/tr>\n | ||||||
| 472<\/td>\n | \u00a7482.57 CoP: Respiratory Care Services <\/td>\n<\/tr>\n | ||||||
| 479<\/td>\n | \u00a7482.58 CoP: Special Requirements for Hospital Providers of Long-Term Care Services (\u201cSwing-Beds\u201d) <\/td>\n<\/tr>\n | ||||||
| 491<\/td>\n | \u00a7483.5 CoP: Definitions <\/td>\n<\/tr>\n | ||||||
| 492<\/td>\n | \u00a7483.10 CoP: Resident Rights <\/td>\n<\/tr>\n | ||||||
| 505<\/td>\n | \u00a7483.12 CoP: Freedom from Abuse, Neglect, and Exploitation <\/td>\n<\/tr>\n | ||||||
| 508<\/td>\n | \u00a7483.15 CoP: Admission, Transfer, and Discharge Rights <\/td>\n<\/tr>\n | ||||||
| 528<\/td>\n | \u00a7483.21 CoP: Comprehensive Person-Centered Care Planning <\/td>\n<\/tr>\n | ||||||
| 533<\/td>\n | \u00a7483.40 CoP: Behavioral Health Services \u00a7483.55 CoP: Dental Services <\/td>\n<\/tr>\n | ||||||
| 537<\/td>\n | \u00a7483.65 CoP: Specialized Rehabilitative Services <\/td>\n<\/tr>\n | ||||||
| 541<\/td>\n | Part 3: 2024 Joint Commission and CMS Psychiatric Hospital Crosswalk <\/td>\n<\/tr>\n | ||||||
| 543<\/td>\n | \u00a7482.60 CoP: Special Provisions Applying to Psychiatric Hospitals <\/td>\n<\/tr>\n | ||||||
| 544<\/td>\n | \u00a7482.61 CoP: Special Medical Record Requirements for Psychiatric Hospital <\/td>\n<\/tr>\n | ||||||
| 570<\/td>\n | \u00a7482.62 CoP: Special Staff Requirements for Psychiatric Hospitals <\/td>\n<\/tr>\n | ||||||
| 585<\/td>\n | Part 4: Joint Commission Hospital Standards\/EPs Equivalent to CoPs <\/td>\n<\/tr>\n | ||||||
| 587<\/td>\n | Environment of Care (EC) <\/td>\n<\/tr>\n | ||||||
| 590<\/td>\n | Emergency Management (EM) <\/td>\n<\/tr>\n | ||||||
| 591<\/td>\n | Human Resources (HR) <\/td>\n<\/tr>\n | ||||||
| 592<\/td>\n | Infection Prevention and Control (IC) Information Management (IM) <\/td>\n<\/tr>\n | ||||||
| 593<\/td>\n | Leadership (LD) <\/td>\n<\/tr>\n | ||||||
| 596<\/td>\n | Life Safety (LS) <\/td>\n<\/tr>\n | ||||||
| 600<\/td>\n | Medication Management (MM) <\/td>\n<\/tr>\n | ||||||
| 602<\/td>\n | Medical Staff (MS) <\/td>\n<\/tr>\n | ||||||
| 604<\/td>\n | National Patient Safety Goals (NPSG) Nursing (NR) Provision of Care, Treatment, and Services (PC) <\/td>\n<\/tr>\n | ||||||
| 607<\/td>\n | Performance Improvement (PI) <\/td>\n<\/tr>\n | ||||||
| 608<\/td>\n | Record of Care, Treatment, and Services (RC) <\/td>\n<\/tr>\n | ||||||
| 609<\/td>\n | Rights and Responsibilities of the Individual (RI) <\/td>\n<\/tr>\n | ||||||
| 610<\/td>\n | Transplant Safety (TS) <\/td>\n<\/tr>\n | ||||||
| 611<\/td>\n | Part 5: Joint Commission Psychiatric Hospital Standards\/EPs Equivalent to CoPs <\/td>\n<\/tr>\n | ||||||
| 613<\/td>\n | Human Resources (HR) Information Management (IM) Leadership (LD) <\/td>\n<\/tr>\n | ||||||
| 614<\/td>\n | Medical Staff (MS) Nursing (NR) Provision of Care, Treatment, and Services (PC) <\/td>\n<\/tr>\n | ||||||
| 615<\/td>\n | Record of Care, Treatment, and Services (RC) Rights and Responsibilities of the Individual (RI) <\/td>\n<\/tr>\n<\/table>\n","protected":false},"excerpt":{"rendered":" Joint Commission and CMS Crosswalk: Comparing Hospital Standards and CoPs<\/b><\/p>\n |