HFAP Acute Care Hospital Manual
Crosswalk of 2014 v 3 Standards against 2015 Standards
2014 v 3
Standard
CMS Acute Care
Hospital CfR
2014 v 3 Standard
TitleRevised Deleted 2015 Standard Changes
01.00.00 §482.11
Condition of
Participation:
Compliance with
Federal, State, and
Local Laws
01.00.01 Governance Plan
01.00.02 §482.11(a)Compliance with
Laws
01.00.03§482.11(b)(1)
§482.11(b)(2)Hospital Licensure
01.00.04 §482.11(c)Licensure of
Personnel
01.00.05 §482.12
Condition of
Participation:
Governing Body
XRe‐numbered
01.01.00CMS update
01.00.06
Articles of
Incorporation &
Documentation of
Actions
01.00.07Governing Body
ResponsibilitiesX Clarifications
01.00.08§482.12(a)
§482.12(a)(1)
Categories Eligible
for AppointmentX
Re‐numbered
01.01.01CMS update
01.00.09 §482.12(a)(2)Medical Staff
Appointment
Re‐numbered
01.01.02
01.00.10 §482.12(a)(3)
Provision of
Medical Staff
Bylaws
Re‐numbered
01.01.03
Chapter 1 Administration of the Organizational Environment Page 1
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2014 v 3
Standard
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2014 v 3 Standard
TitleRevised Deleted 2015 Standard Changes
01.00.11 §482.12(a)(4)
Approval of
Medical Staff
Bylaws
Re‐numbered
01.01.04
01.00.12 §482.12(a)(5)Medical Staff
Quality of Care
Re‐numbered
01.01.05
01.00.13 §482.12(a)(6)
Selection Criteria
for Appointment
to the Staff
Re‐numbered
01.01.06
01.00.14 §482.12(a)(7)Required Criteria
for Appointment
Re‐numbered
01.01.07
01.00.15 §482.12(a)(8)
Telemedicine
Agreements with
Distant Hospitals
XRe‐numbered
01.01.08CMS update
01.00.16 §482.12(a)(9)
Telemedicine
Agreements with
Distant Sites
XCombine into
01.01.08CMS update
01.00.17 §482.12(b) CEO AppointmentRe‐numbered
01.01.11
01.00.18
§482.12(c)
§482.12(c)(1)(i)
§482.12(c)(1)(ii)
§482.12(c)(1)(iii)
§482.12(c)(1)(iv)
§482.12(c)(1)(v)
§482.12(c)(1)(vi)
Licensed
Practitioner Care
Requirements
Re‐numbered
01.01.12 & New
title, "Care of
Patients"
01.00.19 §482.12(c)(2)State Privilege
Requirements
Re‐numbered
01.01.13
01.00.20 §482.12(c)(3)Physician
Availability
Re‐numbered
01.01.14
Chapter 1 Administration of the Organizational Environment Page 2
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2014 v 3
Standard
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2014 v 3 Standard
TitleRevised Deleted 2015 Standard Changes
01.00.21 §482.12(c)(4)Medical Staff
Oversight
Re‐numbered
01.01.15
01.00.22
§482.12(d)
§482.12(d)(1)
§482.12(d)(2)
§482.12(d)(3)
§482.12(d)(4)
Institutional Plan &
Budget
Re‐numbered
01.01.16
01.00.23 §482.12(d)(5) Plan SubmissionRe‐numbered
01.01.17
01.00.24 §482.12(d)(6)Plan Review &
Update
Re‐numbered
01.01.18
01.00.25 §482.12(d)(7) Plan PreparationRe‐numbered
01.01.19
01.00.26
Oversight of the
Physical
Environment
XRe‐numbered
01.01.20Clarifications
01.00.27Oversight of the
QAPI Plan
Re‐numbered
01.01.21
01.00.28 §482.12(e)Contracted
ServicesX
Re‐numbered
01.01.22CMS update
01.00.29 §482.12(e)(1)Contractor Quality
Monitoring
Re‐numbered
01.01.23
01.00.30 §482.12(e)(2)List of Contracted
Services
Re‐numbered
01.01.24
Chapter 1 Administration of the Organizational Environment Page 3
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Standard
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2014 v 3 Standard
TitleRevised Deleted 2015 Standard Changes
01.00.31
Policy, Procedure
Review, &
Approval
Re‐numbered
01.01.25
01.00.32
Medically‐related
Patient Care
Services
XRe‐numbered
01.01.26Clarifications
01.00.33 §482.12(a)(10)
Governing Body
Periodically
Consults with the
Medical Staff
X 01.01.10 CMS update
01.01.01Compliance
ProgramX Retired
01.01.02Coding Policies &
ProceduresX Retired
01.01.03Compliance Officer
ResponsibilitiesX Retired
01.01.04
Mandatory
Education on
Fraud & Abuse
Regulations
X Retired
01.01.05
Fraud & Abuse
Reporting
Mechanism
X Retired
01.01.06Fraud & Abuse ‐
Corrective ActionX Retired
01.01.07Investigation of
MisconductX Retired
Chapter 1 Administration of the Organizational Environment Page 4
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2014 v 3
Standard
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Hospital CfR
2014 v 3 Standard
TitleRevised Deleted 2015 Standard Changes
01.01.08Reporting of Fraud
& Abuse to the OIGX Retired
01.02.01 §482.12(f)Emergency
Services X Format
01.02.02 §482.12(f)(1)
Emergency
Services
Compliance with
Federal Laws
X Format
01.02.03 §482.12(f)(2)
Policies Regarding
Emergency Care
When Services Are
Not Provided
X Format
01.02.04 §482.12(f)(3)Off‐site Emergency
CareX Format
Chapter 1 Administration of the Organizational Environment Page 5
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Standard
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Hospital CfR
2014 v 3 Standard
TitleRevised Deleted 2015 Standard Changes
02.00.01
Allied Health
Practitioner
Categories
X
Incorporated into
the Medical Staff
standards (refer
to 03.00.01 and
03.01.03)
02.00.02
Credentialing
Procedures and
Scope of Practice
X
Incorporated into
the Medical Staff
standards (refer
to 03.00.02,
03.01.03, and
03.01.06)
02.00.03
Federal and State
Regulations
Regarding
Privileges
X
Incorporated into
the Medical Staff
standards (refer
to 03.00.01 and
03.00.02)
02.00.04 Not Applicable
02.00.05
Supervision of
Allied Health
Practitioners
X
Incorporated into
the Medical Staff
standards (refer
to 03.00.01 and
03.00.02)
02.00.06
Quality
Assessment‐
Performance
Improvement
X
Incorporated into
the Medical Staff
standards (refer
to 03.15.01 and
03.15.02)
02.00.07
Allied Health
Professional
Membership
X
Incorporated into
the Medical Staff
standards (refer
to 03.00.01)
Chapter 2 Allied Health Practitioners Page 6
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2014 v 3
Standard
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Hospital CfR
2014 v 3 Standard
TitleRevised Deleted 2015 Standard Changes
03.00.00 §482.22
Condition of
Participation:
Medical Staff
X CMS Updates
03.00.01 §482.22(a)Composition of
the Medical Staff X
Retitled,
"Eligibility and
Process for
Appointment to
the Medical
Staff"
CMS Updates
03.00.02 §482.22(a)(1)Periodic Appraisal
of MembersX
CMS Update
addresses
Non‐physician
Practitioners
03.00.03 Not Applicable
03.00.04 Not Applicable
03.00.05
Responsibilities of
Credentialed
Professionals
03.00.06 §482.22(a)(2)
Recommendation
of Appointment to
Governance
X CMS Updates
03.00.07
Duties &
Responsibilities to
Patients
03.00.08
§482.22(a)(3)
§482.22(a)(3)(i)
§482.22(a)(3)(ii)
§482.22(a)(3)(iii)
§482.22(a)(3)(iv)
Telemedicine
Privileging
Provisions
Through Distant‐
Site Hosptial
Agreements
X CMS Updates
03.00.09
§482.22(a)(4)
§482.22(a)(4)(i)
§482.22(a)(4)(ii)
§482.22(a)(4)(iii)
§482.22(a)(4)(iv)
Telemedicine
Privileging
Provisions
Through Distant‐
Site Telemedicine
Entity Agreements
X CMS Updates
Chapter 3 Medical Staff Page 7
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2014 v 3
Standard
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Hospital CfR
2014 v 3 Standard
TitleRevised Deleted 2015 Standard Changes
03.00.10
§482.22(b)
§482.22(b)(1)
§482.22(b)(2)
§482.22(b)(3)
§482.22(b)(3)(i)
§482.22(b)(3)(ii)
§482.22(b)(3)(iii)
Medical Staff
Responsibilities to
the Governing
Body
X CMS Updates
03.01.01 §482.22(c)Medical Staff
Bylaws
03.01.02 §482.22(c)(1)
Medical Staff
Bylaws: Approval
by Governance
X Title Change Format
03.01.03 §482.22(c)(2)
Medical Staff
Bylaws:
Categories, Duties,
& Responsibilities
of the Medical
Staff
X Title Change Format
03.01.04 §482.22(c)(3)
Medical Staff
Bylaws:
Organization of
the Medical Staff
X Title Change Format
03.01.05
Attestation
Statements in
Bylaws
03.01.06 §482.22(c)(4)
Medical Staff
Bylaws: Process
for Application
and Reapplication
and Criteria for
Membership
X Title Change
CMS Update
addresses Non‐
physician
practitioners
03.01.07§482.22(c)(5)
§482.22(c)(5)(i)
Medical Staff
Bylaws: History
and Physical
Requirement
X Title Change Clarification
03.01.08 §482.22(c)(5)(ii)
Medical Staff
Bylaws: History
and Physical Prior
to Admission
X Title Change Clarification
Chapter 3 Medical Staff Page 8
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Standard
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Hospital CfR
2014 v 3 Standard
TitleRevised Deleted 2015 Standard Changes
03.01.09 §482.22(c)(6)
Medical Staff
Bylaws: Granting
of Privileges
X Title Change Clarification
03.01.10
Medical Staff
Policies and
Procedures
03.01.11
Medical Staff
Bylaws: Periodic
Review
X Title Change Clarification
03.01.12
Uniform
Application of
Membership
Criteria
03.01.13 Not Applicable
03.01.14
Non‐
discrimination in
Application of
Membership
Criteria
03.01.15
Required
Application‐
Reapplication
Information for
Review
X Clarification
03.01.16 Not Applicable
03.01.17Emergency
PrivilegesX Format
03.01.18Temporary
PrivilegesX Format
03.01.19Suspension of
PrivilegesX Format
03.01.20Fair Hearing
ProcessX Format
03.01.21
Medical Staff
Bylaws: Definition
of a Clinical
Emergency
X Title Change Format
Chapter 3 Medical Staff Page 9
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Standard
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Hospital CfR
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TitleRevised Deleted 2015 Standard Changes
03.01.22 Not Applicable
03.01.23
Medical Staff
Bylaws: Meeting
Frequency and
Attendance
X Title Change Format
03.01.24
Medical Staff
Bylaws: Clinical
Department
Structure
X Title Change Format
03.02.01 Autopsies X Clarification
03.03.01Medical Executive
CommitteeX Format
03.03.02Medical Executive
Committee ScopeX Format
03.04.01 §482.30
Condition of
Participation:
Utilization Review
X 03.04.00 Clarification
03.04.02 §482.30(a) Applicability X 03.04.01 Clarification
03.04.03
§482.30(b)(1)
§482.30(b)(2)
§482.30(b)(3)
Composition of
Utilization Review
Committee (URC)
03.04.02
03.04.04
§482.30(c)
§482.30(c)(1)
§482.30(c)(1)(i)
§482.30(c)(1)(ii)
§482.30(c)(1)(iii)
§482.30(c)(2)
§482.30(c)(3)
§482.30(c)(4)
§482.30(c)(4)(i)
§482.30(c)(4)(ii)
UR Review
Requirements03.04.03
Chapter 3 Medical Staff Page 10
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Standard
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TitleRevised Deleted 2015 Standard Changes
03.04.05
§482.30(d)
§482.30(d)(1)
§482.30(d)(1)(i)
§482.30(d)(1)(ii)
§482.30(d)(2)
§482.30(d)(3)
Determination
Regarding
Admissions or
Continued Stays
X 03.04.04 Clarification
03.04.06 §482.30(e)
Utilization Review
Scope in Non‐PPS
Hospitals ‐
Extended Stay
Reviews
X 03.04.05 Clarification
03.04.07 §482.30(f)
Review of
Professional
Services
X 03.04.06 Clarification
03.04.08
The Utilization
Review
Committee
Meeting
Frequency and
Attendance
03.04.07
03.05.01
Utilization of
Osteopathic
Methods and
Concepts
Committee
(OMCC)
03.05.02
OMCC Functions
(Osteopathic
Methods and
Concepts
Committee)
03.05.03
OMCC
Documentation
and Meeting
Frequency and
Attenance
Requirements
(Osteopathic
Methods and
Concepts
Committee)
Chapter 3 Medical Staff Page 11
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Standard
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Hospital CfR
2014 v 3 Standard
TitleRevised Deleted 2015 Standard Changes
03.06.01
Credentials
Committee
(function)
03.06.02
Credentials
Committee
Responsibility
03.06.03Credentials
Committee ScopeX Clarification
03.06.04 Not Applicable
03.06.05 Not Applicable
03.06.06Incomplete
Applications
03.06.07 Not Applicable
03.06.08
Timeframe for
Processing of
Applications
03.06.09
Meeting
Frequency and
Attendance
03.07.01 Not Applicable
03.08.01
Joint Advisory
Committee
Responsibility
X Retired
03.08.02
Meeting
Frequency and
Attendance
X Retired
03.09.01 Not Applicable
03.10.01Mortality Review
Committee ScopeX Clarification
Chapter 3 Medical Staff Page 12
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Standard
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TitleRevised Deleted 2015 Standard Changes
03.10.02
Mortality Review
Committee
Responsibility‐
Appropriateness
of Care
X Clarification
03.10.03
Mortality Review
Committee
Responsibility‐
Attending
Physician
Involvement
X Clarification
03.10.04Mortality Chart
ReviewX Clarification
03.10.05Mortality Review
Education X Retired
03.10.06
Meeting
Frequency and
Attendance
03.11.01 Not Applicable
03.12.01
Availability of
Professional
Literature
03.13.01 Not Applicable
03.14.01
Transfusion
Review
Committee
(function)
X Clarification
03.14.02
Scope of the
Transfusion
Review
Committee
X Clarification
03.14.03Performance
ImprovementX Clarification
03.15.01
Ongoing
Professional
Practice
Evaluation (OPPE)
X Clarification
Chapter 3 Medical Staff Page 13
HFAP Acute Care Hospital Manual
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2014 v 3
Standard
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Hospital CfR
2014 v 3 Standard
TitleRevised Deleted 2015 Standard Changes
03.15.02
Focused
Professional
Practice
Evaluation (FPPE)
Chapter 3 Medical Staff Page 14
HFAP Acute Care Hospital Manual
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2014 v 3
Standard
CMS Acute Care
Hospital CfR
2014 v 3 Standard
TitleRevised Deleted 2015 Standard Changes
04.00.01
Governance
Responsibility for
Staffing
04.00.02 Licensure
04.00.03 Not Applicable
04.00.04
License Pending &
Lapse or
Restriction of
Licensure/
Certification
04.00.05 Competency
04.00.06
Federal
Employment
Regulations
04.00.07 Staffing Plans
04.00.08
Staffing
Assignment
Criteria
04.00.09Evaluation of
Competence
04.00.10New Employee
Orientation
04.00.11
Required
Orientation
Curriculum
04.00.12Annual Required
Competencies
04.00.13
Employee
Identification
System
X 04.00.11 Revised
Chapter 4 Human Resources Page 15
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Standard
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TitleRevised Deleted 2015 Standard Changes
Chapter 5 For Future Use Page 16
HFAP Acute Care Hospital Manual
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Standard
CMS Acute Care
Hospital CfR
2014 v 3 Standard
TitleRevised Deleted 2015 Standard Changes
Chapter 6 For Future Use Page 17
HFAP Acute Care Hospital Manual
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Standard
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Hospital CfR
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TitleRevised Deleted 2015 Standard Changes
07.00.00 §482.42 Infection Control X
07.01.01 §482.42(a)Infection Control
Officer (ICO)X Clarification
07.01.02 §482.42(a)(1)Infection
PreventionX CMS Update
07.01.03 §482.42(a)(2) Incident Log X Retired
07.01.04
§482.42(b)
§482.42(b)(1)
§482.42(b)(2)
Responsibilities of
Chief
Executive Officer,
Medical
Staff & Director of
Nursing
Services
X
07.01.05 Not Applicable
07.01.06 Not Applicable
07.01.07 Corrective Action
07.01.08Classification of
Infections
07.01.09 Infections Clusters
07.01.10Infection Control
Precautions
07.01.11 Staff Orientation
07.01.12State & Local
Reporting
07.01.13Committee/
Function StructureX Clarification
Chapter 7 Infection Control Page 18
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Standard
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Hospital CfR
2014 v 3 Standard
TitleRevised Deleted 2015 Standard Changes
07.01.14Infection Control
PlanX Clarification
07.01.15Reporting
RequirementsX
07.01.16Periodic Review of
the PlanX Clarification
07.01.17
Healthcare‐
Associated
Infections (HAI)
X Clarification
07.01.18
Quality
Improvement
Priorities
X Clarification
07.01.19
Prevention of
Infection‐Central
Venous Catheters
XPATIENT SAFETY
INITIATIVE
07.01.20Surgical Site
InfectionsX
PATIENT SAFETY
INITIATIVE
07.01.21Hand‐washing
GuidelinesX
PATIENT SAFETY
INITIATIVE
07.01.22Environmental
SurveillanceX Clarification
07.01.23 Employee Health X Clarification
07.01.24Employee Health
PoliciesX Clarification
07.01.25Employee Health‐
Influenza VaccineX
PATIENT SAFETY
INITIATIVE
07.01.26 Annual Report X Clarification
07.02.00 Central Supply X Clarification
07.02.01Decontamination
& Sterilization
Chapter 7 Infection Control Page 19
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Standard
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TitleRevised Deleted 2015 Standard Changes
07.02.02 Required Policies
07.02.03
Decontamination
of Reusable Items
& Reuse of Single
Use Devices
07.02.04
Preparing,
Assembling,
Wrapping, Storage
of & Distribution
of Sterile
Equipment &
Supplies
07.02.05Monitoring
DevicesX Clarification
07.02.06Sterilization Date
Requirements
07.02.07 Shelf Life
07.02.08 Cold Sterilization
07.02.09Load Control
Numbers
07.02.10 Recall Process
07.02.11
Environment
Requirements in
Decontamination
Rooms
07.03.00 Housekeeping X Clarification
07.03.01Cleaning Products
InventoryX Clarification
07.03.02High Risk Cleaning
ProceduresX Clarification
Chapter 7 Infection Control Page 20
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Standard
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TitleRevised Deleted 2015 Standard Changes
07.03.03Air Supply &
Return Grills
07.03.04Maintenance of
CeilingsX Clarification
07.03.05Hand‐washing
Sink
07.03.06
Maintenance of
Housekeeping &
Laundry
Equipment
07.03.07 Waste Disposal
07.03.08
Use of Personal
Protective
Equipement
07.04.01 Laundry
07.04.02 Not Applicable
07.04.03Clean Linen
Storage
07.05.01 Pest Control
07.05.02Extermination
Program
Chapter 7 Infection Control Page 21
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Standard
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TitleRevised Deleted 2015 Standard Changes
08.00.01 Inventory
08.00.02Supplies for
Patient Care
08.00.03Safe Storage of
SuppliesX Clarification
08.00.04Policies on Supply
Availability
08.00.05Special Storage
Requirements
08.00.06 Product Recall X Clarification
Chapter 8 Materials Management Page 22
HFAP Acute Care Hospital Manual
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Standard
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Hospital CfR
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TitleRevised Deleted 2015 Standard Changes
09.00.01Emergency
Operations PlanX Clarification
09.00.02
Emergency
Hazard
Vulnerability
Analysis (HVA)
X Clarification
09.01.01Emergency Safety
& Security
09.01.02Emergency
Supplies
09.01.03Emergency
Utilities
09.01.04Emergency
DecontaminationX Clarification
09.01.05
Emergency
Personal
Protective
Equipment
09.01.06
Emergency
Nutritional
Services
09.01.07Emergency
CommunicationsX Clarification
09.01.08Incident
Command Center
09.01.09 Emergency Triage X Clarification
09.01.10Emergency
EvacuationX Clarification
09.01.11Volunteer
ManagementX Clarification
09.01.12Business
Continuity
Chapter 9 Emergency Management Page 23
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Standard
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09.02.01Emergency
ExercisesX Clarification
09.02.02Emergency
Education
Chapter 9 Emergency Management Page 24
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Standard
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TitleRevised Deleted 2015 Standard Changes
10.00.01 §482.24
Condition of
Participation:
Medical Record
Services
10.00.00 Re‐numbered
10.00.02 §482.24(a)Organization &
StaffingX 10.00.01 Clarification
10.00.03 §482.24(b)Retention of
Medical RecordsX 10.00.02 Clarification
10.00.04 §482.24(b)(1)
Record Security &
Retention
Requirements
10.00.03
10.00.05 §482.24(b)(2) Coding & Indexing X 10.00.04 Clarification
10.00.06 §482.24(b)(3)
Security of
Medical
Information
X 10.00.05 CMS Update
10.01.01 §482.24(c)Content of the
RecordX Clarification
10.01.02Information in
Medical RecordsX Clarification
10.01.03 §482.24(c)(1)Legible &
Complete
10.01.04 §482.24(c)(2)
Dating, Timing, &
Authentication of
Orders
X Clarification
10.01.05
§482.24(c)(3)
§482.24(c)(3)(i)
§482.24(c)(3)(ii)
§482.24(c)(3)(iii)
§482.24(c)(3)(iv)
Pre‐printed
Orders, Order
Sets, & Protocols
X CMS Update
10.01.06Abbreviations &
SymbolsX
Patient Safety
Initiative
Chapter 10 Medical Records Page 25
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Standard
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TitleRevised Deleted 2015 Standard Changes
10.01.07§482.24 (c)(4)
§482.24(c)(4)(i)(A)
History & Physical
RequirementsX Clarification
10.01.08§482.24(c)(4)(i)
§482.24(c)(4)(i)(B)
History & Physical
Update
Requirements
X Clarification
10.01.09 §482.24(c)(4)(ii)Admitting
Diagnosis
10.01.10 §482.24(c)(4)(iii)Required
ConsultationX
Retitled:
"Consultative
Reports
10.01.11
Required
Consultations ‐
Categories
X Retired
10.01.12Consultation
Requirements
10.01.13Indications for
Consultation X Retired
10.01.14 Second Opinions X Retired
10.01.15 §482.24(c)(4)(iv)Required
Documentation X
Retitled:
Documentation
of Complications
Clarification
10.01.16 §482.24(c)(4)(v) Informed ConsentPatient Safety
Initiative
10.01.17§482.24(c)(2)(vi)
Adequacy of
Available
Information
10.01.18§482.24(c)(2)(vii) Discharge
Summary
10.01.19§482.24(c)(2)(viii) Medical Record
DelinquencyX Clarification
Chapter 10 Medical Records Page 26
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TitleRevised Deleted 2015 Standard Changes
10.01.20§485.641(a)(1)(ii)
Multi‐disciplinary
Medical Record
Review & Audit
Requirements
X Retired
10.01.21
Patient
Assessments ‐
Content &
Authentication
X Retired
10.01.22Patient / Family
EducationX Retired
10.01.23
For Doctors of
Osteopathic
Medicine only)
Osteopathic
Musculoskeletal
Exam (OME)
10.01.24Initial
Assessments
10.01.25 Progress Notes
10.01.26Multi‐disciplinary
Plan of Care
10.01.27Outpatient
Problem List
10.01.28
Plan of Care ‐
Assessment &
Re‐assessment
10.01.29 Newborn Care
10.01.30
Pediatric /
Adolescent
Patients
10.01.31 Obstetric Patients X Clarification
Chapter 10 Medical Records Page 27
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TitleRevised Deleted 2015 Standard Changes
10.01.32
Actions Taken to
Improve Glycemic
Control
Patient Safety
Initiative
10.01.33Discharge
Summary
10.02.01
Medical Records
Committee ‐
Scope
X Retired
10.02.02
Medical Records
Committee ‐
Responsibility
X Retired
10.02.03
Medical Records
Committee ‐
Written Reports
X Retired
10.02.04Record Use or
Format ChangesX Retired
10.02.05 Required Policies
10.02.06
Policies on
Confidentiality &
Release of
Records
10.02.07
Medical Records
Committee ‐
Meeting
Frequency &
Attendance
Requirements
X Retired
Chapter 10 Medical Records Page 28
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TitleRevised Deleted 2015 Standard Changes
11.00.01 §482.41
Condition of
Participation:
Physical
Environment
11.00.02
Required Plans &
Performance
Standards
X Clarification
11.01.01
Building Safety ‐
Periodic
Monitoring for
Safety Issues
X Clarification
11.01.02 §482.41(a)(1) Building Safety X Clarification
11.01.03Safety Team /
Committee
11.01.04
Safety
Team/Committee
Facilitator
X
Retitled,
"Safety Team /
Committee
Chairperson"
Clarification
11.01.05 Safety Officer
11.01.06
Teams Appointed
for Specific Safety
Areas
X Retired
11.01.07
Safety Team/
Committee
Functions
11.01.08
Review of Safety
Policies/
Procedures
X Clarification
11.01.09
Smoking /
Tobacco Products
Policy
11.02.01 Building Security
Chapter 11 Physical Environment Page 29
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TitleRevised Deleted 2015 Standard Changes
11.02.02Security
Management
11.02.03Local Security
Support
11.02.04Security Sensitive
Areas
11.02.05Security Incident
Procedures
11.03.01
Hazardous
Materials & Waste
Program
11.03.02 §482.41(b)(6)Storage &
Disposal of Trash
11.03.03
Program
Minimizes
Exposure
11.03.04Labels, Inventory
& MSDSX
Changed to
"SDS"Clarification
11.03.05
Personal
Protective
Equipment (PPE)
11.03.06
Hazardous
Materials ‐
Routine
Monitoring
11.04.01 §482.41(b)(6)Written Fire
Control Plans
11.04.02Fire Drills ‐
QuarterlyX Clarification
11.04.03 Fire Drill ‐ Critique X Clarification
Chapter 11 Physical Environment Page 30
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11.04.04 §482.41(b)(8)
Approval by State
& Local Fire
Agencies
X Clarification
11.04.05
Minimize the Risk
of Danger from
Fire
X Clarification
11.05.01
Medical
Equipment &
Sytems:
Maintenance
11.05.02
Medical
Equipment
Inventory
11.05.03Patient Call
System
11.05.04
Safe Medical
Device Act
(SMDA)
11.05.05
Medical
Equipment
Procurement
11.06.01 §482.41(a)(1)Emergency Power
& Lighting
11.06.02Emergency Power
Electrical System
11.06.03Generator
Inspection13.05.04
11.06.04Generator
Monthly Load Test13.05.05
11.06.05Generator 3‐Year
Load Test13.05.06
11.06.06
Automatic
Transfer Switch
Test
13.05.07
Chapter 11 Physical Environment Page 31
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11.06.07 Potable Water
11.06.08Medical Gas Shut‐
Off Valves13.05.08
11.06.09
Plant Equipment
& Systems:
Maintenance
11.06.10Plant Equipment
Inventory
11.06.11
Medical Gas
Systems &
Equipment ‐
Maintenance
13.05.10
11.06.12
Water
Temperature
Control
11.07.01
§482.41(c)
§482.41(c)(2)
§482.41(c)(3)
Adequate
Facilities and
Supplies
11.07.02 §482.41(c)(1)
Facilities Located
for Safety of
Patients
11.07.03 §482.41(c)(4)
Ventilation, Light,
& Temperature
Controls
X Clarification
11.07.04
Americans with
Disabilities Act
(ADA)
Retired
11.07.05
Occupational
Safety & Health
Act (OSHA)
Retired
11.07.06
Assessing Risk
Prior to
Construction
11.07.07
Monitoring the
Physical
Environment
Chapter 11 Physical Environment Page 32
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11.08.01Fire Response ‐
Staff Training11.04.06
Chapter 11 Physical Environment Page 33
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TitleRevised Deleted 2015 Standard Changes
12.00.01 §482.21
Condition of
Participation:
Quality Assurance
Performance
Improvement
12.00.00 Re‐numbered
12.00.02
Quality
Management
Position
12.01.01
12.00.03 §482.21(a)(1) Program Scope X 12.00.01 CMS Updates
12.00.04Leadership
AccountabilityX 12.01.03
12.00.05
Quality
Committee /
Function
12.01.02
12.00.06
Meetings &
Documentation of
Activities
12.01.03
12.00.07Annual Quality
ReportsX 12.01.04 Clarification
12.00.08Education
ProgramX 12.01.05 Clarification
12.00.09 §482.21(a)(2)Program
Accountability12.00.01 CMS Updates
12.00.10§482.21(b)(1)
§482.21(b)(2)(i)
§482.21(b)(2)(ii)
Program Data X12.00.01
12.00.02CMS Updates
12.00.11 Quality Principles X12.00.01
12.00.02
12.00.12 §482.21(b)(3) Data Collection X12.00.01
12.00.02CMS Updates
Chapter 12 Quality Assessment Performance Improvement Page 34
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12.00.13
§482.21(c)(1)(i)
§482.21(c)(1)(ii)
§482.21(c)(1)(iii)
§482.21(c)(iv)
Program Activities X 12.00.02 CMS Updates
12.00.14 §482.21(c)(2) Medical Errors X 12.00.03 CMS Updates
12.00.15 §482.21(c)(3)Sustained
ImprovementsX 12.00.03 CMS Updates
12.00.16§482.21(d)
§482.21(d)(1)
Performance
Improvement
Projects
X 12.00.04 CMS Updates
12.00.17 §482.21(d)(2)
Information
Technology
Systems
X 12.00.04 CMS Updates
12.00.18 §482.21(d)(3)Required
DocumentationX 12.00.04 CMS Updates
12.00.19 §482.21(d)(4)
Quality
Improvement
Organization
Projects
X 12.00.04 CMS Updates
12.00.20
HFAP Clinical
Quality
Measurement
Program
12.01.06
12.00.21
§482.21(e)(1)
§482.21(e)(2)
§482.21(e)(3)
§482.21(e)(4)
§482.21(e)(5)
Governing Body
ResponsiblitiesX 12.00.05 CMS Updates
12.00.22 Culture of Safety X 12.02.01PATIENT SAFETY
INITIATIVE
12.00.23Adverse Event
Review ProcessX 12.02.02
12.01.01Tracking Medical
ErrorsX
12.00.01
12.00.03
Chapter 12 Quality Assessment Performance Improvement Page 35
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12.01.02
Monitoring
System
Accountability
X12.00.01
12.00.03
12.01.03
Participation in
Analysis of
Medical Errors
X12.00.01
12.00.03
12.01.04Analysis of
Medical ErrorsX
12.00.01
12.00.03
12.01.05 Corrective Action X12.00.01
12.00.03
12.01.06Medical Error
ReportingX
12.00.01
12.00.03
12.01.07Reporting of QAPI
DataX Retired
12.01.08Reporting to the
Board of TrusteesX 12.01.07
12.01.09 Statistical Analysis X 12.00.01
12.01.10
Communication to
the Patient of an
Adverse Event
X 12.02.03PATIENT SAFETY
INITIATIVE
12.01.11Support of
CaregiversX 12.02.04
PATIENT SAFETY
INITIATIVE
Chapter 12 Quality Assessment Performance Improvement Page 36
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13.00.01
§482.41(b)(1)(i)
§482.41(b)(1)(ii)
§482.41(b)(3)
Life Safety Code
Compliance
13.00.02
Alternative Life
Saety Measures ‐
Policy
X Clarification
13.00.03
Alternative Life
Saety Measures ‐
Implementation
13.00.04
Notification of
Emergency
Response Forces
13.00.05
Facility
Demographic
Report (FDR)
X Clarification
13.00.06
Testing &
Inspection ‐
Definition of Time
13.00.07
Testing &
Inspection ‐
Documentation
X Clarification
13.01.01Corridor Door
LatchingX Retitle, "Doors" Clarification
13.01.02 Door Locks X Clarification
13.01.03 Corridor Width X
Retitle,
"Corridor
Clutter"
Clarification
13.01.04 Suites
13.01.05 Exit Signs XRetitle,
"Signage"Clarification
Chapter 13 Life Safety Code Page 37
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13.01.06 Exit Discharge X Clarification
13.01.07 Corridor
ProjectionsX
Retitle,
"Corridor"Clarification
13.02.01 Fire Alarm System ‐
InstallationX Clarification
13.02.02 Fire Alarm System ‐
Testing
13.02.03
Fire Alarm System ‐
Transmitting
Signal
X Clarification
13.02.04
Fire Alarm System ‐
Technician
Qualifications
X Clarification
13.03.01
Water‐Based Fire
Protection System ‐
Installation
X Clarification
13.03.02
Water‐Based Fire
Protection System ‐
Testing &
Inspection
X Clarification
13.03.03
Water‐Based Fire
Protection System ‐
Control Valves,
Piping and
Hangers
13.03.04Fire Pumps ‐
Weekly Test
13.03.05Fire Pumps ‐
Annual Test
13.03.06
Alternative Fire
Suppression
Systems ‐
Installation &
Testing
Chapter 13 Life Safety Code Page 38
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13.03.07
Water‐Based
Standpipes &
Hoses ‐ Inspection
& Test
X Clarification
13.03.08
Water‐Based Fire
Department
Connections ‐
Inspection
X Clarification
13.03.09
Portable Fire
Extinguishers ‐
Installation,
Inspection and
Maintenance
X Clarification
13.04.01 Fire Rated Barriers
13.04.02
Smoke
Compartment
Barriers
13.04.03Fire & Smoke
Damper ‐ TestingX Clarification
13.04.04
Overhead Rolling /
Horizontal Sliding
Fire Doors ‐
Testing
13.04.05 Construction Type X Clarification
13.04.06Separated
Occupancies
13.04.07Fire Rated Door
Assemblies
13.04.08 Hazardous Areas
13.04.09 Ceilings
Chapter 13 Life Safety Code Page 39
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13.04.10 Corridor Walls
13.05.01 Fireplaces
13.05.02 Elevator Recall X Clarification
13.05.03Trash & Linen
Chutes
13.06.01 Decorations
13.06.02 Trash Receptacles
13.06.03 Portable Heaters
13.06.04Life Safety
DrawingsX Clarification
13.06.05 §482.41(b)(9)(ii)
Alcohol Based
Hand‐Rub
Dispensers
X Clarification
13.06.06
Definition of New
Construction &
Existing Conditions
13.07.01 §482.41(b)(2)CMS Waiver of
Life Safety Code
13.07.02
Fire Safety
Evaluation System
(FSES)
X Clarification
Chapter 13 Life Safety Code Page 40
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14.00.01 §482.45
Condition of
Participation:
Organ, Tissue, and
Eye Procurement
14.00.00 Re‐numbered
14.00.02§482.45(a);
§482.45(a)(1)
Organ/Tissue
Donation and
Transplantation
14.00.01
14.00.03 §486.316(e)OPO Waiver
Requests14.00.02
14.00.04§482.45(a)(2) Tissue and Eye
Bank Agreements14.00.03
14.00.05§482.45(a)(3) Informed Consent
Requirements14.00.04
14.00.06 §482.45(a)(3)Designated
Requestors14.00.05
14.00.07 §482.45(a)(4)Sensitivity
Training14.00.06
14.00.08 §482.45(a)(5)OPO
Responsibilities14.00.07
14.00.09§482.45(b)(1);
§482.45(b)(2)
Organ Transplant
Facilities14.00.08
14.00.10 §482.45(b)(3)Data Collection
and Reporting14.00.09
14.00.11§482.24(b)(3);
§486.306(o)
Confidentiality of
Patient Records14.00.10
Chapter 14 Organ Procurement Page 41
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Chapter Title
Changed to:
Patient Rights &
Discharge
Planning
15.00.00 §482.13
Condition of
Participation:
Patient's Rights
15.01.00 Not Applicable
15.01.01 Not Applicable
15.01.02§482.13(a)
§482.13(a)(1)
Notice of Patient
Rights
15.01.03 §482.13(a)(2)Patient
Grievances
15.01.04 §482.13(a)(2)
Governing Body
Responsibility for
the
Grievance Process
15.01.05 §482.13(a)(2) Timely Referrals
15.01.06 §482.13(a)(2)(i) Grievance Process
15.01.07 §482.13(a)(2)(ii)
Grievance Process
Response
Timeframes
15.01.08 §482.13(a)(2)(iii)
Patient
Notification of the
Grievance Process
Chapter 15 Patient Rights and Discharge Planning Page 42
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15.01.09
§482.13(b)(1)
§482.13(b)(2)
§482.13(b)(3)
§482.13(b)(4)
§482.13(c)(1)
§482.13(c)(2)
§482.13(c)(3)
§482.13(d)(1)
§482.13(d)(2)
§482.13(e)(1)§482.13(h)(1)(2)(3)(4)
Exercise of
Patient’s Rights
15.01.10 §482.13(b)(1)Participation in
the Plan of Care
15.01.11 §482.12(b)(2)Participation in
Decision Making
15.01.12 §482.13(b)(3)Advance
Directives
15.01.13 Not Applicable
15.01.14 §482.13(b)(4)Admission
Notification
15.01.15 Not Applicable
15.01.16§482.13(c)
§482.13(c)(1)
Privacy & Safety:
Personal Privacy
15.01.17 §482.13(c)(2)Privacy & Safety:
Safe Setting
15.01.18 §482.13(c)(3)Privacy & Safety:
Free From Abuse
15.01.19 Not Applicable
15.01.20 Not Applicable
Chapter 15 Patient Rights and Discharge Planning Page 43
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15.01.21§482.13(d)
§482.13(d)(1)
Confidentiality of
Patient Records:
Confidentiality of
Medical Records
15.01.22 §482.13(d)(2)Access to Medical
Records
15.01.23 Not Applicable
15.01.24 Not Applicable
15.01.25 §482.13(h) Visitation Rights
15.01.26§482.13(h)(1)
§482.13(h)(2)
Patient Visitation
Rights
15.01.27 Not Applicable
15.01.28§482.13(h)(3)
§482.13(h)(4)
Visitation Rights ‐
Discrimination
15.01.29 Not Applicable
15.02.00 §482.13(e)Restraint or
Seclusion
15.02.01 §482.13(e)(1)(i)(A)Restraint
Definitions
15.02.02 §482.13(e)(1)(i)(B)Medication as a
Restraint
15.02.03 §482.13(e)(1)(i)(C) Non‐Restraints X Clarification
15.02.04 §482.13(e)(1)(ii)Definition of
Seclusion
Chapter 15 Patient Rights and Discharge Planning Page 44
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15.02.05 §482.13(e)(2)Least Restrictive
Interventions
15.02.06 Not Applicable
15.02.07 §482.13(e)(3)Effective
Restraints
15.02.08§482.13(e)(4)
§482.13(e)(4)(i)
Modification of
the Plan of Care ‐
Restraint or
Seclusion
15.02.09 §482.13(e)(4)(ii) Safe Application
15.02.10 §482.13(e)(5)
Orders for
Restraint or
Seclusion
15.02.11 §482.13(e)(6)Use of Standing or
PRN Orders
15.02.12 §482.13(e)(7)
Physician
Notification of
Restraint Use
15.02.13 §482.13(e)(8)(i)
Restraint Orders
for Management
of Violent
Behavior
15.02.14 §482.13(e)(8)(ii)Physician
Assessment
15.02.15 §482.13(e)(8)(iii)Renewal of
Restraint Orders
15.02.16 §482.13(e)(9)Discontinuation of
Restraints
15.02.17 §482.13(e)(10)Monitoring of the
Patient
Chapter 15 Patient Rights and Discharge Planning Page 45
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15.02.18 §482.13(e)(11) Physician Training
15.02.19 §482.13(e)(12)(i)One Hour Face‐to‐
Face
15.02.20 §482.13(e)(12)(ii)
Physician
Assessment
Requirements
15.02.21 §482.13(e)(13)State
Requirements
15.02.22 §482.13(e)(14)Physician
Notification
15.02.23 §482.13(e)(15)
Simultaneous Use
of Restraint and
Seclusion
15.02.24 §482.13(e)(16)(i)Requirements for
Documentation
15.02.25 §482.13(e)(16)(ii)Requirements for
Documentation
15.02.26 §482.13(e)(16)(iii)Requirements for
Documentation
15.02.27 §482.13(e)(16)(iv)Requirements for
Documentation
15.02.28 §482.13(e)(16)(v)Requirements for
Documentation
15.02.29 §482.13(f)
Staff Training
Requirements ‐
Use of Restraints
or Seclusion
15.02.30
§482.13(f)(1)(i)
§482.13(f)(1)(ii)
§482.13(f)(1)(iii)
Training Intervals
Chapter 15 Patient Rights and Discharge Planning Page 46
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15.02.31 §482.13(f)(2)(i) Training Content
15.02.32 §482.13(f)(2)(ii)
Training
Requirements:
Nonphysical
Intervention
15.02.33 §482.13(f)(2)(iii)
Training
Requirements:
Least Restrictive
Intervention
15.02.34 §482.13(f)(2)(iv)
Training
Requirements:
Safe Application
15.02.35 §482.13(f)(2)(v)
Training
Requirements:
Restraint Removal
15.02.36 §482.13(f)(2)(vi)
Training
Requirements:
Patient
Monitoring
15.02.37 §482.13(f)(2)(vii)
Training
Requirements:
CPR Training
15.02.38 §482.13(f)(3)Trainer
Requirements
15.02.39 §482.13(f)(4)Training
Documentation
15.02.40 Not Applicable
Chapter 15 Patient Rights and Discharge Planning Page 47
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15.02.41
§482.13(g)(1)
§482.13(g)(1)(i)(ii)(iii)
§482.13(g)(2)
§482.13(g)(2)(i)(ii)
§482.13(g)(3)
§482.13(g)(3)(i)(ii)
§482.13(g)(4)
§482.13(g)(4)(i)(ii)(iii)
Death Related to
Restraint or
Seclusion ‐
Reporting
Requirements
15.03.00 §482.43
Condition of
Participation:
Discharge
Planning
15.03.01 §482.43(a)
Discharge
Planning ‐
Identification of
Patients in Need
15.03.02
§482.43(b)
§482.43(b)(1)
§482.43(b)(3)
§482.43(b)(4)
Discharge
Planning
Evaluation
15.03.03 §482.43(b)(2)
Discharge
Planning ‐ Staff
Qualifications
15.03.04 Not Applicable
15.03.05 Not Applicable
15.03.06 §482.43(b)(5)Timeliness of
Assessment
15.03.07 §482.43(b)(6)
Patient
Involvement &
Documentation
Requirements
15.03.08 Not Applicable
Chapter 15 Patient Rights and Discharge Planning Page 48
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2014 v 3 Standard
TitleRevised Deleted 2015 Standard Changes
15.03.09§482.43(c)
§482.43(c)(1)
Discharge
Planning:
Required
Supervision
15.03.10 §482.43(c)(2)Discharge Plan ‐
Physician Request
15.03.11§482.43(c)(3)
§482.43(c)(5)
Implementation
of the Discharge
Plan
15.03.12 §482.43(c)(4)Plan
Reassessment
15.03.13 Not Applicable
15.03.14
§482.43(c)(6)
§482.43(c)(6)(i)
§482.43(c)(6)(ii)
§482.43(c)(6)(iii)
§482.43(c)(7)
§482.43(c)(8)
Selection of
Discharge Care
Providers
15.03.15 Not Applicable
15.03.16 Not Applicable
15.03.17 Not Applicable
15.03.18 Not Applicable
15.03.19 Not Applicable
15.03.20 Not Applicable
15.03.21 Not Applicable
Chapter 15 Patient Rights and Discharge Planning Page 49
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2014 v 3 Standard
TitleRevised Deleted 2015 Standard Changes
15.03.22 Not Applicable
15.03.23 §482.43(d)Transfer or
Referral
15.03.24 §482.43(e)Discharge Plan
Reassessment
15.03.25 Not Applicable
15.03.26Discharge
InstructionsX Clarification
15.03.27Discharge
Checklist
Chapter 15 Patient Rights and Discharge Planning Page 50
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Standard
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Hospital CfR
2014 v 3 Standard
TitleRevised Deleted 2015 Standard Changes
16.00.00 §482.23
Condition of
Participation:
Nursing Services
16.00.01 Not Applicable
16.00.02 Not Applicable
16.00.03 §482.23(a) Nursing
OrganizationX Clarification
16.00.04 §482.23(b)Staffing and
Delivery of CareX
Title change:
Staffing and
Delivery of Care
16.00.05 §482.23(b)(1) 24‐Hour Provision
of Services
16.00.06 §482.23(b)(2) Licensure
16.00.07 Not Applicable
16.00.08 Not Applicable
16.00.09 §482.23(b)(3)Supervision of
Care
16.00.10 §482.23(b)(4) Plan of Care
16.00.11 §482.23(b)(5) Care Assignments
16.00.12 Not Applicable
16.00.13 §482.23(b)(6)
Supervision of
Non‐employee
Staff
16.00.14 Not Applicable
Chapter 16 Nursing Department Page 51
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16.00.15 Not Applicable
16.00.16 Not Applicable
16.01.01
§482.23(c)
§482.23(c)(1)(i)
§482.23(c)(2)
Preparation and
Administration of
Drugs
16.01.02 Not Applicable
16.01.03
§482.23(c)(1)(ii)
§482.23(c)(3)
§482.23(c)(3)(iii)
Medication
Orders
16.01.04 §482.23(c)(3)(i) Verbal Orders
16.01.05 §482.23(c)(3)(ii)Accepting Verbal
Orders
16.01.06 §482.23(c)(4)
Administration of
Blood Products
and IV
Medications
16.01.07 §482.23(c)(5)
Adverse Drug
Reactions,
Transfusion
Reaction, &
Medical Error
Reporting
16.01.08 Not Applicable
16.01.09
§482.23(c)(6)
§482.23(c)(6)(i)
§482.23(c)(6)(i)(A)
§482.23(c)(6)(i)(B)
§482.23(c)(6)(i)(C)
§482.23(c)(6)(i)(D)
§482.23(c)(6)(i)(E)
Self‐
Administration of
Medications:
Hospital‐Issued
Medications
Chapter 16 Nursing Department Page 52
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Standard
CMS Acute Care
Hospital CfR
2014 v 3 Standard
TitleRevised Deleted 2015 Standard Changes
16.01.10
§482.23(c)(6)(ii)
§482.23(c)(6)(ii)(A)
§482.23(c)(6)(ii)(B)
§482.23(c)(6)(ii)(C)
§482.23(c)(6)(ii)(D)
§482.23(c)(6)(ii)(E)
Self‐
Administration of
Medications:
Medications
Brought into the
Hospital
16.02.00 Not Applicable
16.02.01 Not Applicable
16.02.02 Patients at RiskPatient Safety
Initiative
16.02.03List of Patient
ProblemsX Retired
16.02.04 Not Applicable
16.02.05Reassessements
of PatientsX Retired
16.03.00Standards of
Practice & CareX Retired
16.03.01Standards of
PracticeX Retired
16.03.02Clinical Practice
StandardsX Retired
16.03.03 Standards Content X Retired
16.03.04 Standards of Care X Retired
16.03.05Standards
AvailabilityX Retired
16.03.06 Standards Review X Retired
Chapter 16 Nursing Department Page 53
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TitleRevised Deleted 2015 Standard Changes
16.04.01
Nursing Quality
Assessment
Performance
Improvement
(QAPI)
X Retired
16.04.02 Use of QAPI Data X Retired
Chapter 16 Nursing Department Page 54
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2014 v 3 Standard
TitleRevised Deleted
2015
StandardChanges
17.00.00 §482.57
Condition of
Participation:
Respiratory
Services
X Clarification
17.00.01 §482.57(a)Organization &
Staffing
17.00.02 §482.57(a)(1) Medical Director X Clarification
17.00.03 §482.57(a)(2)Staffing &
Qualifications
17.00.04 §482.57(b)Policies &
ProceduresX Clarification
17.00.05 §482.57(b)(1) Qualified Staff X Clarification
17.00.06 §482.57(b)(2)
Clinical
Laboratory
Testing
X Clarification
17.00.07 §482.57(b)(3) Services Provided X Clarification
17.00.08 §482.45(b)(4)Respiratory Care
Services Orders
17.00.09Therapeutic
Medical Gases
17.00.10
Adverse Drug
Reactions &
Medication Errors
17.00.11 Not Applicable
17.00.12Equipment
Availability
17.00.13 Assessment
Chapter 17 Respiratory Care Page 55
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TitleRevised Deleted 2015 Standard Changes
18.00.00
Cardiovascular
Services and
Interventional
Radiology Services
X 18.00.01 Clarification
18.00.01Applicable
StandardsX 18.00.05 Clarification
18.00.02Physical
EnvironmentX 18.00.02 Clarification
18.00.03
Availability of
Applicable Rules
and Regulations
X Retired
18.00.04
Moderate
Sedation ‐
Monitoring
X18.00.08
18.00.09Clarification
18.00.05
Moderate
Sedation ‐
Assisting with
Procedure
X 18.00.10 Clarification
18.00.06 Instrumentation X 18.00.04 Clarification
18.00.07Preoperative
AssessmentX 18.00.11 Clarification
18.00.08 Patient Eligibility X 18.00.01 Clarification
18.00.09Physical
EnvironmentX 18.00.03 Clarification
18.00.10Outpatient
ProceduresX 18.00.01 Clarification
18.00.11
Outpatient
Discharge
Requirements
X 18.00.13 Clarification
18.00.12Discharge
InstructionsX 18.00.14 Clarification
Chapter 18 Cardiovascular Services and Interventional Radiology Page 56
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TitleRevised Deleted 2015 Standard Changes
18.00.13
Outpatient
Discharge
Summary
X 18.00.12 Clarification
18.00.14 Outpatient Follow‐
upX 18.00.15 Clarification
Chapter 18 Cardiovascular Services and Interventional Radiology Page 57
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Standard
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Hospital CfR
2014 v 3 Standard
TitleRevised Deleted 2015 Standard Changes
19.00.00 §482.26
Condition of
Participation:
Radiological
Services
X CMS Update
19.00.01 §482.26(a) Scope of Service X CMS Update
19.00.02 §482.26(b) Safety of Services X
Safety for
Patients and
Personnel
CMS Update
19.00.03 §482.26(b)(1) Shielding X CMS Update
19.00.04 §482.26(b)(2)Equipment
InspectionsX CMS Update
19.00.05 §482.26(b)(3) Exposure Meters X CMS Update
19.00.06 §482.26(b)(4) Orders X CMS Update
19.00.07Physicist
Inspections
19.00.08Equipment Output
Monitoring
19.00.09
Approval of
Policies &
Procedures
19.00.10 §482.26(c) Personnel
19.00.11 §482.26(c)(1)Medical
SupervisionX CMS Update
19.00.12Personnel
Requirements
19.00.13 §482.26(c)(2)Qualified
PersonnelX CMS Update
Chapter 19 Diagnostic Radiology and Radiation Therapy Services Page 58
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2014 v 3 Standard
TitleRevised Deleted 2015 Standard Changes
19.00.14Order
Requirement
19.00.15 §482.26(d)Record
MaintenanceX CMS Update
19.00.16 §482.26(d)(1)Report
AuthenticationX
Combined with
19.00.15
19.00.17Qualified
Physicians
19.00.18 Contrast MediaPatient Safety
Initiative
19.00.19 §482.26(d)(2)Retention of
RecordsX
Combined with
19.00.15
19.00.20Labeling of
Radiographs
Patient Safety
Initiative
Chapter 19 Diagnostic Radiology and Radiation Therapy Services Page 59
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Standard
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Hospital CfR
2014 v 3 Standard
TitleRevised Deleted 2015 Standard Changes
20.00.01 §482.55
Condition of
Participation:
Emergency
Services
X
02.00.00;
02.00.01;
06.00.06
20.00.02§482.55(a);
§482.55(a)(1)
Medical Staff
LeadershipX
20.00.03 §482.55(a)(2) Integration X
20.00.04 §482.55(a)(3)Policies &
ProceduresX
06.00.00;
06.00.01;
06.00.02;
06.00.03;
06.00.04
20.00.05 Required Policies
& ProceduresX 02.01.00
20.00.06§482.55(b);
§482.55(b)(1)Personnel X
20.00.07 482.55(b)(2)
Personnel:
Staffing & Staff
Qualifications
X 02.00.07
20.00.08 Staff Training X 02.01.01
20.00.09 Records X 02.01.02
20.00.10Emergency Room
LogX 02.01.03
20.00.11
Change in
Treatment Plan
Log
X 02.01.04
20.00.13 §482.12(f)(3)
Provision of
Emergency
Services in Off‐
Campus
Departments
X
Chapter 20 Emergency Services Page 60
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TitleRevised Deleted 2015 Standard Changes
20.00.14
(20.00.17)
Personnel‐Medical
Screening
Examinations by a
Registered Nurse
X 02.00.07
20.00.15Personnel ‐
Registered NurseX 02.00.07
20.00.16
Coordination with
Emergency
Response Systems
X 02.00.08
20.00.17
Equipment,
Supplies, &
Medication
X
02.00.02;
02.00.03;
02.00.04;
06.01.00
20.00.18Blood & Blood
ProductsX
02.00.05;
02.00.06
Chapter 20 Emergency Services Page 61
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TitleRevised Deleted 2015 Standard Changes
21.00.01Endoscopic
ServicesX 18.00.01
21.00.02
Medical Staff
Rules &
Regulations
X Retired
21.00.03Moderate
SedationX 18.00.08
21.00.04Staffing
RequirementsX 18.00.09
21.00.05 Not Applicable
21.00.06Clean
EnvironmentX 18.00.04
21.00.07Physical
Environment X 18.00.03
21.00.08 Patient Eligibility X 18.00.01
21.00.09 Outpatient X 18.00.01
21.00.10
Outpatient
Discharge
Requirements
X 18.00.13
21.00.11
Outpatient
Discharge
Instructions
X 18.00.14
21.00.12Outpatient Follow‐
upX 18.00.15
Chapter 21 Endoscopic Services Page 62
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Hospital CfR
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TitleRevised Deleted 2015 Standard Changes
22.00.00 Laboratory
ServicesX
Condition of
Participation:
Laboratory
Services
Clarification
22.00.01 §482.27
Contion of
Participation:
Scope of Services
22.00.00
22.00.02 §482.27(a)
Accreditation/
Certification of
Laboratory
Services
22.00.01
22.00.03 §482.27(a)(1)
Emergency
Service
Availability
22.00.02
22.00.04 §482.27(a)(2)
Laboratory
Services
Description
X 22.00.03 Clarification
22.00.05 §482.27(a)(3) Tissue Specimens X 22.00.04 Clarification
22.00.06 §482.27(a)(4)Required Tissue
Examination22.00.05
22.01.01 §482.27(b)
Potentially
Infectious Blood &
Blood
Components
X Clarification
22.01.02
Exposure
Resulting in HIV
Conversion
22.01.03§482.27(c)(1)
§482.27(c)(2)
General Blood
Safety Issues
22.02.01Point of Care
Testing
Chapter 22 Laboratory Services Page 63
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Hospital CfR
2014 v 3 Standard
TitleRevised Deleted 2015 Standard Changes
23.00.00 §482.53
Condition of
Participation:
Nuclear Medicine
Services
X CMS Update
23.00.01§482.53(a)
Organization &
StaffingX CMS Update
23.00.02 §482.53(a)(1) Medical Director XCombined with
23.00.01CMS Update
23.00.03 §482.53(a)(2)Personnel
Requirement X
Combined with
23.00.01CMS Update
23.00.04§482.53(b)
§482.53(b)(1)
Policy and
Procedure
Requirements
X
Re‐titled to
"Delivery of
Service"
CMS Update
23.00.05 §482.53(b)(1)
In‐House
Preparation of
Radio
pharmaceuticals
X CMS Update
23.00.06 §482.53(b)(2)Storage and
Disposal of WasteX
Combined with
23.00.01CMS Update
23.00.07Shielding
Requirements
23.00.08Monitoring of
ExposureX Clarification
23.00.09
Nuclear
Regulatory
Commission
Licensure
23.00.10 §482.53(b)(3) Laboratory Testing X CMS Update
23.00.11 §482.53(c)
Safe Handling of
Reagents and
Equipment
Maintenance
XRe‐titled to
"Facilities"CMS Update
Chapter 23 Nuclear Medicine Services Page 64
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Standard
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2014 v 3 Standard
TitleRevised Deleted 2015 Standard Changes
23.00.12§482.53(c)(1)
§482.53(c)(2)Equipment Safety X
Combined with
23.00.11CMS Update
23.00.13
Handling and
Disposal of
Radium Elements
23.00.14
Approval of
Policies and
Procedures
23.00.15Order
Requirements
23.00.16 §482.53(d)Medical Record
RequirementsX CMS Update
23.00.17 §482.53(d)(1)Record Retention
RequirementsX
Combined with
23.00.16CMS Update
23.00.18 §482.53(d)(2)Qualified
PractitionersX
Combined with
23.00.16CMS Update
23.00.19 §482.53(d)(3)Documentation
RequirementsX CMS Update
23.00.20 §482.53(d)(4)Qualified Ordering
PractitionersX CMS Update
Chapter 23 Nuclear Medicine Services Page 65
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Standard
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Hospital CfR
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TitleRevised Deleted 2015 Standard Changes
24.00.00 §482.28
Condition of
Participation:
Food and Dietetic
Services
X Clarification
24.00.01 §482.28(a) Organization
24.00.02
§482.28(a)(1)
§482.28(a)(1)(i)
§482.28(a)(1)(ii)
§482.28(a)(1)(iii)
Food and Dietetic
ServicesX Clarification
24.00.03 §482.28(a)(2) Dietitian Services X Clarification
24.00.04 §482.28(a)(3)Staffing
QualificationsX Clarification
24.00.05§482.28(b)
Nutritional
Screening
Assessments
X Retired
24.00.06 §482.28(b)(1)Patient Nutritional
NeedsX Clarification
24.00.07 §482.28(b)(2) Diet Orders X Clarification
24.00.08 §482.28(b)(3) Diet Manual X Clarification
24.00.09
Access to
Professional and
Evidence‐Based
Dietetics Practice
Resources
24.00.10
Nutrition
Counseling and
Education
24.00.11Outcomes
Management
Chapter 24 Nutritional Services Page 66
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Standard
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TitleRevised Deleted 2015 Standard Changes
24.00.12Emergency
Preparedness Plan
24.01.01
Food Service
Department ‐
General
Requirements
24.01.02
Policy
Requirement ‐
Tube Feedings
24.01.03
Policy
Requirement ‐
Food Preparation
and Storage in
Patient Care Areas
24.01.04
Preparation and
Storage of
Formula and
Breastmilk
X Clarification
24.01.05 Vending Machines X Retired
24.01.06 Ice Machines X Retired
24.01.07 Trash Disposal
24.01.08Physical
Environment
24.01.09
Lighting,
Ventilation, and
Temperature
Control
24.01.10 Staff Education
24.01.11Staff Hygiene and
Health
24.01.12 China and Utensils
Chapter 24 Nutritional Services Page 67
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Standard
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Hospital CfR
2014 v 3 Standard
TitleRevised Deleted 2015 Standard Changes
24.01.13 Traffic Control
24.01.14
Food Storage and
Preparation in
Remote Areas
24.01.15Local Health
Standards
24.01.16 Infection Control
Chapter 24 Nutritional Services Page 68
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Standard
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TitleRevised Deleted 2015 Standard Changes
25.00.00 §482.25
Conditon of
Participation:
Pharmaceutical
Services
25.00.01 Licensure
25.00.02Permits &
Certifications
25.00.03 Scope of Service
25.00.04 §482.25(a)(1)
Pharmacy
Management &
Administration
X Clarification
25.00.05 §482.25(a)(1) Management
25.00.06 §482.25(a)(2) Staffing X Clarification
25.00.07 §482.25(a)(3) Scheduled Drugs
25.00.08Space
Requirements
25.01.01 §482.25(b)
Medication
Control &
Distribution
X Clarification
25.01.02 §482.25(b)(1)
Supervision of
Pharmacy
Activities
X Clarification
25.01.03§482.25(b)(2)(i) Security of
Medications
25.01.04 §482.25(b)(2)(ii)Controlled
Substances
Chapter 25 Pharmacy Services / Medication Use Page 69
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Standard
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2014 v 3 Standard
TitleRevised Deleted 2015 Standard Changes
25.01.05 §482.25(b)(2)(iii)
Access to
Controlled
Substances
25.01.06 Pharmacy Security
25.01.07 §482.25(b)(3)
Inventory
Management
System
25.01.08 §482.25(b)(4) Pharmacy Access X Clarification
25.01.09 §482.25(b)(5)Automatic Stop
Medication Order
25.01.10 §482.25(b)(6)
Drug Reactions,
Administration
Errors, &
Incompatibilities
X Clarification
25.01.11 §482.25(b)(7)
Reporting of
Controlled Drug
Loss and/or Abuse
X Clarification
25.01.12 §482.25(b)(8)Informational
ResourcesX Clarification
25.01.13 §482.25(b)(9) Formulary System X Clarification
25.01.14Integrity of
MedicationsX Clarification
25.01.15
Consultations/
Resource
Availability
25.01.16Medication
Protocols
25.01.17Home
Medications X Clarification
Chapter 25 Pharmacy Services / Medication Use Page 70
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Standard
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2014 v 3 Standard
TitleRevised Deleted 2015 Standard Changes
25.01.18 Labeling
25.01.19Standardization of
Labeling
25.01.20High‐Alert
Medications
Patient Safety
Initiative
25.01.21Dispensing
Methods
Patient Safety
Initiative
25.01.22
Preparation of
Intravenous Drugs
& Fluids
25.01.23 Sample Drugs
25.01.24Patient
Medication Profile
25.01.25 Profile ReviewPatient Safety
Initiative
25.01.26Drug
Administration
25.01.27
Label Medications
& Solutions on the
Sterile Field
Patient Safety
Initiative
25.01.28Investigational
Drugs
25.01.29 Documentation
25.01.30Antithrombotic
Therapy
Patient Safety
Initiative
25.02.01
Preparation &
Administration of
Drugs
Patient Safety
Initiative
Chapter 25 Pharmacy Services / Medication Use Page 71
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Standard
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Hospital CfR
2014 v 3 Standard
TitleRevised Deleted 2015 Standard Changes
25.02.02
Medication
Preparation
Environment
Patient Safety
Initiative
25.02.03Medication
Reconciliation
Patient Safety
Initiative
25.03.01Performance
Improvement
25.03.02Data Collection &
Monitoring
25.03.03Medication Use
Review
25.03.04 Data Reporting
25.03.05Annual Report on
Medication Use
25.03.06
Performance
Improvement in
Medication Use
Patient Safety
Initiative
Chapter 25 Pharmacy Services / Medication Use Page 72
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TitleRevised Deleted 2015 Standard Changes
26.00.00Rehabilitation
Unit Services
Moved to
Chapter 33:
Distinct Part Unit
26.00.01Rehabilitation
Unit Services
26.00.02 §412.25(a)(1)Excluded Hospital
Units33.00.01
26.00.03 §412.25(a)(2) Admission Criteria X 33.00.02 Clarification
26.00.04 §412.25(a)(3)Separate Medical
RecordsX 33.00.03 Clarification
26.00.05 §412.25(a)(4)
Availability of
Clinical Records &
Information
X 33.00.04 Clarification
26.00.06 §412.25(a)(5)State Licensure
RequirementsX 33.00.05 Clarification
26.00.07 §412.25(a)(6)Utilization Review
Requirements33.00.06
26.00.08 §412.25(a)(7)Distinct Unit
StructureX 33.00.07 Clarification
26.00.09§412.29
§412.29(a)
Provider
AgreementX
33.01.00
33.01.01Clarification
26.00.10 §412.29(b)Preadmission
ScreeningX 33.01.04 CMS Update
26.00.11 §412.29(c)
Medical
Supervision &
Personnel
Qualifications
X 33.01.06 CMS Update
26.00.12 §412.29(d) Plan of Treatment X 33.01.08 CMS Update
Chapter 26 DPU Distinct Part Unit ‐ Physical Rehabilitation Services Page 73
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TitleRevised Deleted 2015 Standard Changes
26.00.13 §412.29(e)
Coordinated
Multidisciplinary
Team Approach
X 33.01.09 CMS Update
26.00.14Multidiciplinary
Team33.02.01
26.00.15 §412.29(f)Director ‐
Requirements33.01.07
26.00.16Physician
Responsibility33.02.02
26.00.17 Nursing Care 33.02.03
26.00.18Organizational
Plan33.02.04
26.00.19Collaborative
Goals33.02.05
26.00.20Patient / Family
Education33.02.06
26.00.21
Quality
Assessment
Performance
Improvement
33.02.07
26.00.22 §412.25(b) Change in Size X 33.00.14 Clarification
26.00.23§412.25(c)(1)
§412.25(c)(2)Change in Status X 33.00.15 Clarification
26.00.24 §412.25(d)Number of
Excluded UnitsX 33.00.16 Clarification
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TitleRevised Deleted 2015 Standard Changes
26.01.00 §482.56
Condition of
Participation:
Rehabilitation
Services
26.00.00
Renumbered;
standards are
separated for
General
Rehabilitation
Services
26.01.01 §482.56(a)Organization &
StaffingX 26.00.01 Clarification
26.01.03 §482.56(a)(1) Leadership 26.00.02
26.01.04 §482.56(a)(2)Staff
Qualifications26.00.03
26.01.05Minimum Staffing
Requirements26.00.04
26.01.06 Therapy Orders X 26.00.05 Clarification
26.01.07 §482.56(b)Delivery of
ServicesX 26.00.06 Clarification
26.01.08 §482.56(b)(1)Rehabilitation
Orders26.00.07
26.01.09 §482.56(b)(2)Standards of
PracticeX 26.00.08 Clarification
26.01.10 Plan of Care X
26.00.09
Organizational
Plan
26.01.11
Program
Objective &
Standards of
Practice
XCombine with
26.00.10Clarification
26.01.12Initial
Assessments26.00.10
26.01.13Treatment Plan /
Plan of CareX 26.00.11 Clarification
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26.01.14 Treatment Goals 26.00.12
26.01.15 Patient Education 26.00.13
26.01.16 Reassessment 26.00.14
26.01.17
Quality Assurance
Performance
Improvement
(QAPI)
26.00.15
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27.00.00 §482.60
Condition of
Participation:
Psychiatric
Hospitals
X
THESE
REQUIREMENTS
DO NOT APPLY TO
ACUTE CARE
HOSPITALS
27.00.01 §482.60(a) Clinical Focus X
27.00.02 §482.60(b)
Compliance with
Hospital
Requirements
X
27.00.03 §482.60(c)Medical Records
RequirementsX
27.00.04 §482.60(d)Staffing
RequirementsX
27.01.01 §482.61
Condition of
Participation:
Special Medical
Records
Requirements for
Psychiatric
Hospitals
X
27.01.02 §482.61(a)
Development of
Assessment /
Diagnostic Data
X
27.01.03 §482.61(a)(1)Patient Legal
StatusX
27.01.04 §482.61(a)(2)Admitting
DiagnosisX
27.01.05 §482.61(a)(3)Patient Reason for
AdmissionX
27.01.06 §482.61(a)(4)
Psychosocial
History /
Assessment
X
27.01.07 §482.61(a)(5)Neurological
ExaminationX
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27.01.08Confidentiality of
InformationX
27.01.09 §482.61(b)Psychiatric
EvaluationX
27.01.10 §482.61(b)(1)Timeframe for
CompletionX
27.01.11 §482.61(b)(2) Medical History X
27.01.12 §482.61(b)(3) Mental Status X
27.01.13 §482.61(b)(4)Reason for
AdmissionX
27.01.14 §482.61(b)(5)Behavioral
AssessmentX
27.01.15 §482.61(b)(6)Cognitive
AssessmentX
27.01.16 §482.61(b)(7)Inventory of
StrengthsX
27.01.17 §482.61(c) Treatment Plan X
27.01.18 §482.61(c)(1)Treatment Plan ‐
IndividualizedX
27.01.19Treatment Plan ‐
DocumentationX
27.01.20 §482.61(c)(1)Treatment Plan
FoundationX
27.01.21 §482.61(c)(1)(i)
Treatment Plan
Contents ‐
Diagnosis
X
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27.01.22 §482.61(c)(1)(ii)Treatment Plan
Contents ‐ GoalsX
27.01.23 §482.61(c)(1)(iii)
Treatment Plan
Contents ‐
Treatment
Modalities
X
27.01.24 §482.61(c)(1)(iv)
Treatment Plan
Contents ‐
Individual Staff
Responsibilities
X
27.01.25 §482.61(c)(1)(v)
Treatment Plan
Contents ‐
Justification of
Diagnosis
X
27.01.26 §482.61(c)(2)Documentation of
Active TreatmentX
27.01.27 §482.61(d) Progress Notes X
27.01.28 §482.61(d)Frequency of
Progress NotesX
27.01.29 §482.61(e)
Discharge
Planning &
Summary
X
27.02.00 §482.62
Condition of
Participation:
Special Staffing
Requirements for
Psychiatric
Hospitals
X
27.02.01 §482.62(a)(1)Staffing
RequirementsX
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27.02.02 §482.62(a)(2)Staffing
RequirementsX
27.02.03 §482.62(a)(3)Staffing
RequirementsX
27.02.04 §482.62(a)(4)Staffing
RequirementsX
27.02.05 §482.62(b) Clinical Director X
27.02.06 §482.62(b) Medical Staff X
27.02.07 §482.62(b)(1)Medical Director
QualificationsX
27.02.08 §482.62(b)(2)Medical Director
ResponsibilitiesX
27.02.09 §482.62(c)Availability of
Medical PersonnelX
27.02.10 §482.62(d) Nursing Services X
27.02.11 §482.62(d)(1)
Director of
Nursing
Qualifications
X
27.02.12 §482.62(d)(2) Staffing X
27.02.13 §482.62(e)Psychological
ServicesX
27.02.14 §482.62(f) Social Services
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27.02.15 §482.62(f)
Social Service
Staff Standards of
Practice
X
27.02.16 §482.62(f)(1)
Social Services
Director
Qualifications
X
27.02.17 §482.62(f)(2)
Social Services
Staff
Responsibilities
X
27.02.18 §482.62(g)Therapeutic
Activities ProgramX
27.02.19 §482.62(g)(1)Activities Program
FocusX
27.02.20 §482.62(g)(2)Activities Program
StaffingX
27.02.21
Scope &
Description of
Available Services
X
27.03.01 Physical Facilities X
27.03.02Treatment
EnvironmentX
27.03.03
Patient Bedrooms ‐
Safety and
Security
X
27.03.04Sleeping
AccommodationsX
27.03.05 Personal Property X
Chapter 27 A Psychiatric Hospital Page 81
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27.03.06 Laundry X
27.03.07Patient Hygiene
NeedsX
27.03.08 Treatment Space X
27.03.09 Barrier‐Free X
27.04.01 Patient Rights X
27.05.01Convulsive
TherapyX
27.05.02
Convulsive
Therapy ‐ Use
with Children
X
27.05.03Administrative
PolicyX
27.05.04 Psychosurgery X
27.05.05
Referral for
Specialized
Services
X
27.05.06Aversive
ConditioningX
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27.06.00 §412.25(a)
Distinct Part
Psychiatric Unit /
Propsective
Payment System
Excluded Unit
Distinct Part
Psychiatric Unit
/ Propsective
Payment
System
Excluded Unit
27.06.01
§412.25(a)
§412.25(a)(1)
§412.25(a)(1)(i)
§412.25(a)(1)(ii)
§412.25(a)(1)(iii)
Excluded Hospital
Units34.00.01
27.06.02 412.25(a)(2) Admission Criteria 34.00.02
27.06.03 412.25(a)(3)Separate Medical
Records34.00.03
27.06.04 412.25(a)(4)
Availablity of
Clinical Records &
Information
34.00.04
27.06.05 412.25(a)(5)State Licensure
Requirements34.00.05
27.06.06 412.25(a)(6)Utilization Review
Requirements34.00.06
27.06.07 412.25(a)(7)Distinct Unit
Structure34.00.07
27.06.08
Excluded
Psychiatric Units:
Additional
Requirements
34.01.01
27.06.09 412.27(a) Admission Criteria 34.01.02
27.06.10 412.27(b) Scope of Service 34.01.03
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27.06.11 412.27(c) Treatment Plan 34.01.04
27.06.12 412.27(c)(1)
Development of
Assessment /
Diagnostic Data
34.01.05
27.06.13 412.27(c)(1)(i) Legal Status 34.01.06
27.06.14 412.27(c)(1)(ii)Admission
Diagnosis34.01.07
27.06.15 412.27(c)(1)(iii)Patient Reason for
Admission34.01.08
27.06.16 412.27(c)(1)(iv)Social History and
Assessment34.01.09
27.06.17 412.27(c)(1)(v)Neurological
Examination34.01.10
27.06.18 412.27(c)(2)Psychiatric
Evaluation34.01.11
27.06.19 412.27(c)(2)(i)
Psychiatric
Evaluation ‐
Timeframe
34.01.12
27.06.20 412.27(c)(2)(ii)
Psychiatric
Evaluation ‐
Medical History
34.01.13
27.06.21 412.27(c)(2)(iii)
Psychiatric
Evaluation ‐
Mental Status
34.01.14
27.06.22 412.27(c)(2)(iv)
Psychiatric
Evaluation ‐ Onset
of Illness
34.01.15
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27.06.23 412.27(c)(2)(v)
Psychiatric
Evaluation ‐
Description of
Attitudes and
Behaviors
34.01.16
27.06.24 412.27(c)(2)(vi)
Psychiatric
Evaluation ‐
Cognition
34.01.17
27.06.25 412.27(c)(2)(vii)Psychiatric
Evaluation ‐ Assets34.01.18
27.06.26 §412.27(c)(3)(i) Treatment Plan 34.01.19
27.06.27 §412.27(c)(3)(ii)Documentation of
Active Treatment34.01.20
27.06.28 §412.27(c)(4)Progress Notes
Requirements34.01.21
27.06.29 §412.27(c)(5)
Discharge
Planning and
Discharge
Summary
34.01.22
27.06.30 §412.27(d)(1)(i)Staffing
Requirements34.01.23
27.06.31 §412.27(d)(1)(ii)Staffing
Requirements34.01.24
27.06.32 §412.27(d)(1)(iii)Staffing
Requirements34.01.25
27.06.33 §412.27(d)(1)(iv)Staffing
Requirements34.01.26
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27.06.34 §412.27(d)(2)
Director of
Inpatient
Psychiatric
Services: Medical
Staff
34.01.27
27.06.35 §412.27(d)(2)(i)Medical Director
Qualifications34.01.28
27.06.36 §412.27(d)(2)(ii)Medical Director
Responsibilities34.01.29
27.06.37 §412.27(d)(3) Nursing Services 34.01.30
27.06.38 §412.27(d)(3)(i)Nursing Services
Leadership34.01.31
27.06.39 §412.27(d)(3)(ii) Staffing 34.01.32
27.06.40 §412.27(d)(4)Psychological
Services34.01.33
27.06.41 §412.27(d)(5) Social Services 34.01.34
27.06.42 §412.27(d)(6)Therapeutic
Activities34.01.35
27.06.43 §412.27(d)(6)(i) Program Scope 34.01.36
27.06.44 §412.27(d)(6)(ii) Program Staffing 34.01.37
27.06.45
Scope and
Description of
Available Services
34.02.01
27.06.46 Physical Facilities 34.02.02
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27.06.47
Patient Bedrooms ‐
Safety and
Security
34.02.03
27.06.48Patient Hygiene
Needs34.02.04
27.06.49Handicapped
Accessiblity34.02.05
27.06.50Confidentiality of
Information34.02.06
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28.00.01Organizational
Chart
28.00.02
Scope and
Description of
Services
28.00.03
The Continuum of
Substance Abuse
Services
28.00.04Criteria for Client
Placement
28.00.05
Patient Placement
Criteria
for Level 0.5 –
Early
Intervention
28.00.06
Patient Placement
Criteria for Level I ‐
Outpatient
Treatment
28.00.07
Patient Placement
Criteria
for Level II –
Intensive
Outpatient
Treatment /
Partial
Hospitalization
28.00.08
Patient Placement
Criteria
for Level III –
Residential
/ Inpatient
Treatment
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28.00.09
Patient Placement
Criteria
for Level IV –
Medically
Managed
Intensive
Inpatient
Treatment
28.00.10
Opioid
Maintenance
Therapy (OMT)
28.00.11Treatment
Modalities
28.00.12
Treatment of Co‐
Occurring
Substance
Abuse and Mental
Health
Disorders
28.00.13
Treatment
Protocols –
Alcohol
Withdrawal
28.00.14
Treatment
Protocols – Use
of FDA Approved
Medications in
Treatment
of Alcohol Abuse
Disorders
28.00.15
Treatment
Protocols – Use
of FDA Approved
Medications in
Treatment
of Opiate
Addiction
Chapter 28 Substance Abuse Services Page 89
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28.00.16
Medical Staff
Qualifications for
Administration of
Buprenorphine
28.00.17 Informed Consent
28.00.18 Activities Program
28.00.19
Referral and
Access to
Special Services
28.00.20
Family
Psychosocial
Assessment
28.00.21Personal
Belongings
28.00.22Policies and
Procedures
28.00.23
Common Areas
and Space
Requirements
28.00.24
Work Space and
Therapeutic
Equipment
Requirements
28.00.25Client Access to
Staff
28.00.26After Hours
Resources
28.00.27 Patient Rights
28.00.28 Written Consent
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28.00.29
Referral and
Access to
Special Services
28.00.30
Required
Emergency
Services
28.00.31Intermediate Plan
of Care
28.00.32Outpatient Follow‐
up Care
28.01.01 Medical Staff
28.01.02
Availability of
Medical
Personnel
28.01.03
Staff Knowledge
of Client
Legal Rights and
the
Criminal Judicial
System
28.01.04
§482.62;
§482.62(a);
§482.62(a)(1);
§482.62(a)(2);
§482.62(a)(3);
§482.62(a)(4)
Staffing
Qualifications
28.01.05
Competencies of
Addiction
Counselors and
Specialists
28.01.06
Coordination of
Social
Services
28.01.07
Case / Care
Manager ‐
Qualifications
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28.02.01Medical Record
Requirements
28.02.02
History
Assessment
Requirements
28.02.03
Physical
Assessment
Requirements
28.02.04
Individualized
Treatment
Plan
28.02.05 §482.61(c)(2)
Documentation of
Active
Treatment
28.02.06§482.61(c)(2)
(vii)
Discharge
Summary
28.02.07Statement of
Ability
28.02.08 For Future Use
28.03.01
Confidentiality of
Substance Abuse
Patient
Records
28.03.02
Consent for
Disclosure of
Information
28.03.03Notice of Privacy
Practices
28.04.01
Quality
Assessment /
Performance
Improvement
(QAPI)
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29.00.01 Special Care Unit
29.00.02 Medical Care
29.00.03 Nursing Care
29.00.04 Admission Criteria
29.00.05 Discharge Criteria
29.00.06Prioritization of
Care
29.00.07 Staff Orientation
29.00.08Physical
Environment
29.00.09 Not Applicable
29.00.10 Not Applicable
29.00.11Equipment ‐
Training
29.00.12Equipment ‐
Required
29.00.13 Supply Storage
29.00.14Required Policies
and Procedures
29.00.15
Policy ‐
Collaborative
Development
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29.00.16
Policies ‐
Subspecialty
Patient Needs
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30.00.00 §482.51
Condition of
Participation:
Surgical Services
30.00.01 §482.51(a)Organizational
Structure
30.00.02 §482.51(a)(1) Leadership
30.00.03 §482.51(a)(2) Scrub Nurses X CMS Update
30.00.04 §482.51(a)(3) Circulating Nurses X CMS Update
30.00.05 §482.51(a)(4) Surgical Privileges X CMS Update
30.00.06
Medical Staff
Rules &
Regulations
X Retired
30.00.07 First Assistants
30.00.08Physician
AvailabilityX Clarification
30.00.09 §482.51(b)Standards of
PracticeX CMS Update
30.00.10 §482.51(b)(1) History & Physical X CMS Update
30.00.11 §482.51(b)(2) Informed Consent XPatient Safety
Initiative
30.00.12 §482.51(b)(3)Required
EquipmentX Clarification
Chapter 30 Surgical Services Page 95
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30.00.13
Supply &
Instrumentation
Availability &
Flash Sterilization
X IUSS Update
30.00.14Operative Site
Verification
Patient Safety
Initiative
30.00.15 Risk Assessment X Retired
30.00.16Pneumatic
Tourniquets
Patient Safety
Initiative
30.00.17 §482.51(b)(4)Postoperative
CareX CMS Update
30.00.18 §482.51(b)(5)Operating Room
RegisterX CMS Update
30.00.19 §482.51(b)(6) Operative Report X Clarification
30.00.20Pathology Review
Exemptions
30.00.21
Label Medications
& Solutions on the
Sterile Field
Patient Safety
Initiative
30.00.22Postoperative
Medical CareX Retired
30.01.00Anesthesia
ServicesX Retired
30.01.01 §482.52
Condition of
Participation:
Medical
Leadership ‐
Anesthesia
Services
X 30.01.00 CMS Update
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30.01.02 §482.52(a)Scope of Service ‐
Anesthesia30.01.01
30.01.03
§482.52(a)
§482.52(a)(2)
§482.52(a)(3)
§482.52(a)(4)
§482.52(a)(5)
§482.52(c)(1)§482.52(c)(2)
Anesthesia
ProvidersX 30.01.02 CMS Update
30.01.04
Moderate
Sedation
(Conscious
Sedation)
30.01.03
30.01.05 §482.52(b) Required Policies X 30.01.04 CMS Update
30.01.06 §482.52(b)(1)Preanesthesia
EvaluationX 30.01.05 Clarification
30.01.07 §482.52(b)(2)Intra‐operative
Anesthesia RecordX 30.01.06 Clarification
30.01.08 §482.52(b)(3)Post‐anesthesia
AssessmentX 30.01.07 Clarification
30.01.09 Equipment Safety 30.01.08
30.02.01
Medical Staff
Rules &
Regulations ‐
Regulations
Availability ‐
Postanesthesia
X Retired
30.02.02 Not Applicable
30.02.03Nursing Care ‐
Postanesthesia
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30.02.04
Registered Nurse
Supervision ‐
Postanesthesia
Recovery
30.02.05
Staff Orientation
& Training ‐
Postanesthesia
Recovery
30.02.06 §482.51(b)(3)Required
EquipmentX Clarification
30.02.07
Supply &
Equipment
Availability
30.02.08 Not Applicable
30.02.09 Not Applicable
30.02.10 Required Policies
30.02.11
Policy ‐ Bypass of
Postanesthesia
Recovery Service
30.02.12Recovery in Non‐
PACU Locations
30.02.13 Discharge Criteria
30.02.14Documentation
Requirements
30.02.15Staffing
Requirements
30.03.01
Outpatient
Discharge
Requirement
X Clarification
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30.03.02
Outpatient
Discharge
Instructions
X Clarification
30.03.03Post‐Procedure
Follow‐up CallX Clarification
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31.00.00§482.54
Condition of
Participation:
Outpatient
Services
X CMS Update
31.00.01 §482.54(a)Integration of
Services
31.00.02§482.54(b)(1)
§482.54(b)(2) Personnel X CMS Update
31.00.03Documentation in
Patient Records
31.00.04Patient
Satisfaction
31.00.05 Activity Logs
31.00.06After‐Hours
Resources
31.00.07 Referrals
31.00.08 For Future Use
31.00.09 For Future Use
31.00.10 Storage
31.00.11
§482.54(c)
§482.54(c)(1)
§482.54(c)(2)
§482.54(c)(3)
§482.54(c)(4)
Orders for
Outpatient
Services
X CMS Update
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32.00.00 §482.58
Special
Requirements for
CAH Providers of
Long‐Term Care
Services ("Swing‐
Beds").
X CMS Updates
32.00.01
§482.58(a)
§482.58(a)(1)
§482.58(a)(2)
§482.58(a)(3)
§482.58(a)(4)
Eligibility X CMS Updates
32.00.02 Bed Size XCombined with
32.00.01CMS Updates
32.00.03 Hospital Location XCombined with
32.00.01CMS Updates
32.00.04 Nursing Waiver XCombined with
32.00.01CMS Updates
32.00.05
No Termination of
Swing Bed
Approval
XCombined with
32.00.01CMS Updates
32.00.06 §482.58(b)Skilled Nursing
Facility ServicesX CMS Updates
32.01.01 §483.10 Resident Rights
32.01.02 §483.10(b)(3)Notice of Rights
and Services
32.01.03 §483.10(b)(4)Right to Refuse
Treatment
32.01.04§483.10(b)(5)
§483.10(b)(6)
Medicaid &
Medicare
Notification
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32.01.05 §483.10(b)(8) Advance
Directives
32.01.06§483.10(d)
§483.10(d)(1) Personal Physician
32.01.07 §483.10(d)(2)Informed of Care
and Treatment
32.01.08 §483.10(d)(3)Participation in
Care
32.01.09
§483.10(e)
§483.10(e)(1)
§483.10(e)(2)
§483.10(e)(3)
§483.10(e)(3)(i)
§483.10(e)(3)(ii)
Personal Privacy
and
Confidentiality
X CMS Update
32.01.10
§483.10(h)(1);
§483.10(h)(2)
§483.10(h)(2)(i);
§483.10(h)(2)(ii)
§483.10(h)(2)(iii)
§483.10(h)(2)(iv)
Work
32.01.11
§483.10(i)
§483.10(i)(1)
§483.10(i)(ii)
32.01.12
§483.10(j)(1)
§483.10(j)(1)(vii)
§483.10(j)(1)(viii)
Access and
Visitation Rights
32.01.13 §483.10(l)Personal
Possessions
32.01.14 §483.10(m) Married Couples
32.01.15
§483.12(a)
§483.12(a)(1)Transfer and
Discharge
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32.01.16
§483.12(a)(2)
§483.12(a)(2)(i)
§483.12(a)(2)(ii)
§483.12(a)(2)(iii)
§483.12(a)(2)(iv)
§483.12(a)(2)(v)
§483.12(a)(2)(vi)
Transfer &
Discharge
Requirements
32.01.17
§483.12(a)(3)
§483.12(a)(3)(i)
§483.12(a)(3)(ii)Documentation
32.01.18
§483.12(a)(4)
§483.12(a)(4)(i)
§483.12(a)(4)(ii)
§483.12(a)(4)(iii)
Notice Before
Transfer
32.01.19
§483.12(a)(5)
§483.12(a)(5)(i)
§483.12(a)(5)(ii)
§483.12(a)(5)(ii)(A)
§483.12(a)(5)(ii)(B)
§483.12(a)(5)(ii)(C)
§483.12(a)(5)(ii)(D)
§483.12(a)(5)(ii)(E)
Timing of the
Notice
32.01.20
§483.12(a)(6)
§483.12(a)(6)(i)
§483.12(a)(6)(ii)
§483.12(a)(6)(iii)
§483.12(a)(6)(iv)
§483.12(a)(6)(v)
§483.12(a)(6)(vi)
§483.12(a)(6)(vii)
Contents of the
Notice
32.01.21 §483.12(a)(7)
Orientation for
Transfer or
Discharge
32.01.22
§483.10(a)(1)
§483.10(a)(2)
§483.10(a)(3)
§483.10(a)(4)
Exercise of Rights
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32.02.01
§483.13
§483.13(a)Restraints X 11.03.00
32.02.02 §483.13(b) Abuse X 11.03.01
32.02.03
§483.13(c)
§483.13(c)(1)(i)Staff Treatment of
ResidentsX
11.03.02;
11.03.03
32.02.04
§483.13(c)(1)(ii)
§483.13(c)(1)(ii)(A)
§483.13(c)(1)(ii)(B)
§483.13(c)(1)(ii)(B)(i
ii)
Screening of Staff
32.02.05 §483.13(c)(2)
Reporting of
Patient
Mistreatment,
Neglect, or Abuse
32.02.06 §483.13(c)(3) Investigation of
Alleged Abuse
32.02.07 §483.13(c)(4) Reporting of
Investigations
32.03.01 Not Applicable
32.03.02
§483.15(f)
§483.15(f)(1)
§483.15(f)(2)
§483.15(f)(2)(i)
§483.15(f)(2)(i)(A)
§483.15(f)(2)(i)(B)
§483.15(f)(2)(ii)
§483.15(f)(2)(iii)
§483.15(f)(2)(iv)
Activities X CMS Update
32.03.03 Activities Director XCombined into
32.03.02
32.03.04
§483.15(g)
§483.15(g)(1) Social Services X CMS Update
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32.03.05
§483.15(g)(2)
§483.15(g)(3)
§483.15(g)(3)(i)
§483.15(g)(3)(ii)Qualifications of
Social WorkerX CMS Update
32.03.06
§483.20(l)
§483.20(l)(1)
§483.20(l)(2)
§483.20(l)(3)
Discharge
SummaryX CMS Update
32.04.01
§483.45
§483.45(a)
§483.45(a)(1)
§483.45(a)(2)
Specialized
Rehabilitative
Services
X
Retitled,
"Specialized
Rehabilitative
Services:
Provision of
Services"
CMS Update
32.04.02 §483.45(b)Rehabilitative
Service OrdersX
Retitled:
"Rehabilitative
Service Orders:
Qualifications"
Clarification
32.05.01 §483.55 Dental Services
32.05.02§483.55(a)(1)
§483.55(a)(2)
Patient Liability
for Dental Care
Retitled: "Skilled
Nursing Facility:
Patient Liability
for Dental Care"
32.05.03
§483.55(a)(3)
§483.55(a)(3)(i)
§483.55(a)(3)(ii)
§483.55(a)(4)
Resident Dental
Appointment
Retitled: "Skilled
Nursing Facility:
Resident Dental
Appointments"
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32.05.04
§483.55(b)
§483.55(b)(1)
§483.55(b)(1)(i)
§483.55(b)(1)(ii)
Provision of
Dental Services
Retitled:
"Nursing
Facilities:
Provision of
Dental
Services"
32.05.05
§483.55(b)(2)
§483.55(b)(2)(i)
§483.55(b)(2)(ii)
§483.55(b)(3)
Appointments and
Referrals
Retitled:
"Nursing
Facilities:
Appointments
and Referrals"
Chapter 32 Swing Beds Page 106