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CMS seeks feedback on new survey for long-term, acute-care hospitals

CMS is asking Medicare patients or their family members to help them develop a new patient-satisfaction survey of long-term, acute-care facilities. The comments will help CMS decide what sorts of information the survey will need to collect. Some of the suggested topics areas include:

• Communication with providers
• Mechanical ventilation
• Therapy services
• Wound care
• Pain management/control or non-pain symptom management
• Rehabilitation services
• Medical and nursing care
• Interdisciplinary team goal setting and care planning
• Family training
• Discharge planning

The survey will also be used in Medicare’s quality reporting program, meaning facilities that fail to deliver data could get a 2% reduction in their payment updates. CMS is accepting comments until 5 p.m. on Jan. 19.

December webcast to highlight survey hot spots for 2016

What are the CMS and Joint Commission hot spots for 2016? Join Bud Pate, REHS, and Lisa Eddy, RN, CPHQ, on Wednesday, December 16 at 1 p.m. ET as they examine current survey focuses and point out where CMS and The Joint Commission will concentrate their efforts during your next survey.

In just 90 minutes, find out how to prepare for your next accreditation survey and comply with the most troublesome CMS and Joint Commission requirements. Pate and Eddy will provide strategies for preparing your staff for survey and give you valuable tips about what surveyors will expect when they arrive at your facility.

For more information and to register for the webcast, call HCPro customer service at 800-650-6787 or visit the HCPro Marketplace.

New name for Briefings on The Joint Commission

Briefings on The Joint Commission has a new name: Briefings on Accreditation and Quality!

For the last few years, in addition to covering the latest Joint Commission happenings, we’ve also included a broad focus on CMS compliance and quality improvement. We think our new name better reflects the quality content we strive to bring you each month. You’ll still be able to access prior issues of Briefings on The Joint Commission on our website.

The November issue should be in your inbox. You can view it here and if you haven’t had a chance to subscribe to the newsletter, click here for more information.

We’re excited about this change and hope you will be too. If there are any topics you would like to see covered in upcoming editions of Briefings on Accreditation and Quality, please email me at


CMS announces Physician Quality Reporting Programs Strategic Vision

When CMS shared the findings of the 2015 Physician Quality Reporting System (PQRS) payment system, they also released the publication of the Physician Quality Reporting Programs Strategic Vision, or “Strategic Vision”.

The Strategic Vision is part of a long-term quality measurement plan for healthcare providers and public reporting programs and how those can be enhanced to support better decision-making from physicians, consumers, and everyone involved in healthcare.

For more information about the plan, click here.

CMS updates eCQMs for 2016 reporting

Last Friday, CMS posted the annual update for the 2014 electronic clinic quality measure (eCQMs) for eligible hospitals and professionals. Providers should use these measures to report 2016 quality data for CMS reporting programs, including the Physician Quality Reporting System (PQRS), Inpatient Quality Reporting Program (IQR), and the EHR Incentive Programs.

CMS updated 29 measures for eligible hospitals and 64 measures for eligible professionals.

Read the updated measures here.

CMS releases final hospital/CAH CoPs

Last week, the Centers for Medicare and Medicaid Services (CMS) posted the final rule reforming the Hospital/CAH CoPs. This rule is available on display copy only and will publish officially to the Federal Register on May 16th.  The DC office is in the process of completing a thorough review of the final rule and will pull a team together to discuss the provisions, and will provide a comparative analysis of the final provisions to the comments that Joint Commission submitted.

A quick review of the final rule can be found here.

HHS encourages equal visitation and representation rights

The Department of Health and Human Services (HHS) issued a press release this week to give added support to The Centers for Medicare & Medicaid Services (CMS) Conditions of Participation (COP) rules released in November of last year giving patients the right to choose their own visitors during a hospital stay.

The guidance given by the HHS emphasizes that hospitals should respect patients’ wishes concerning their representatives (whether expressed in writing, orally, or through other evidence unless prohibited by state law) in an effort to make it easier for family members, including a same-sex domestic partner, to make informed care decisions for loved ones who are incapacitated.

The CMS also sent a letter this week to State Survey Agencies (SSAs), highlighting the equal visitation and representation rights requirements and directing SSAs to be aware of the guidance when surveying for hospitals’ compliance with CoPs.

Read the full press release here.

Latest Sentinel Event Alert:Radiation risks of diagnostic imaging

The Joint Commission released its latest Sentinel Event Alert this morning highlighting the need for healthcare facilities and staff to maintain radiation doses as low as possible during diagnostic imaging in order to decrease exposure to repeat doses. The Alert asks healthcare organizations to address contributing factors to eliminate avoidable exposure by weighing the medical necessity of a given level of radiation against the risks.

According to the Alert, the US population’s total radiation exposure has nearly doubled over the past two decades, and  studies have estimated that 29,000 future cancers and 14,500 future deaths could develop due to radiation from the 72 million CT scans performed in the US in 2007.

In response, the Centers for Medicare & Medicaid Services (CMS) will require accreditation of all facilities providing advanced imaging services (CT scans, MRI, PET, nuclear medicine) including non-hospital, freestanding settings beginning January 1, 2012. The state of California is also requiring facilities that furnish CT X-ray services to become accredited by July 1, 2013.

The Joint Commission gives some suggested actions leaders can take to raise awareness among staff and patients of the risk associated with aggregate radiation doses and provide proper testing and dosage through effective processes, safe technology, and a culture of safety.

Click here to download the Sentinel Event Alert and the full list of recommendations.

HHS aims to improve health and cost for dual eligible patients

The U.S. Department of Health and Human Services (HHS) has introduced three new initiatives to help states lower the cost of healthcare for patients with dual eligibility for both Medicare and Medicaid, as well as reduce hospitalization for this group.

The three separate proposals include:

  • A demonstration program to test two new financial models in hopes to better coordinate care for individuals enrolled in Medicare and Medicaid
  • A demonstration program aimed at helping states improve the quality of care for people in nursing homes in order to reduce hospitalizations
  • Creating a technical resource center to help states improve care for high-need high-cost beneficiaries

The dual eligible population is represented by approximately nine million Americans, and accounts for more than $300 billion in state and federal healthcare spending every year.

The idea is that these initiatives will bring better care coordination and for this population, which in turn will improve the health of dual eligible beneficiaries making them less frequent consumers of healthcare services in general.

Source: Healthcare Finance News

CMS proposes new rule for community mental health centers

The Centers for Medicare and Medicaid Services (CMS) issued a proposed rule that would provide conditions of participation for community mental health centers (CMHCs).

Medicare beneficiaries who receive care from a CMHC have an alternative to inpatient treatment, and are provided with partial hospitalization services, including physician services, psychiatric nursing, counseling, and other social services.

CMS’ new rule includes the following standards:

• Establishing qualifications for CMHC employees and contractors.
• Mandating CMHCs to notify clients of their rights and to investigate and report violations of client rights. These proposed requirements also promote continuity of care by highlighting the need for communication of client needs when they are discharged or transferred.
• Organizing a treatment team, developing an active treatment plan, and coordinating services to ensure an interdisciplinary approach to individualized client care.
• Creating a Quality Assessment and Performance Improvement (QAPI) program. This will require CMHCs to identify program needs by evaluating outcome and client satisfaction data and making changes based on that data to improve their quality of care.
• Put into place organization, governance, administration of services, and partial hospitalization services requirements, with special attention to governance structure.

CMS is accepting comments until August 16, 2011. If you’d like to submit one, visit and search for rule “CMS-3202-P.”

To view the press release, click here.