The updated Interpretive Guidelines for CMS surveyors includes most—but not all—of the new or revised Conditions of Participation for discharge planning and burden reduction outlined in two final rules published in September.
CMS announced the new electronic form and provided instructions on how to use it, including a video, in a Quality, Safety & Oversight Group memo, on December 2.
Infection control dominated the day’s presentations, which also looked at expectations for sterile compounding, Legionella control, using personal protective equipment, medication management, lowering maternal death rates, and, of course, ligature risk and suicide prevention.
In its final action, the EPA explains that new regulations are not necessary to regulate spills of hazardous substances (HS) because the “existing cumulative framework of regulatory requirements adequately serves to prevent and contain CWA HS discharges.”
This standard (MM.09.01.03) is not brand new—in fact, it is an extension of the original standard (MM.09.01.01), which has been in place since January 1, 2017. Most hospitals and nursing care centers have been under the original standard’s authority in an effort to curb antibiotic resistance in the U.S.
The August 21 ban on the sewering of hazardous waste pharmaceuticals is the first deadline set out in new regulations published by the EPA in a final rule in February that overall sets up a new category, Subpart P, under the federal Resource Conservation and Recovery Act.
According to the 2019 HFAP Quality Review, incomplete processes and insufficient documentation were the most-cited standards during 2018 on-site surveys at acute care hospitals, critical access hospitals, laboratories, and ambulatory surgery centers.
Element of performance (EP) 3 requires that the suicide risk assessment include risk factors, which TJC describes as “a combination of individual, biological, psychological, familial, community, cultural, and/or societal characteristics or factors that may contribute to the risk of suicide.”
The proposed rule establishes a process AOs with Medicare-approved accreditation programs must follow if there is a sale, transfer, and/or purchase of assets related to the ownership of an AO.
The added emphasis on suicide comes at a time of national concern about suicides in hospitals and is meant to complement the “Zero Suicide” campaign, an effort by several outreach groups to eliminate suicide in healthcare facilities nationwide, according to Joint Commission literature.