HFAP Acute Care Hospital Manual Crosswalk of 2014 HFAP Standards against 2012 HFAP Standards
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1 CMS Condition of Participation: Patient Rights Not Applicable Patient Rights Not Applicable (a) (a)(1) Notice of Patient Rights (a)(2) Patient Grievances (a)(2) Governing Body Responsibility for the Grievance Process (a)(2) Timely Referrals (a)(2)(i) Grievance Process (a)(2)(ii) Grievance Process Response Timeframes (a)(2)(iii) Patient Notification of the Grievance Process Chapter 15 Patient Rights and Discharge Planning Page 1
2 CMS (b)(1) (b)(3) (b)(3) (b)(4) (c)(1) (c)(2) (c)(3) (d)(1) (d)(2) (e)(1) (b)(2) (h)(1)(2)(3)(4) Exercise of Patient s Rights (b)(1) Participation in the Plan of Care (b)(2) Participation in Decision Making (b)(3) Advance Directives Not Applicable Patient Self- Determination (Advance Directives) (b)(4) Admission Notification Not Applicable (c) (c)(1) Privacy & Safety: Personal Privacy (c)(2) Privacy & Safety: Safe Setting (c)(3) Privacy & Safety: Free From Abuse Chapter 15 Patient Rights and Discharge Planning Page 2
3 CMS Not Applicable Suspected Abuse / Neglect Patients Not Applicable (d) (d)(1) Confidentiality of Patient Records changed from "Confidentiality of Patient Records: Confidentiality of Medical Records" (d)(2) (e) Access to Medical Records Restraint or Seclusion Re-numbered Not Applicable (h) Visitation Rights (h)(1) (h)(2) Patient Visitation Rights Visitation Rights - Clinical Restrictions (h)(2) Visitation Rights - Patient Determination Incorporate into (h)(3) (h)(4) Visitation Rights - Discrimination (h)(4) Visitation Rights - Fair Application of Process Incorporate into (e) Restraint or Seclusion Chapter 15 Patient Rights and Discharge Planning Page 3
4 CMS (e)(1)(i)(A) (e)(1)(i)(B) Restraint Definitions Medication as a Restraint (e)(1)(i)(C) Non-Restraints (e)(1)(ii) (e)(2) Definition of Seclusion Least Restrictive Interventions Not Applicable (e)(3) Effective Restraints (e)(4) (e)(4)(i) Modification of the Plan of Care - Restraint or Seclusion (e)(4)(ii) Safe Application (e)(5) Orders for Restraint or Seclusion (e)(6) Use of Standing or PRN Orders (e)(7) Physician Notification of Restraint Use (e)(8)(i) Restraint Orders for Management of Violent Behavior (e)(8)(ii) Physician Assessment (e)(8)(iii) Renewal of Restraint Orders (e)(9) Discontinuation of Restraints Chapter 15 Patient Rights and Discharge Planning Page 4
5 CMS (e)(10) Monitoring of the Patient (e)(11) Physician (e)(12)(i) One Hour Face-to- Face (e)(12)(ii) Physician Assessment Requirements (e)(13) State Requirements (e)(14) Physician Notification (e)(15) Simultaneous Use of Restraint and Seclusion (e)(16)(i) Requirements for (e)(16)(ii) Requirements for (e)(16)(iii) Requirements for (e)(16)(iv) Requirements for (e)(16)(v) Requirements for Clarification (f) Staff Requirements - Use of Restraints or Seclusion (f)(1)(i) (f)(1)(ii) (f)(1)(iii) Intervals (f)(2)(i) Content Chapter 15 Patient Rights and Discharge Planning Page 5
6 CMS (f)(2)(ii) Requirements: Nonphysical Intervention (f)(2)(iii) Requirements: Least Restrictive Intervention (f)(2)(iv) (f)(2)(v) Requirements: Safe Application Requirements: Restraint Removal (f)(2)(vi) Requirements: Patient Monitoring (f)(2)(vii) (f)(3) (f)(4) Requirements: CPR Trainer Requirements Not Applicable Restraint Data (g)(1) (g)(1)(i)(ii)(iii) (g)(2) (g)(2)(i)(ii) (g)(3) (g)(4) (g)(4)(i)(ii)(iii) Death Related to Restraint or Seclusion - Reporting Requirements Condition of Participation: Discharge Planning Chapter 15 Patient Rights and Discharge Planning Page 6
7 CMS (a) Discharge Planning - Identification of Patients in Need (b) (b)(1) (b)(3) (b)(4) Discharge Planning Evaluation (b)(2) Discharge Planning - Staff Qualifications Not Applicable Not Applicable (b)(5) Timeliness of Assessment Incorporate into Incorporate into (b)(6) Patient Involvement & Requirements Not Applicable (c) (c)(1) Discharge Planning: Required Supervision (c)(2) Discharge Plan - Physician Request (c)(3) (c)(5) Implementation of the Discharge Plan (c)(4) Plan Reassessment Not Applicable Incorporate into Chapter 15 Patient Rights and Discharge Planning Page 7
8 CMS (c)(6) (c)(6)(i) (c)(6)(ii) (c)(6)(iii) (c)(7) (c)(8) Selection of Discharge Care Providers Not Applicable Not Applicable Not Applicable Not Applicable Not Applicable Not Applicable Not Applicable Not Applicable (d) (e) Transfer or Referral Discharge Plan Reassessment Not Applicable Incorporate into Discharge Instructions Discharge Checklist Chapter 15 Patient Rights and Discharge Planning Page 8
9 CMS Condition of Participation: Nursing Services Not Applicable Not Applicable Plan for Nursing Care Re-numbered (a) (b) Nursing Organization Staffing and Delivery of Care Staffing (b)(1) 24-Hour Provision of Services (b)(2) Licensure Not Applicable Not Applicable (b)(3) Supervision of Care (b)(4) Plan of Care (b)(5) Care Assignments Not Applicable (b)(6) Supervision of Nonemployee Staff Format Chapter 16 Nursing Department Page 9
10 CMS Not Applicable Not Applicable Not Applicable (c) (c)(1) (c)(1)(i) (c)(2) Preparation and Administration of Drugs Medication Administration Not Applicable Incorporated into (c)(1)(ii) (c)(3) (c)(3)(iii) Medication Orders (c)(3)(i) Verbal Orders (c)(3)(ii) Accepting Verbal Orders (c)(4) Administration of Blood Products and IV Medications (c)(5) Adverse Drug Reactions, Transfusion Reaction, & Medical Error Reporting Not Applicable Incorporated into Chapter 16 Nursing Department Page 10
11 CMS (c)(6) (c)(6)(i) (c)(6)(i)(A) (c)(6)(i)(B) (c)(6)(i)(C) (c)(6)(i)(D) (c)(6)(i)(E) Self-Administration of Medications: Hospital Issued Medications Incorporated (c)(6)(ii) (c)(6)(ii)(A) (c)(6)(ii)(B) (c)(6)(ii)(C) (c)(6)(ii)(D) (c)(6)(ii)(E) Self-Administration of Hospital Issued Medications: Medications Brought into the Hospital Incorporated into Not Applicable Re-numbered Not Applicable Assessment Patients at Risk Relocated to the new Chapter 33 Patient Safety Patient Safety Initiative List of Patient Problems Not Applicable Reassessements of Patients Standards of Practice & Care Standards of Practice Chapter 16 Nursing Department Page 11
12 CMS Clinical Practice Standards Standards Content Standards of Care Standards Availability Standards Review Nursing Quality Assessment Performance Improvement (QAPI) Use of QAPI Data Chapter 16 Nursing Department Page 12
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