Preparing for the Changes in CMS Conditions of Participation

In this issue of Insights, we explore the implications of recent changes to the Centers for Medicare and Medicaid Services (CMS) Conditions of Participation. These changes have far-reaching implications for your hospital, particularly for those responsible for discharge planning. With effective assessment and planning, you can assure continued compliance and performance that meets CMS requirements. The assessment and planning, and ultimately the execution of the plans developed, require the input and involvement of multiple hospital functions, including case management, nursing, medical staff, and finance, to name a few.

"Hospitals are required to be in compliance with the Federal requirements set forth in the Medicare Conditions of Participation (CoP) in order to receive Medicare/Medicaid payment." [1] Failure to comply could place the hospital in immediate jeopardy and cause the hospital to lose Medicare and Medicaid reimbursement.
On May 17, 2013, the CMS released a Revision to State Operations Manual (SOM), Hospital Appendix A - Interpretive Guidelines for 42 CFR 482.43, Discharge Planning.1 "In order for a hospital to be Medicare-certified and assigned a CMS Certification Number (CCN) and also be accredited, it must be able to demonstrate that it meets all of the Conditions of Participation (CoPs), and Joint Commission standards in addition to the CoPs..." [2] The CoP includes 144 specific survey procedures to be used by The Joint Commission, CMS and other auditors to evaluate hospital compliance with discharge planning.
These changes and revisions took effect immediately and without any warning. The memorandum was sent to State Survey Agency Directors who were advised that, "This policy should be communicated to all survey and certification staff, their managers, and the State/Regional Office training coordinators within 30 days of this memorandum."[3] This means that surveyors, agents, and auditors can, and will, evaluate hospitals based upon the new requirements effective retroactive to May 17, 2013. 

Ensuring that each of these conditions have been addressed according to the interpretive guidelines with policies, procedures, and practices that are measurably being used can be a daunting prospect.
The CoPs contain multiple conditions, each with detailed requirements that the hospital must meet. Assuring that the hospital meets the requirements necessitates that the hospital reviews the revisions, objectively assesses how well the hospital meets the requirements, and develops a definitive action plan to close the compliance gap. Accomplishing this in today's operating environment, requires focused hospital case management, medical staff leadership and other stakeholder attention.  
CoP §482.43 details each requirement specific to discharge planning. The CoP §482.43 includes 21 specific criteria that the hospital must meet in entirety. Specific to these 21 criteria, CMS has developed 144 survey procedures to be used by auditors and surveyors. In most hospitals, case management generally has responsibility for ensuring that the hospital meets all the requirements found in CoP §482.43.
One example of an excerpt from CoP §482.43 illustrates the challenge of meeting the conditions' complexity: Discharge Planning, (b) Standard: Identification of patients in need of discharge planning states the hospital must identify at an early stage of hospitalization all patients who are likely to suffer adverse health consequences upon discharge if there is not adequate discharge planning. The Joint Commission and CMS surveyors receive interpretive guidelines and survey procedures to determine whether the hospital's case management department has adequate policies and procedures in place to ensure compliance and, further, follows those policies and procedures routinely.
The interpretive guidelines for CoP §482.43: Discharge Planning, (b) Standard: Identification of patients in need of discharge planning follow. 

For every inpatient identified under the process required at §482.43(a) as at potential risk of adverse health consequences without a discharge plan, a discharge planning evaluation must be completed by the hospital. In addition, an evaluation must also be completed if the patient, or the patient's representative, or the patient's attending physician requests one. Unless the hospital has adopted a voluntary policy of developing an evaluation for every inpatient, the hospital must also have a process for making patients, including the patient's representative, and attending physician aware that they may request a discharge planning evaluation, and that the hospital will perform an evaluation upon request. Hospitals must perform the evaluation upon request, regardless of whether the patient meets the hospital's screening criteria for an evaluation. In contrast to the screening process, the evaluation entails a more detailed review of the individual patient's post-discharge needs, in order to identify the specific areas that must be addressed in the discharge plan." [2]
To prepare for the increasing level of scrutiny, the hospital must review its policies, procedures, and practices objectively to assure that it meets the intent and specifics of the CoPs. Doing so requires that the hospital examine its performance in a manner similar to that which the surveyors might use. For the above CoP, the hospital needs to assess itself by asking and answering the following questions, among others.

The hospital can conduct tracers, similar to The Joint Commission process, to determine objective answers to these questions and others specific to meeting the 21 conditions.
The above offers a brief example of the objective, demonstrable questions the hospitals must develop and assess to assure continued compliance with the CMS CoPs. Given that this represents a sampling of the questions for one condition, doing so for the 21 conditions within this one CoP can prove to be challenging, but necessary to assure meeting CMS requirements.

Regulatory scrutiny on hospital performance will continue to escalate as pressures on utilization and resources remain in the forefront of the national healthcare agenda. Hospitals must assure compliance with those requirements to assure patient safety and continued reimbursement for services rendered. Assuring compliance requires assessing one's performance against the requirements. Assessing one's performance requires developing objective criteria and gauging one's performance against those criteria critically.

We are pleased to have the opportunity to provide this information to you. For additional information and dialogue, please contact Kathy Kirkland, RN, BSN, CCM, or me at 484-840-1984.
Best Regards,
Bob Gift

[1] Centers for Medicare and Medicaid Services. May 17, 2013. Revision to State Operations Manual (SOM), Hospital Appendix A - Interpretive Guidelines for 42 CFR 482.43, Discharge Planning. Retrieved from
[2] The Joint Commission. October 15, 2010. Frequently Asked Questions about Accrediting Hospitals in Accordance with their CMS' Certification Number (CCN). Retrieved from
[3] Centers for Medicare and Medicaid Services. May 17, 2013. Revision to State Operations Manual (SOM), Hospital Appendix A - Interpretive Guidelines for 42 CFR 482.43, Discharge Planning.