RSSAll Entries Tagged With: "CMS"

Joint Commission to adopt 2012 Life Safety Code®

The Joint Commission announced this week that it would join CMS in adopting the 2012 edition of the Life Safety Code® (LSC). CMS and Joint Commission surveyors will begin using the 2012 LSC on July 5. In a press release, the accreditor said it would be updating its Life Safety standards chapter in the near future. Details on the update will be published in a future edition of Joint Commission Perspectives.

Click here for our previous coverage on CMS’ adoption of the 2012 LSC. 

AAHHS hopes to get deeming status in 2017

The Accreditation Association for Hospitals/Health Systems (AAHHS) hopes to receive deeming status from the CMS by 2017, according to AAHHS spokesperson Laura Bohacz. AAHHS acquired the Health Facilities Accreditation Program (HFAP) last year, with all HFAP-accredited hospitals expected to be fully switched over to AAHHS standards by 2020.
AAHHS had originally hoped to get its deeming status by the end of 2016, though Bohacz says the delay won’t have any other effects on the transition process.

Read the full story on the HFAP acquisition and its impact in the June issue of Briefings on Accreditation and Quality.

New bill would change Medicare readmissions reduction program

A bill is currently being considered by the House of Representatives that would change the structure of Medicare’s Hospital Readmissions Reduction Program (HRRP) to reflect socioeconomic factors. Many in the industry have claimed that facilities are unduly penalized when things like poverty or rurality aren’t considered.

As part of that argument, Steven Lipstein, CEO of BJC HealthCare System, spoke to Kaiser Health News about the costs of HRRP. One of BJC’s facilities, Christian Hospital of St. Louis, is expected to lose $600,000 in Medicare reimbursements because of HRRP, he said. He pointed out that figure doesn’t include the amount lost at BJC’s 13 other facilities. Lipstein said that if Medicare readjusted its reimbursement policy to reflect patients with socioeconomic disadvantages, Christian Hospital would only have to pay $140,000 in penalties.

Medicare penalized almost half of all hospitals for excessive readmissions in 2015 for a total of $420 million.

CMS adopts 2012 Life Safety Code®


In a highly-anticipated move expected to significantly affect the regulatory rules that hospitals and other healthcare facilities are held to, the Centers for Medicare & Medicaid Services (CMS) has officially adopted the 2012 edition of the Life Safety Code® (LSC).

CMS has confirmed that the final rule adopts updated provisions of the National Fire Protection Association’s (NFPA) 2012 edition of the LSC as well as provisions of the NFPA’s 2012 edition of the Health Care Facilities Code. The New Life Safety Code® Field Guide for Healthcare Facilities cover


Healthcare providers affected by this rule must comply with all regulations by July 4—60 days from the publication date of the rule in the Federal Register.

The adoption of the rule has long been anticipated, as the LSC, which governs fire safety regulations in U.S. hospitals, is updated every three years, and CMS has not formally adopted a new update since 2003, when it adopted the 2000 edition. As a result, CMS surveyors have been holding healthcare facilities to different standards to other regulatory agencies that have gradually adopted provisions of the new LSC in their survey requirements.

Some of the main changes required under the final rule include:

  • Healthcare facilities located in buildings that are taller than 75 feet are required to install automatic sprinkler systems within 12 years. after the rule’s effective date.
  • Healthcare facilities are required to have a fire watch or building evacuation if their sprinkler systems is out of service for more than 10 hours.
  • The provisions offer long-term care facilities greater flexibility in what they can place in corridors. Currently, they cannot include benches or other seating areas because of fire code requirements limiting potential barriers to firefighters. Moving forward, LTC facilities will be able to include more home-like items such as fixed seating in the corridor for resting and certain decorations in patient rooms.
  • Fireplaces will be permitted in smoke compartments without a one-hour fire wall rating, which makes a facility more home-like for residents.
  • For ASCs, alcohol-based hand rub dispensers now may be placed in corridors to allow for easier access.

To get up to speed on the 2012 Life Safety Code®  check out the following resources from HCPro Marketplace:

Visit the Federal Register document to read the final rule in full, and view the CMS press release on the LSC here.

Questions that CMS surveyors will now ask about CT services

CMS surveyors are no longer required to determine a facility’s compliance with Advanced Diagnostic Imaging (ADI) supplier requirements or hospital outpatient department requirements. Accrediting organizations like HFAP will still evaluate compliance on these requirements, though they won’t audit billings submitted by providers.

ADI suppliers and hospital outpatient areas with computed tomography (CT) services must meet safety requirements under NEMA Standard XR-29-2013. The ruling applies to hospitals and critical access hospitals and went into effect on January 1, 2016.

Although none of the standards have been changed, surveyors will now ask facilities:

  • Does the facility have outpatient areas providing CT services?
  • If yes, the surveyors will request the manufacturer’s certification of NEMA XR-29 compliance.

CMS has published a FAQ on this new policy and its impact on healthcare facilities. 

Petitions ask Joint Commission and CMS to change pain management policies

More than 60 medical experts and nonprofit organizations sent petitions this week to The Joint Commission and CMS asking for changes in their respective pain management policies. The petitions say that making physicians routinely ask patients about their pain level encourages excessive prescriptions of opioids.

“Mandating routine pain assessments for all patients in all settings is unwarranted and can lead to overtreatment and overuse of opioid analgesics,” they wrote to The Joint Commission. “Healthcare professionals are capable of using their clinical judgment to determine when to assess patients for pain.”

Specifically, petitioners are asking for changes to The Joint Commission standards PC.01.02.07, PC.01.02.01, and RI.01.01.01 and for CMS to remove pain treatment questions from its Hospital Consumer Assessment of Healthcare Providers and Systems survey.

The petitions were headed by the Physicians for Responsible Opioid Prescribing and are co-signed by the heads of the National Center on Addiction and Substance Abuse, the National Women’s Health Network, the American Society of Addiction Medicine, and health commissioners from Vermont, Pennsylvania, Alaska, and Rhode Island.

Opponents try to delay five-star CMS rating system

This month, CMS plans to add a new “five-star” hospital rating system to its Hospital Compare website.  Under the system, hospitals would receive more stars for better compliance with a set of 62 measures that focus on mortality, safety, hospital readmissions, and the timeliness and effectiveness of care.

Complaints that CMS's new rating system is oversimplified

Complaints that CMS’s new “five star” rating system is oversimplified

The plan has come under fire, however, with many saying the rating system is too simplified to show true quality and puts too much emphasis on patient satisfaction. So far, 60 senators, two congressmen, and the American Hospital Association (AHA) have sent or published letters to criticizing the rating system.

“While the AHA supports the concept of providing an easier way for patients and communities to understand quality data, we are concerned that an overall hospital star rating oversimplifies the complexity of delivering high-quality care,” the organization wrote in a press release. “This is especially true because the measures in the [inpatient quality reporting program] and [outpatient quality reporting program] were not chosen with the intention of creating a single score reflecting all aspects of quality.”

Using the rating system to look at past data, CMS said that out of 3,647 hospitals, 142 would get one star, about 1,881 would get three stars, and 87 would get five. 

Update: CMS has announced it will delay the release of the five star rating system until July.

Physicians spend $15.4 billion reporting quality metrics

A study published in Health Affairs found that the time lost reporting on quality measures costs medical practices around $15.4 billion annually. The time spent reporting on quality costs practices around $40,069 per physician each year, with 80% of practices saying that time spent on quality reporting has increased over the last three years.

Hundred Dollar Bills

Reporting on quality costs around $40,069 per physician annually

The study compared 1,000 practices across four specialties: cardiology, orthopedics, primary care, and multispecialty. Researchers found that a single physician generates about 15.1 hours’ worth of quality data per week. Physicians typically spent 2.6 hours doing quality measure reporting, with the rest falling to staff. A majority of the work was data entry. How much time a physician personally spent each week on quality measures varied between primary care physicians (3.9 hours), multispecialty physicians (3.0 hours), cardiologists (1.7 hours), and orthopedists (1.1 hours).

“There is much to gain from quality measurement, but the current system is far from being efficient and contributes to negative physician attitudes toward quality measures,” the authors wrote.

Most healthcare insurers have their own unique quality measure sets and reporting methods. However, this is expected to change with the recent CMS announcement of new nationally accepted core quality measures, which are currently being phased in by CMS and 70% of private insurers.

CMS: Nationally recognized hospital quality measures released

CMS and a consortium of health organizations and insurers on February 16 revealed a new agreement to create a nationally accepted set of quality measures for hospitals and physicians. The agency said the new measure sets will improve consumer decision-making, value-based payment and purchasing, reduce the variability in measure selection, and decrease the collection burden and cost for providers.

“In the U.S. healthcare system, where we are moving to measure and pay for quality, patients and care providers deserve a uniform approach to measure quality,” acting CMS Administrator Andy Slavitt said in a news release. “This agreement today will reduce unnecessary burden for physicians and accelerate the country’s movement to better quality.”

CMS has been working with members of the Core Quality Measures Collaborative (CQMC) on the seven measure sets, with links to the new measures included below:

  1. Accountable Care Organizations (ACO), Patient Centered Medical Homes (PCMH), and Primary Care
  2. Cardiology
  3. Gastroenterology 
  4. HIV and Hepatitis C 
  5. Medical Oncology
  6. Obstetrics and Gynecology 
  7. Orthopedics

CMS says the promotion of evidence-based measurement will help patients, consumers, and physicians.  Some of the CQMC members now recognizing the new measures include:

  • Aetna
  • America’s Health Insurance Plans, Inc.
  • Anthem
  • BlueCross BlueShield Association;
  • Cigna
  • HealthPartners
  • Humira
  • Kaiser Permanente
  • The American Academy of Family Physicians
  • The American Medical Association
  • The National Partnership for Women and Families
  • The National Quality Forum
  • United Health Insurance




Featured Webcast- “CMS Surveys: Preparing With Confidence”

When: 1:00–2:30 p.m. EST, Wednesday, February 24, 2016

What: CMS has increased the frequency of its hospital surveys, and many healthcare facilities are finding themselves unprepared for the bump in federal scrutiny. This webcast will arm attendees with the preparatory steps and strategies needed to survive a CMS survey.  Attendees will also examine a real-life case study for specific examples of survey citations and how to respond to them. 

Why: This webinar will teach you how to:

  • Utilize a compliance plan to develop an organization-specific, comprehensive approach to accreditation and compliance readiness
  • Identify at least three sources of information to review changes in the Conditions of Participation/survey process
  • Implement a gap analysis of your organization’s compliance readiness

Who: Victoria Fennel, PhD, RN-BC, CPHQ, is the director of accreditation and clinical compliance for Compass Clinical Consulting and has 20 years of healthcare leadership experience. She has spent the majority of her career in nursing leadership roles and brings expertise in evidence-based practice, nursing education, quality management, performance improvement, accreditation, risk management, patient safety, and patient-centered care.

Julie Campbell, MHA, BSN, NE-BC, HACP, is the Baylor Scott & White Health North Texas Division vice president and has than 25 years of nursing leadership experience. Campbell assists in survey preparation, development of corporate policies and procedures, communications on revisions to regulations/standards, and recommendations of regulatory changes to various system councils to maintain continuous readiness. 

For more details on how to join the webcast, please visit our website.