Published on February 20, 2015
|
|
- Priscilla Harvey
- 6 years ago
- Views:
Transcription
1 EQUIPMENT MANAGEMENT How the Medical Equipment Management Landscape Will Change in 2015 Published on February 20, 2015 To ensure timely compliance with new requirements, hospitals must review and revise their medical equipment management policies and practices By Stephen L. Grimes and Jillyan Morano In December 2013, the Centers for Medicare & Medicaid Services (CMS) issued a survey and certification memo that made substantial changes in hospital equipment maintenance guidelines used by surveyors to determine a hospital s eligibility for Medicare and Medicaid reimbursement. 1 Those CMS changes referenced the ANSI/AAMI standard EQ56:2013, Recommended practice for a medical equipment management program. 2 Six months later, The Joint Commission (TJC) released substantial changes to its Environment of Care (EC) accreditation standards to align with the new CMS guidelines for those hospitals that use TJC accreditation for deeming status. 3 (CMS has granted deeming authority to TJC and DNV Healthcare, so that hospitals accredited by these organizations under CMS guidelines are considered deemed as having met CMS requirements.) The effects of these changes will be substantial. They will require the vast majority of US hospitals to make significant modifications to their procedures, and will have a long-term impact on the medical equipment maintenance management landscape. The New Requirements Under the new requirements, hospitals must maintain an inventory of all medical equipment in the organization (regardless of ownership or service source). Previously, many hospitals could elect to maintain an inventory of medical equipment that they determined to be of sufficient risk (that is, a riskbased approach to including medical equipment on the inventory). The latitude to leave medical equipment of sufficiently low risk off the inventory is no longer an option. Hospitals must also identify critical/high-risk medical equipment in the inventory. Any medical equipment that, if it were to fail, could result in serious injury or death of a patient or staff member is defined as critical by CMS and high-risk by TJC. Note that life support equipment (a former focus of TJC) is a subset of critical/high-risk equipment. Maintenance activities and frequencies for maintaining, inspecting, and testing all medical equipment in the inventory must be documented in writing. Before medical equipment is first used as well as after major repairs or upgrades safety, operational, and functional checks must be performed.
2 These new requirements must be met in accordance with manufacturers recommendations for the following categories of equipment: Equipment subject to federal or state laws or Medicare Conditions of Participation (CoP) by which maintenance be in accordance with manufacturers recommendations, or which otherwise establishes more stringent requirements. Medical laser devices. Imaging and radiologic equipment (whether used for diagnostic or therapeutic purposes). New equipment with insufficient maintenance history to consider an alternate equipment maintenance (AEM) program. For equipment not in the categories above, hospitals may deviate from manufacturers recommendations and institute an AEM program under the following conditions: Available medical equipment histories suggest that deviating from manufacturer recommendations would have no adverse affect on patient or staff safety. Qualified staff (for example, a clinical engineer or biomedical engineering technician) use written criteria to support any determination to apply an AEM approach. These written criteria should encompass how the equipment is used (including the seriousness or prevalence of harm during normal use), the likely consequences of equipment failure, the availability of backup equipment, incident history of the same or comparable equipment, and maintenance requirements. Recommended Steps Compliance with these new requirements can best be achieved if there is an effective plan for implementation, such as outlined in the following 10 steps. 1) Meet with hospital leadership and compliance office to inform them of the new standards. Keep them up to date on plans to achieve compliance and the progress made in executing those plans. They should also be apprised of the resources (including manpower and financial support) necessary to achieve compliance. 2) Verify that the medical equipment inventory is complete. It should include equipment regardless of ownership (such as loaners, leased, rentals, etc) and regardless of how it is serviced (in-house, contractor, vendor time, and materials). 3) Obtain manufacturer recommendations for maintenance frequencies and activities. Use inventory to create a list of unique manufacturer-model combinations and request that manufacturers provide recommendations for their models. Keep records of all communications attempts. You should also require vendors to provide manufacturer recommended maintenance frequencies and activities for all new acquisitions. In making requests for this documentation, consider citing excerpts from two standards that address the manufacturers obligation to provide documentation.
3 One is NFPA 99 (2012) Health Facilities Code. It states that the manufacturer of the appliance shall furnish documents containing at least a technical description, instructions for use, and a means of contacting the manufacturer, and that these documents shall include preventive and corrective maintenance and repair procedures. The second standard to cite is AAMI/ANSI ES :2005 (R) 2012, Medical Electrical Equipment Part 1: General Requirements for Basic Safety and Essential Performance. It states that equipment shall be accompanied by instructions for use and a technical description, and that instructions for use shall instruct the OPERATOR or RESPONSIBLE ORGANIZATION in sufficient detail concerning preventive maintenance, maintenance and calibration to be performed by them, including the frequency of such maintenance. 4) In the complete medical equipment inventory, have the ability to flag the following characteristics: Equipment that is considered critical or high-risk because knowledgeable hospital staff agree there is a risk of serious injury or death if the equipment should fail (CMS and TJC requirement). Equipment that is identified as AEM ineligible (that is, medical lasers and imaging and therapeutic radiology equipment). Equipment for which analysis by knowledgeable hospital staff has resulted in decision to apply an alternative equipment maintenance approach (CMS and TJC requirement) Whether manufacturers recommendations for maintenance activities and frequencies are on file (attach to the CMMS as a PDF file where possible). Source of service (in-house staff or vendor) and location of file with service staff credentials (or attach PDF with credentials where possible). 5) In corrective maintenance records, have the ability to categorize thedegree and type of equipment failure. The degree of failure may be categorized as either major, where equipment is hard down, or minor, where equipment remains operational and does not compromise safety. The goal is to be able to focus on operational failures or safety-related failures in service history. The types of failure are maintenance preventable, spontaneous, and use- orprocess-related. Maintenance preventable or wear and tear failure is the result of gradual degradation of one or more components over a period of time that may be detected by regular testing or prevented by recalibration or prophylactic replacement of parts. Spontaneous failure is where no reasonable frequency of inspections, testing, or preventive maintenance could have predicted or prevented failure. Use- or process-related failure is the result of factors external to the equipment. In assigning the types of failure, the goal is to be able to focus on maintenance preventable failures in service history. 6) Establish policies and procedures that describe under what circumstances deviation from manufacturer-recommended maintenance is considered acceptable and how the risk assessment to
4 determine any such deviation is conducted. Identify the multidisciplinary team that will participate in judging the severity and frequency of equipment failures (that is, the basis of risk assessment). Typically, the team would include clinicians, clinical engineering, risk management specialists, safety officers, and others as appropriate. 7) Document sources of service histories used to conduct risk assessment. These sources could include in-house records, associations such as ECRI or AAMI, vendors, or other authorities. 8) Document the credentials of those participating in the risk assessment process leading to inclusion of equipment in an AEM program, such as degrees, certifications, and training certificates. 9) Include language in service contracts that requires vendors to follow manufacturer-recommended frequencies and activities for medical equipment, or, if applicable, to follow the AEM program; to document all service performed (according to the organization s own service documentation requirements); and to demonstrate the qualifications of vendor staff providing service. 10) Finally, assign responsibility for monitoring compliance with CMS requirements and TJC standards regardless of service source, and document the credentials of the responsible party. The Experience of One Healthcare System To understand some of the challenges posed by compliance with these new requirements, it is useful to look at how one healthcare system is preparing itself to address the requirements and the issues arising from its efforts. Care New England (CNE) is a group of four hospitals and other affiliates located in and around Providence, Rhode Island. Healthcare technology management services at CNE are provided through the organization s resident clinical engineering department, which is operated under contract byabm Healthcare Support Services. Clinical engineering supports a combined inventory of 13,500 medical devices using a resident staff of 11 clinical engineers and biomedical engineering technicians, as well as a number of managed service contracts. The Compliance Process. The CNE clinical engineering department began its compliance process by preparing and making presentations to the Environment of Care and Safety Committees at each hospital. These presentations were designed to inform key stakeholders on those committees of the new requirements and the implications for their hospital, and to outline a plan to meet those requirements. Stakeholders were afforded the opportunity to make suggestions that would make the plan and its implementation most effective. Clinical engineering also informed senior leadership at each hospital of the requirements, the plan for addressing the requirements, and the resources that would be needed to achieve the plan. Clinical engineering staff members and key vendors were also informed of the new requirements and plan and of their expected role in its implementation. Inventory Management. Early in the plan s execution, clinical engineering recognized that the medical equipment inventory was going to increase significantly. Before the new rules, hospitals were
5 able to establish and follow a process that permitted the removal of low-risk equipment from their inventories. Because the new requirements mandate tracking of all medical equipment, clinical engineering had to enlist the help of various stakeholders and committees to identify the equipment not previously tracked. One of the challenges of inventorying and tracking groups of equipment (particularly, small items like regulators/flowmeters) involved tracking them by device type and location rather than by specific asset or serial numbers. This group approach helped avoid the burden of having to track equipment in excessive detail while still satisfying the new requirements. Another challenge involved departments like central processing (CPD), which clinical engineering identified as having maintained an inventory of the medical equipment those departments processed. The new rules don t require the use of one common inventory, but only that all inventories be available in one location, on demand. As a result, clinical engineering was able to work with CPD and other departments to ensure that they continued to maintain an adequate inventory and could provide that inventory to clinical engineering as needed. Rounding by clinical engineering staff helps to ensure proper inventories are being maintained in these departments and also to detect medical equipment that may have been previously undetected. As a complete picture of the entire inventory emerged, clinical engineering identified and flagged all equipment categories it considered high-risk/critical with a user-defined field. After clinical engineering made the initial identification, the appropriate safety or environment of care committee was asked to verify the classification and their decision was documented. Manufacturers Maintenance Recommendations. Another challenge clinical engineering has encountered is obtaining manufacturers maintenance recommendations for all medical equipment. Under the new requirements, having documentation of these recommendations is necessary to ensure that staff and vendors are either following those recommendations or deviating from them appropriately (that is, following established AEM program guidelines). Fortunately, clinical engineering already had manufacturers maintenance recommendations for most of the most critical equipment. Where the department did not have the recommendations or had conflicting versions of them obtaining them from manufacturers has proven to be a labor-intensive and slow process. In some cases, manufacturers consider the documentation proprietary, withholding it unless the organization is willing to pay for the documentation and the required training. The department contacts manufacturers with a form letter requesting their recommendations for each model in their list. Priority is being given first to manufacturers and models serviced in-house by clinical engineering staff, and will eventually extend to those under service contract by the manufacturers themselves.
6 Also, all purchase orders for new equipment now include the request for manufacturers maintenance recommendations. All new service contracts require the vendor to provide work orders verifying that their maintenance complies with manufacturers recommendations or with clinical engineering s AEM approach, if that is an option. The department documents all its communications with manufacturers to demonstrate its efforts. Alternate Equipment Maintenance. Without the option of adopting an AEM approach, clinical engineering would be forced by the new requirements to follow manufacturers maintenance recommendations on all of the hospitals medical equipment. The overall support cost and number of clinical engineering staff necessary would likely have to double as a result. To apply an AEM approach to some number of medical equipment categories on the inventory, clinical engineering was able to analyze a multiyear service history for all of its medical equipment categories from a database provided by the its clinical engineering contractor. Analysis of the service history revealed that about 60% of the medical equipment on the inventory would experience no compromise in safety if clinical engineering followed an AEM approach. For the remaining 40% of the inventory, manufacturers recommendations would be followed either because the service history could not justify the AEM approach or because the particular equipment category was ineligible for the AEM. Once it was determined that an equipment category qualified for the AEM approach, clinical engineering had to update appropriate maintenance activities and schedules for those categories, making sure to reference manufacturers recommendations as a baseline, and then to apply industry best practices and clinical engineering s own experience. To ensure that medical equipment maintenance is sufficiently effective in minimizing maintenancerelated (wear and tear) failures, clinical engineering updated the failure cause codes in its work order system to call out these types of failures and to distinguish them from spontaneous failures (those where no scheduled maintenance could have realistically prevented the failure) or use- or processrelated failures. The ability to call out maintenance-related failures is extremely helpful in evaluating the real effect of the medical equipment maintenance program. There are many other elements involved in implementing a compliance plan to meet the new requirements. This partial list of steps taken by CNE and its clinical engineering services illustrates some of the issues associated with the more significant steps. Other issues are important too, including the significant rewriting required for the medical equipment management plan and related medical equipment policies and procedures. Conclusion These new requirements and standards will require a substantial expenditure of resources on the part of healthcare organizations and their healthcare technology management and clinical engineering programs in order to achieve any significant level of compliance. However challenging, these requirements are the new reality and are in effect now. While compliance will take time, healthcare
7 organizations need to ensure that they fully understand the requirements, have a plan for achieving compliance, and can demonstrate that they are making a good-faith effort in executing that plan. Stephen L Grimes, FACCE, FAIMBE, FHIMSS, is chief technology officer for ABM Healthcare Support Services, Boston, Mass. Jillyan Morano, BSE, MHA, is director of clinical engineering services for Care New England, Providence, RI. For more information, contact editorial director John Bethune at jbethune@allied360.com. References 1. Centers for Medicare & Medicaid Services. Hospital equipment maintenance requirements. S&C: Hospital. December 20, Available at: Certification/SurveyCertificationGenInfo/Downloads/Survey-and-Cert-Letter pdf. Accessed February 18, ANSI/AAMI EQ56:2013. Recommended practice for a medical equipment management program. 3. The Joint Commission. Revised Requirements for the Environment of Care (EC) Chapter. Available at: 4.pdf. Accessed February 18,
How the Industry Must Take in Stride New CMS and TJC Requirements
Two Steps Forward, One Step Back How the Industry Must Take in Stride New CMS and TJC Requirements Stephen L. Grimes About the Author Stephen L. Grimes, FACCE, FHIMSS, FAIMBE, is chief technology officer
More informationMedical Equipment Management. Medical Equipment Management Activities (EC and EC )
Medical Equipment Management Plan 2017 I. Introduction, Mission Statement, and Scope The Medical Equipment Management Plan defines the mechanisms for interaction and oversight of the medical equipment
More information1 What is an AAAHC/Medicare Deemed Status survey? 2 What are the Medicare Conditions for Coverage (CfC)?
FREQUENTLY ASKED QUESTIONS ABOUT MEDICARE DEEMED STATUS SURVEYS 1 What is an AAAHC/Medicare Deemed Status survey? The Centers for Medicare and Medicaid Services (CMS) accepts AAAHC s recommendation for
More informationEQUIPMENT MANAGEMENT MEDICAL EQUIPMENT: EC , EC UTILITY SYSTEMS: EC , EC
EQUIPMENT MANAGEMENT MEDICAL EQUIPMENT: EC.02.04.01, EC.02.04.03 UTILITY SYSTEMS: EC.02.05.01, EC.02.05.05 ONLY APPLIES TO HOSPITAL & CAH PROGRAMS George Mills, Director Engineering Department The Joint
More informationProposed CMS Requirements to Follow OEM Guideline for Medical Equipment Maintenance
Proposed CMS Requirements to Follow OEM Guideline for Medical Equipment Maintenance Stephen L Grimes, FACCE FHIMSS FAIMBE Chief Technology Officer ABM Health Stephen.Grimes@ABM.com New England Society
More informationAdministrative Policies and Procedures. Policy No.: N/A Title: Medical Equipment Management Plan
Administrative Policies and Procedures Originating Venue: Environment of Care Title: Medical Equipment Management Plan Cross Reference: Date Issued: 11/14 Date Reviewed: Date: Revised: Attachment: Page
More informationQA offers significant economic benefits!
and Safety Systems in the USA J. Tobey Clark, MSEE, CCE, SASHE University of Vermont, USA Definitions Quality assurance Planned and systematic actions that can be demonstrated to provide confidence that
More informationNew Maintenance Requirements from CMS. Intermountain Clinical Instrumentation Society
New Maintenance Requirements from CMS Conditions of Participation (COPs) Interpretive Guidelines State Operations Manual 482.41(c)(2): Buildings Facilities, supplies, and equipment must be maintained to
More informationExcerpts of the Code of Federal Regulations Referenced in Proposed Rule CMS 1403 P
Excerpts of the Code of Federal Regulations Referenced in Proposed Rule CMS 1403 P The document below reflects the sections of the regulations currently in effect for Independent Diagnostic Testing Facilities
More informationTHE HEALTHCARE ENVIRONMENT
2015 THE HEALTHCARE ENVIRONMENT Anne M. Guglielmo, Engineer Department of Engineering The Joint Commission 2013/2014 CHALLENGING STANDARDS THE TOP 20 ISSUES Department of Engineering 2014-2 TOP SCORED
More information(9) Efforts to enact protections for kidney dialysis patients in California have been stymied in Sacramento by the dialysis corporations, which spent
This initiative measure is submitted to the people in accordance with the provisions of Article II, Section 8, of the California Constitution. This initiative measure amends and adds sections to the Health
More informationConflict of Interest Disclosure. Telemedicine: Credentialing And Best Practices. Learning Objectives. Learning Objectives. Telehealth.
Conflict of Interest Disclosure Telemedicine: Credentialing And s Catherine M. Ballard Partner Bricker & Eckler LLP 614-227-8806/cballard@bricker.com Use the following statement or disclose any relationships
More informationTrends in Nursing Facility Standard Health Survey Citations
Trends in Nursing Facility Standard Health Survey Citations Prepared by Research Department American Health Care Association March 2015 Trends in Nursing Facilities Standard Health Survey Citations TABLE
More informationMedicare Home Health Prospective Payment System
Medicare Home Health Prospective Payment System Payment Rule Brief Final Rule Program Year: CY 2013 Overview On November 8, 2012, the Centers for Medicare and Medicaid Services (CMS) officially released
More informationTexas Tech University Health Sciences Center El Paso
Texas Tech University Health Sciences Center El Paso Medical Equipment Management Plan Medical Equipment Management Plan Contents I. Objective and Purpose II. III. IV. Selection and Acquisition Equipment
More informationPart 3. Condition of medical equipment
Part 3 Condition of medical equipment 27 INTRODUCTION 3.1 As medical equipment assets have to be replaced or upgraded at some point in time, it is important to identify the life expectancy of each item
More informationAEM Program Guide. Matthew F. Baretich, P.E., Ph.D. Baretich Engineering, Inc. Fort Collins, Colorado. Acknowledgements
AEM Program Guide Matthew F. Baretich, P.E., Ph.D. Baretich Engineering, Inc. Fort Collins, Colorado Acknowledgements This document has benefited immensely from comments and contributions by these reviewers:
More informationHospice Program Integrity Recommendations
Hospice Program Integrity Recommendations Projected increases in the elderly population and the number of Medicare beneficiaries will likely result in continued growth in utilization of hospice services.
More information2012 Medical Staff Update 2011 CHALLENGING STANDARDS/NPSGS
2012 Medical Staff Update Laurel McCourt, M.D. TJC Surveyor: Hospital and Office-Based Surgery Programs, and Special Survey Unit 2011 CHALLENGING STANDARDS/NPSGS 2 Standard/NPSG 2010 Non Compliance 3 2011
More information2014 Medical Staff Update
John Herringer, Associate Director Standards Interpretation Group The Joint Commission 2013 Most Frequently Scored Medical Staff Standards and EPs 2 MS.01.01.01 EP 3 13.01% Scored when any element of performance
More informationGuidelines & Standards. The American Association for Respiratory Care Ables Lane Dallas, Texas 75229
Guidelines & Standards The American Association for Respiratory Care 11030 Ables Lane Dallas, Texas 75229 / Administrative Standards for Respiratory Care Services and Personnel An Official Statement from
More informationEP Review Project: The Joint Commission Deletes 225 Hospital Requirements
PR Review Project: The Joint Commission Deletes 225 Hospital Requirements Project REFRESH (see related articles on pages 1 and 3) includes a project first announced in the December 2015 Perspectives: the
More informationRULES OF ALABAMA STATE BOARD OF HEALTH ALABAMA DEPARTMENT OF PUBLIC HEALTH CHAPTER FREESTANDING EMERGENCY DEPARTMENTS
RULES OF ALABAMA STATE BOARD OF HEALTH ALABAMA DEPARTMENT OF PUBLIC HEALTH CHAPTER 420-5-9 FREESTANDING EMERGENCY DEPARTMENTS EFFECTIVE August 26, 2013 STATE OF ALABAMA DEPARTMENT OF PUBLIC HEALTH MONTGOMERY,
More informationATTACHMENT I. Outpatient Status: Solicitation of Public Comments
ATTACHMENT I The following text is a copy of the Federation of American Hospitals ( FAH ) comments in response to the solicitation of public comments on outpatient status that was contained in CMS-1589-P;
More informationMISSOURI TELEHEALTH NETWORK TRAINING CONFERENCE January 31, 2018 CENTER FOR CONNECTED HEALTH POLICY POLICY DISCLAIMERS
LEGAL & REGULATORY ISSUES TO CONSIDER IN A TELE PROGRAM MISSOURI TELE NETWORK TRAINING CONFERENCE January 31, 2018 877-707-7172 cchpca.org Mei Wa Kwong, JD DISCLAIMERS Any information provided in today
More informationPre-Audit Adaptation: Ensuring Daily Joint Commission Compliance
White Paper Pre-Audit Adaptation: Ensuring Daily Joint Commission Compliance As The Joint Commission (TJC) and other Accreditation Organizations continually increases accountability measures for accredited
More informationIMAGES & ASSOCIATES O UR S ERVICES OPERATIONAL REVIEW AND ENHANCEMENT
O UR S ERVICES OPERATIONAL REVIEW AND ENHANCEMENT The Prospective Payment System (PPS) for Inpatient Rehabilitation Facilities creates both opportunities and challenges for facilities that provide comprehensive
More informationConsulted With Individual/Body Date Medical Devices Group August 2014
Medical Equipment Policy - Safe Use Of Medical Equipment Developed in response to: Contributes to Care Quality Commission Regulation Policy Registration No. 04066 Status: Public MHRA Guidance Regulation
More informationHealth Care Alert. Proposed Rules Seek to Offer Hospitals Clarity and Flexibility. Physician Supervision of Outpatient Services.
July 23, 2009 Authors: Mary Beth F. Johnston marybeth.johnston@klgates.com +1.919.466.1181 Kelly D. Furr kelly.furr@klgates.com +1.919.466.1240 Katharine L. Schaeffer kathy.schaeffer@klgates.com +1.919.466.1114
More informationNIAHO ACCREDITATION PROGRAM FREQUENTLY ASKED QUESTIONS FEBRUARY 10, 2009
DNV HEALTHCARE INC 16340 Park Ten Pl., Suite 100, Houston, Texas 77084 (281) 721-6869 463 Ohio Pike, Suite 203, Cincinnati, Ohio 45255 (513) 947-8343 Who is DNV Healthcare Inc? NIAHO ACCREDITATION PROGRAM
More informationDNV. Established in 1864
DNV Established in 1864 Independent, self supporting Foundation Tax paying entity (in every country it operates) 300 Offices in 100 Countries 9000 Employees (locally employed) Operating in the U.S. since
More informationAgency for Health Care Administration
Page 1 of 50 FED - J0000 - INITIAL COMMENTS Title INITIAL COMMENTS CFR Type Memo Tag FED - J0003 - COMPLIANCE WITH FED,STATE,& LOCAL LAWS Title COMPLIANCE WITH FED,STATE,& LOCAL LAWS CFR 491.4 Type Condition
More informationHCCA South Central Regional Annual Conference November 21, 2014 Nashville, TN. Post Acute Provider Specific Sections from OIG Work Plans
HCCA South Central Regional Annual Conference November 21, 2014 Nashville, TN Kelly Priegnitz # Chris Puri # Kim Looney Post Acute Provider Specific Sections from 2012-2015 OIG Work Plans I. NURSING HOMES
More informationMedicare and Medicaid Program; Application from DNV GL Healthcare (DNV. GL) for Continued Approval of its Hospital Accreditation Program
This document is scheduled to be published in the Federal Register on 04/17/2018 and available online at https://federalregister.gov/d/2018-07982, and on FDsys.gov [Billing Code: 4120-01-P] DEPARTMENT
More informationSurvey Readiness: Balancing Joint Commission and. and CMS requirements
Survey Readiness: Balancing Joint Commission and CMS requirements Understanding and appreciating the similarities and the differences Kurt A. Patton, MS, RPH President, Patton Healthcare Consulting LLC
More informationON JANUARY 27, 2015, THE TEXAS WORKFORCE COMMISSION ADOPTED THE BELOW RULES WITH PREAMBLE TO BE SUBMITTED TO THE TEXAS REGISTER.
CHAPTER 809. CHILD CARE SERVICES ADOPTED RULES WITH PREAMBLE TO BE SUBMITTED TO THE TEXAS REGISTER. THIS DOCUMENT WILL HAVE NO SUBSTANTIVE CHANGES BUT IS SUBJECT TO FORMATTING CHANGES AS REQUIRED BY THE
More informationCITY OF MORRISTOWN RADIO CENTER DISTRICT. Façade Improvement Grant Program Guidelines FY
CITY OF MORRISTOWN RADIO CENTER DISTRICT Façade Improvement Grant Program Guidelines FY 2017-2018 About the Grant The Façade Improvement Grant Program seeks to encourage business owners and tenants to
More informationOverview of Key Policies and CMS Statements of Intent Regarding the Medicaid State Plan HCBS Benefits and HCBS Waiver Final Rule
January 16, 2014 Overview of Key Policies and CMS Statements of Intent Regarding the Medicaid State Plan HCBS Benefits and HCBS Waiver Final Rule On January 10, 2014, the Centers for Medicare and Medicaid
More informationGuidelines for the Virginia Investment Partnership Grant Program
Guidelines for the Virginia Investment Partnership Grant Program Purpose: The Virginia Investment Partnership Grant Program ( VIP ) is used to encourage existing Virginia manufacturers or research and
More informationAdministrative Policies and Procedures
Administrative Policies and Procedures Originating Venue: Environment of Care Policy No.: EC 2007 Title: Environment of Care Management Program Cross Reference: EC 2001 Date Issued: 04/14 Authority Environmental
More informationASHE Resource: Implications of the CMS emergency preparedness rule
CMS EMERGENCY PREPAREDNESS RULE TEXT 482.15 Condition of participation: Emergency preparedness. The hospital must comply with all applicable Federal, State, and local emergency preparedness requirements.
More informationCMS Issues Final Rules on Hospital Medical Staff Conditions of Participation
CMS Issues Final Rules on Hospital Medical Staff Conditions of Participation In early 2013, NAMSS provided comment to the Centers for Medicare & Medicaid Services (CMS) proposals to the Medical Staff Conditions
More informationIs clearly identified which type of inspections should be carried out:
3. PLANNED INSPECTIONS (75) 3.1. Inspection Guidelines (20) 3.1.1. Is clearly identified which type of inspections should be carried out: general (housekeeping inspections)? (1) middle and senior management
More informationTESTIMONY OF THOMAS HAMILTON DIRECTOR SURVEY & CERTIFICATION GROUP CENTER FOR MEDICAID AND STATE OPERATIONS CENTERS FOR MEDICARE & MEDICAID SERVICES
TESTIMONY OF THOMAS HAMILTON DIRECTOR SURVEY & CERTIFICATION GROUP CENTER FOR MEDICAID AND STATE OPERATIONS CENTERS FOR MEDICARE & MEDICAID SERVICES ON CLIA AND GENETIC TESTING BEFORE THE SENATE SPECIAL
More informationPresenting a live 90-minute webinar with interactive Q&A. Today s faculty features:
Presenting a live 90-minute webinar with interactive Q&A Telemedicine Credentialing and Privileging: Complying With the New CMS Rule Protecting Patient Privacy, Avoiding Fraud and Abuse Liability, Ensuring
More informationNational Council on Disability
An independent federal agency making recommendations to the President and Congress to enhance the quality of life for all Americans with disabilities and their families. Analysis and Recommendations for
More informationSafe Transitions Best Practice Measures for
Safe Transitions Best Practice Measures for Nursing Homes Setting-specific process measures focused on cross-setting communication and patient activation, supporting safe patient care across the continuum
More informationMajor Science Initiatives Fund competition Call for Proposals
Major Science Initiatives Fund competition 2017 2022 Call for Proposals October 2015 CONTENTS COMPETITION DESCRIPTION... 4 Background... 4 Objectives... 4 National research facility definition... 4 Competition
More informationEducational Innovation Brief: Educating Graduate Nursing Students on Value Based Purchasing
Rhode Island College Digital Commons @ RIC Master's Theses, Dissertations, Graduate Research and Major Papers Overview Master's Theses, Dissertations, Graduate Research and Major Papers 1-1-2014 Educational
More informationAccountable Care Organizations. What the Nurse Executive Needs to Know. Rebecca F. Cady, Esq., RNC, BSN, JD, CPHRM
JONA S Healthcare Law, Ethics, and Regulation / Volume 13, Number 2 / Copyright B 2011 Wolters Kluwer Health Lippincott Williams & Wilkins Accountable Care Organizations What the Nurse Executive Needs
More informationHospital-Based Ambulatory Care
C H A P T E R 2 Hospital-Based Ambulatory Care ANSWERS TO KNOWLEDGE-BASED QUESTIONS 1. What has been the trend in the utilization of hospital-based services? What factors help to account for this trend?
More information5/1/2017 THE BEST DEFENSE IS A GOOD OFFENSE OBJECTIVES. Preparing for a Home Health Medicare Recertification Survey
THE BEST DEFENSE IS A GOOD OFFENSE Preparing for a Home Health Medicare Recertification Survey OBJECTIVES To gain an understanding how the Medicare Conditions of Participation (CoPs), the individual G-tags,
More informationStatement of Guidance: Outsourcing Regulated Entities
Statement of Guidance: Outsourcing Regulated Entities 1. STATEMENT OF OBJECTIVES 1.1 This Statement of Guidance ( Guidance ) is intended to provide guidance to regulated entities on the establishment of
More informationTable 1. Cost Share Criteria
Under U.S. Government (USG) funding, cost share refers to the resources an organization contributes to the total cost of a USG grant that is not included as part of the grant. Cost share becomes a condition
More informationMONITORING HEALTH CARE INDUSTRY REPRESENTATIVES EXPOSED TO IONIZING RADIATION
MONITORING HEALTH CARE INDUSTRY REPRESENTATIVES EXPOSED TO IONIZING RADIATION NVLAP Accredited Organization Position paper with data analysis from Chris Passmore, CHP and Mirela Kirr In this white paper,
More informationIMPORTANT NOTICE PLEASE READ CAREFULLY SENT VIA FEDEX AND INTERNET (Receipt of this notice is presumed to be May 7, 2018 date notice ed)
Department of Health & Human Services Centers for Medicare & Medicaid Services 61 Forsyth Street, SW, Suite 4T20 Atlanta, Georgia 30303-8909 ` Refer to: 34-5529.NOTC.G.05.07.18.docx IMPORTANT NOTICE PLEASE
More informationThe Impact of Health Care Reform on Long- Term Care
The Impact of Health Care Reform on Long- Term Care AMY RUNGE, CPA Moss Adams LLP Partner & National Practice Leader, Long-Term Care MARCY BOYD, CPA Moss Adams LLP Partner September 22, 2014 1 The material
More informationGUIDELINES FOR CRITERIA AND CERTIFICATION RULES ANNEX - JAWDA Data Certification for Healthcare Providers - Methodology 2017.
GUIDELINES FOR CRITERIA AND CERTIFICATION RULES ANNEX - JAWDA Data Certification for Healthcare Providers - Methodology 2017 December 2016 Page 1 of 14 1. Contents 1. Contents 2 2. General 3 3. Certification
More informationGuidelines for the Major Eligible Employer Grant Program
Guidelines for the Major Eligible Employer Grant Program Purpose: The Major Eligible Employer Grant Program ( MEE ) is used to encourage major basic employers to invest in Virginia and to provide a significant
More informationEffective Date: January 9, 2017
Effective Date: January 9, 2017 Overview: The safety and quality of care, treatment, and services depend on many factors, including the following: - A culture that fosters safety as a priority for everyone
More informationPatient Blood Management Certification Program. Review Process Guide. For Organizations
Patient Blood Management Certification Program Review Process Guide For Organizations 2018 What's New in 2018 Updates effective in 2018 are identified by underlined text in the activities noted below.
More informationHow to Submit Waivers and Equivalencies
How to Submit Waivers and Equivalencies Tuesday, August 7, 2018 Presented by: Alise Howlett, Assoc. AIA, CFPE, CHFM Standards Advisor, EM/PE/LS HFAP A better healthcare survey experience 1 What We Will
More informationDEPARTMENT OF VETERANS AFFAIRS SUMMARY: This document implements a portion of the Veterans Benefits,
This document is scheduled to be published in the Federal Register on 02/21/2017 and available online at https://federalregister.gov/d/2017-03331, and on FDsys.gov DEPARTMENT OF VETERANS AFFAIRS 8320-01
More informationCenter for Medicaid, CHIP, and Survey & Certification/Survey & Certification Group
DEPARTMENT OF HEALTH & HUMAN SERVICES Centers for Medicare & Medicaid Services 7500 Security Boulevard, Mail Stop 02-02-38 Baltimore, Maryland 21244-1850 Center for Medicaid, CHIP, and Survey & Certification/Survey
More informationHEALTHCARE TECHNOLOGY MANAGEMENT (HTM) Tackling Your Top Challenges
HEALTHCARE TECHNOLOGY MANAGEMENT (HTM) Tackling Your Top Challenges Are you maximizing the talents of your HTM team? Discover and utilize their abilities for the benefit of your organization: 1. Make sure
More information2016 Medical Staff Standards Update Panel Featuring TJC, NCQA, URAC, DNV, and HFAP (Part 1) THE JOINT COMMISSION. Objectives
2016 Medical Staff Standards Update Panel Featuring TJC, NCQA, URAC, DNV, and HFAP (Part 1) Paul Ziaya, MD, Veronica C. Locke, MHSA, Donna Merrick, BNS, MEd, Patrick Horine, MHA, and Karen Beem, MS, RN
More informationNORWICH UNIVERSITY TELECOMMUTING POLICY Reviewed and approved on April 30, 2012 OBJECTIVE
NORWICH UNIVERSITY TELECOMMUTING POLICY Reviewed and approved on April 30, 2012 OBJECTIVE This policy is to establish procedures, eligibility requirements, criteria, and responsibilities for approving
More informationLegal Implications Recommended Practices
Legal Implications of Standards and Recommended Practices for CS Departments by Rose Seavey, MBA, BS, RN, CNOR, CRCST, CSPDT Learning Objectives 1. describe applicable terms and how they apply to the CS
More informationNORTHWESTERN UNIVERSITY PROJECT NAME JOB # ISSUED: 03/29/2017
SECTION 26 0800 - COMMISSIONING OF ELECTRICAL SYSTEMS PART 1 - GENERAL 1.1 SUMMARY A. The purpose of this section is to specify the Division 26 responsibilities and participation in the commissioning process.
More informationChapter 02 Hospital Based Care
Chapter 02 Hospital Based Care MULTICHOICE 1. The physician sends the patient to the hospital for a radiological examination. The patient returns to the physician's office for follow-up of test results.
More informationIMPORTANT NOTICE PLEASE READ CAREFULLY SENT VIA FEDEX AND INTERNET
Department of Health & Human Services Centers for Medicare & Medicaid Services 61 Forsyth Street, SW, Suite 4T20 Atlanta, Georgia 30303-8909 Refer to: 5213.abIJ.06.27.18. docx ` June 27, 2018 IMPORTANT
More informationSterile Processing: Preparing for Accreditation Surveys. Monday, March 4, 2013, 8-9am & 9:30-10:30am
SESSION TITLE: SPEAKER NAME: SESSION NUMBER: DATE/TIME: CONTACT HOURS: Sterile Processing: Preparing for Accreditation Surveys Rose E. Seavey, MBA, BS, RN, CNOR, CRCST 9015 & 9106R Monday, March 4, 2013,
More informationUNITED STATES OF AMERICA BEFORE THE FEDERAL ENERGY REGULATORY COMMISSION ) ) )
UNITED STATES OF AMERICA BEFORE THE FEDERAL ENERGY REGULATORY COMMISSION Coordination of Protection Systems for Performance During Faults and Specific Training for Personnel Reliability Standards ) ) )
More informationIs your Home Health Agency ready for the Final Rule to the Conditions of Participation?
Is your Home Health Agency ready for the Final Rule to the Conditions of Participation? Medicare-certified home health agencies have almost doubled from 6,461 in 1990 to 12,268 in 2014 due to longer life
More informationSAN JOAQUIN VALLEY UNIFIED AIR POLLUTION CONTROL DISTRICT COMPLIANCE DEPARTMENT COM 2035
SAN JOAQUIN VALLEY UNIFIED AIR POLLUTION CONTROL DISTRICT COMPLIANCE DEPARTMENT COM 2035 APPROVED: DATE: January 23, 2013 Morgan Lambert Director of Compliance TITLE: SUBJECT: RULE 1100 EQUIPMENT BREAKDOWN
More informationJurisdiction Nebraska. Retirement Date N/A
If you wish to save the PDF, please ensure that you change the file extension to.pdf (from.ashx). Local Coverage Determination (LCD): Independent Diagnostic Testing Facilities (IDTFs) (L31626) Contractor
More informationMAC J-15 Cardiac & Pulmonary Probe Audit / Ohio & Kentucky (March 2012) J. Rosneck MAC 15 Chairperson
Greetings All, MAC J-15 Cardiac & Pulmonary Probe Audit / Ohio & Kentucky (March 2012) I discovered late last week from the AACVPR, prior to presenting at the Kentucky state meeting, that the RAC probe
More informationMEDICAID ENROLLMENT PACKET
MEDICAID ENROLLMENT PACKET Follow the steps below. This will prevent errors which will delay enrollment. Physicians Only: 1. Answer the one page questionnaire 2. SIGN EACH FORM where it indicates Signature
More informationQuality Assessment and Assurance. Guidance Training (F520) (o)
Quality Assessment and Assurance Guidance Training (F520) 483.75(o) 2006 1 Today s Agenda! Regulation! Interpretive Guidelines! Investigative Protocol! Determination of Compliance! Deficiency Categorization
More informationINTRODUCTION TO Mobile Diagnostic Imaging. A quick-start guide designed to help you learn the basics of mobile diagnostic imaging
INTRODUCTION TO Mobile Diagnostic Imaging A quick-start guide designed to help you learn the basics of mobile diagnostic imaging INTRODUCTION TO Mobile Diagnostic Imaging TABLE OF CONTENTS How does mobile
More information1. What are some of the changes that have affected hospitals during the twentieth and. The emergence of health maintenance organizations
1. What are some of the changes that have affected hospitals during the twentieth and twenty-first centuries? Increases in hospital costs Medicare, Medicaid, and CHIP The emergence of health maintenance
More information12/02/2016. It's Survey Time! Preparing for TJC or CMS Accreditation Survey. Welcome! House Keeping. From the GoToWebinar page:
SM 3M Health Care Academy It's Survey Time! Preparing for TJC or CMS Accreditation Survey February 18, 2016 Welcome! Topic: It's Survey Time! Preparing for TJC or CMS Accreditation Survey Facilitators:
More informationReimbursement Information for Contrast Enhanced Spectral Mammography (CESM) Services 1
GE Healthcare Reimbursement Information for Contrast Enhanced Spectral Mammography (CESM) Services 1 May 2018 www.gehealthcare.com/reimbursement This advisory addresses Medicare coding, coverage and payment
More informationGAO DEFENSE CONTRACTING. Improved Policies and Tools Could Help Increase Competition on DOD s National Security Exception Procurements
GAO United States Government Accountability Office Report to Congressional Committees January 2012 DEFENSE CONTRACTING Improved Policies and Tools Could Help Increase Competition on DOD s National Security
More informationRhode Island. Phone. Web Site. Licensure Term
Rhode Island Phone Agency Department of Health, Center for Health Facility Regulation (401) 222-2566 Contact Jennifer Olsen-Armstrong (401) 222-4523 E-mail Jennifer.Olsen@health.ri.gov Web Site http://health.ri.gov/licenses/detail.php?id=213
More informationDNV GL - HEALTHCARE ACCREDITATION PROGRAM FREQUENTLY ASKED QUESTIONS
DNV GL - HEALTHCARE ACCREDITATION PROGRAM FREQUENTLY ASKED QUESTIONS Who is DNV GL - Healthcare? DNV GL - Healthcare is an operating company of DNV GL Business Assurance and The DNV GL Group. DNV GL -
More informationDraft Version Presentation Draft
EMERGENCY VEHICLE TECHNICIAN I CERTIFICATION TRAINING STANDARDS Draft 2011 Version 2.15.11 Presentation Draft Emergency Vehicle Technician I... 2 #1: The Role of the Emergency Vehicle Technician I... 2
More informationJune 2018 Phc newsletter
June 2018 Phc newsletter News from CMS and Joint Commission Inside This Issue: ü Perspectives Leadership Session Be Prepared for Changes SAFER Matrix Placement Under Review - # RFIs Still Important Not
More informationOHIO DEPARTMENT OF MENTAL RETARDATION AND DEVELOPMENTAL DISABILITIES NEW FUTURES WAIVER
OHIO DEPARTMENT OF MENTAL RETARDATION AND DEVELOPMENTAL DISABILITIES NEW FUTURES WAIVER CONCEPT PAPER SUBMITTED TO CMS Brief Waiver Description Ohio intends to create a 1915c Home and Community-Based Services
More informationWriting a shared instrumentation grant (successfully)
Writing a shared instrumentation grant (successfully) Ken Dunn, PhD Scientific Director Indiana Center for Biological Microscopy Indiana University Medical Center Shared Instrumentation Grant Program (S10)
More informationAdmissions and Readmissions Related to Adverse Events, NMCPHC-EDC-TR
Admissions and Readmissions Related to Adverse Events, 2007-2014 By Michael J. Hughes and Uzo Chukwuma December 2015 Approved for public release. Distribution is unlimited. The views expressed in this
More informationARIZONA JOB TRAINING PROGRAM PROGRAM RULES & GUIDELINES (RULES) 1
ARIZONA JOB TRAINING PROGRAM PROGRAM RULES & GUIDELINES (RULES) 1 Section 1. Overview The Arizona Job Training Program (Program), established pursuant to A.R.S. 41-1541 through 1544 and administered by
More informationPartnering with hospitals to create an accountable care organization Elias N. Matsakis, Esq.
Partnering with hospitals to create an accountable care organization Elias N. Matsakis, Esq. There are many opportunities for physicians and hospitals to affiliate and clinically integrate so as to enable
More informationBMC Clinical Research Policies and Procedures
BMC Clinical Research Policies and Procedures Presented by: Ellen N. Jamieson, MS, MBA Associate Director, Grants Administration Alexandria Hui Clinical Trial Financial Analyst Agenda Why New Policy?
More information2. Review the requirements necessary for grant agreement execution; and
1 This is the first in a series of five webinars designed to provide an overview for new CDBG grantees. The webinars will be held over the next three months, each one hour in length, and include: 1. Getting
More informationEVV Requirements in the 21 st Century Cures Act Pre-Conference Intensive
EVV Requirements in the 21 st Century Cures Act Pre-Conference Intensive Division of Long Term Services and Supports Disabled and Elderly Health Programs Group Center for Medicaid and CHIP Services August
More informationDNV ACCREDITATION PROGRAM FREQUENTLY ASKED QUESTIONS
DNV HEALTHCARE INC 1400 Ravello Drive Katy, Texas 77449 281-396-1000 400 Techne Center Drive, Suite 100, Milford, Ohio 45150 (513) 947-8343 Who is DNV Healthcare Inc? DNV ACCREDITATION PROGRAM FREQUENTLY
More informationCHAPTER 29 PHARMACY TECHNICIANS
CHAPTER 29 PHARMACY TECHNICIANS 29.1 HOSPITAL PHARMACY TECHNICIANS 1. Proper Identification as Pharmacy Technician 2. Policy and procedures regulating duties of technician and scope of responsibility 3.
More informationArizona Department of Health Services Licensing and CMS Deficient Practices
Arizona Department of Health Services Licensing and CMS Deficient Practices Connie Belden, RN., Bureau of Medical Facility Licensing August 8, 2013 General Comments Deficient Practices per visit Trend
More information340B Program Mgr Vice President, Finance SVP, Chief Audit, Ethics & Compliance Officer
340B Drug Purchasing Program Page 1 of 7 340B Drug Purchasing Program Policy & Procedure Number Policy Manual Ethics and Compliance Type Policy & Procedure Document Owner Effective Date Next Review Date
More information