New and Revised Standards

CMS recently published new requirements for acute care hospitals for the following:

  1. Ligature risks (CMS S&C Memo 18-06)
  2. Reducing risks of Legionella (CMS S&C Memo 17-30)
  3. Texting (CMS QSO 18-10)

HFAP has developed several standards to address these changes and we are providing this update as “pre-publication” information to encourage our facilities to begin developing compliance strategies while the standards undergo the final approval process. These HFAP requirements will become effective 90 days after CMS approval.

The 2018 v2 standards updates are available at the end of each section and the full document is available at the bottom of this notice.

Please note: All standards are marked as either ‘new standard’ or ‘revised standard.’

I. CMS S&C memo 18-06: Clarification of Ligature Risk Policy

Summary

The presence of ligature risks in the physical environment can compromise safety, especially for a patient with suicidal ideation. The Patient’s Rights Condition of Participation (CoP) at §482.13(c)(2) provides all patients with the right to care in a safe setting. Psychiatric patients receiving care and treatment in a hospital setting are particularly vulnerable.

Standards affected:

  • 04.01.01 – Staff Training – Identification of Patients at Risk for Harm
  • 11.01.01 – Periodic Monitoring for Safety Issues
  • 11.01.02 – Building Safety
  • 11.01.08 – Review of Safety Policies and Procedures
  • 11.02.01 – Building Security
  • 13.00.01 – Life Safety Code Compliance
  • 13.01.06 – Exit Discharge
  • 13.05.09 – Utility Systems
  • 15.01.17 – Privacy and Safety: Safe Setting
  • 15.01.19 – Privacy and Safety: Identify Patients at Risk
  • 15.01.20 – Privacy and Safety: Environmental Risk Assessment
  • 27.03.01 – Privacy and Safety: Identify Patients at Risk
  • 27.03.02 – Privacy and Safety: Environmental Risk Assessment

To view these pre-publication requirements, click on the link below.

2018 v2 Prepublication Updates – Ligature

II. CMS S&C memo 17-30 (revised 06-09-17): Reduce Legionella Risk in Healthcare Facility Water Systems

Summary

Facilities must develop and adhere to policies and procedures that inhibit microbial growth in building water systems that reduce the risk of growth and spread of legionella and other opportunistic pathogens.

Standards affected:

  • 07.01.03 – Reduce Risk of Legionella in Water Systems

To view this pre-publication requirement, click on the link below.

2018 v2 Prepublication Updates – Legionella

III. CMS QSOG memo 18-10 (revised 01-05-18): Texting of Patient Information among Healthcare Providers

Summary

The texting of patient orders is prohibited regardless of the platform utilized. Texting patient information among members of the hospital health care team is permissible if accomplished through a secure platform. Computerized Provider Order Entry (CPOE) is the preferred method of order entry by a provider.

Standards affected:

  • 10.00.00 – Condition of Participation: Medical Record Services
  • 10.00.06 – Security of Medical Information
  • 10.01.03 – Legible and Complete

To view these pre-publication requirements, click on the link below.

2018 v2 Prepublication Updates – Texting

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Questions? Please contact us at info@hfap.org.