On April 7th, CMS revised the State Operations Manual (SOM), Appendix W. This is the guidance state survey agencies and accrediting entities use when surveying CAHs for compliance with the Medicare Conditions of Participation. CMS also issued a transmittal detailing the changes. This revision reflects regulation changes finalized in 2014 and clarifies how survey agencies should assess CAHs’ compliance in these areas. The updates were originally issued on January 16thvia Survey & Certification Letter 15-19. Updates with significantly increased interpretive guidance include:
•Clarification of required MD/DO review of inpatient records when care is provided by non-physician practitioners (review not required for outpatient records unless by state law)
•Inpatient services must be commensurate with the level of other services. (e.g., a CAH with high ED and outpatient utilization but little to no inpatient admissions would be a red flag)
•Therapy services (PT, OT, & SLT) must be provided by staff qualified under state law
•Requirements to monitor patient access to specialty services not available at the CAH
•Expanded medication administration and safety standards
•Drug oversight and drug compounding
•Infection control, monitoring, and reporting of healthcare acquired infections
•Patient nutrition and dietary assessments
