| Every healthcare organization/hospital | | | | governed by §482.13(f)(l-3). The |
| accepting payment for Medicare and Medicaid | | | | individual may be the law enforcement |
| patients is required to meet certain Federal | | | | officer's prisoner but he/she is also the |
| standards called "Conditions of | | | | hospital's patient. The hospital is still |
| Participation" (CoPs). | | | | responsible for providing safe and |
| | | | appropriate care to their patient. The |
| These Federal requirements are promulgated by | | | | condition of the patient must be continually |
| the Centers for Medicare and Medicaid to | | | | assessed, monitored and reevaluate. |
| improve quality and protect the health and | | | | |
| safety of patients. Compliance is based on | | | | JCAHO - 2006 |
| surveys conducted by state agencies on behalf | | | | |
| of the CMS. Conditions of Participation are | | | | (Healthcare Security) |
| regulatory standards hospitals agree to | | | | |
| follow as a condition for receiving federal | | | | ____________________________________________ |
| funding through the Medicare program. | | | | |
| | | | The Joint Commission on Accreditation of |
| Under an agreement with CMS, State healthcare | | | | Healthcare Organizations evaluates and |
| licensure agencies conduct surveys of | | | | accredits more than 18,000 healthcare |
| hospitals and enforce compliance with CoPs | | | | organizations and programs throughout the |
| and ensure that Conditions of Participation | | | | United States. Hospitals aggressively seek |
| are being practiced. Hospitals and other | | | | Joint Commission accreditation to meet |
| healthcare facilities are subject to random | | | | Medicare certification and licensure |
| onsite reviews. Unannounced surveys can | | | | requirements. Accreditation is also a |
| result from patient or public complaints or | | | | condition of reimbursement for many insurers |
| inquiries. Healthcare Security is an | | | | and other payers. In addition, JCAHO |
| important element for the new 2006 Conditions | | | | Accreditation reduces the hospital's |
| of Participation. | | | | liability insurance premiums. Beginning in |
| | | | 2006 JCAHO will conduct all surveys without |
| CONDITIONS of PARTICIPATION | | | | prior notice. |
| | | | |
| Department of Health & Human Services | | | | The Joint Commission has accredited hospitals |
| | | | for more than 50 years and today accredits |
| Centers for Medicare & Medicaid Services | | | | over 80 percent of the nation's hospitals. |
| | | | The Centers for Medicaid & Medicare Services |
| (Healthcare Security) | | | | (CMS) have required JCAHO accreditation by US |
| | | | hospitals since 1965 as a 'Condition of |
| ____________________________________________ | | | | Participation' requirement in order for them |
| | | | to receive Medicaid and Medicare |
| A-0038 | | | | reimbursements. |
| | | | |
| Title 42CFR, Volume 3 - §482.13 Condition | | | | The Joint Commission and Healthcare Security |
| of Participation: Patients' Rights | | | | |
| | | | The Joint Commission's Standards address the |
| A hospital must protect and promote each | | | | hospital's performance in specific areas, and |
| patient's rights | | | | specify requirements to insure that patients |
| | | | are provided a safe and secure environment. |
| Interpretive Guidelines §482.13 | | | | 2006 Environment of Care© requirements |
| | | | include, but are not limited to the |
| These requirements apply to all Medicare or | | | | following: |
| Medicaid participating hospitals including | | | | |
| short-term, acute care, surgical, specialty, | | | | - Development and maintenance of a written |
| psychiatric, rehabilitation, long-term, | | | | Security Management Plan to include an |
| childrens' and cancer, whether or not they | | | | Emergency Management Plan. |
| are accredited. This rule does not apply to | | | | |
| critical access hospitals. (See Social | | | | - Conduct an annual Risk Assessment that |
| Security Act (the Act) §1861(e)). | | | | evaluates the potential adverse impact of the |
| | | | external environment on the security of |
| These requirements, as well as the other | | | | patients, staff, and others coming to the |
| Conditions of Participation in 42 CFR | | | | facility. |
| §482, apply to all parts and locations | | | | |
| (outpatient services, provider-based | | | | - Use the risks identified to select and |
| entities, inpatient services) of the Medicare | | | | implement procedures and controls to achieve |
| participating hospital. | | | | the lowest potential for adverse impact on |
| | | | security. |
| ____________________________________________ | | | | |
| | | | - Identify, as appropriate, patients, staff |
| A-0057 | | | | and other people entering the facility. |
| | | | |
| Title 42, Volume 3 CFR - §482.13(c)(2) The | | | | - Access Control / Physical Protection - |
| patient has the right to receive care in a | | | | control access to and egress from security |
| safe setting. | | | | sensitive areas, as determined by the |
| | | | organization. |
| Interpretive Guidelines for §482.13(c)(2) | | | | |
| | | | - Mitigate Violence in the Emergency |
| The intention of this requirement is to | | | | Department and other locations. |
| specify that each patient receives care in an | | | | |
| environment that a reasonable person would | | | | - Education and Training - staff, licensed |
| consider to be safe. For example, hospital | | | | practitioners, and volunteers have the |
| staff should follow current standards of | | | | knowledge and skills necessary to perform |
| practice for patient environmental safety, | | | | their responsibilities within the |
| infection control and security. The hospital | | | | environment. |
| must protect vulnerable patients, including | | | | |
| newborns and children. Additionally, this | | | | - Develop and implement a proactive infant |
| standard is intended to provide protection | | | | abduction prevention plan. |
| for the patient's emotional health and safety | | | | |
| as well as his/her physical safety. Respect, | | | | - Include information on visitor/provider |
| dignity and comfort would be components of an | | | | identification as well as identification of |
| emotionally safe environment. | | | | potential abductors/abduction situations |
| | | | (during staff orientation and in-service |
| Survey Procedures §482.13(c)(2) | | | | curriculum programs). |
| | | | |
| - Review and analyze patient and staff | | | | - Enhance parent education concerning |
| incident and accident reports to identify any | | | | abduction risks and parent responsibility for |
| incidents or patterns of incidents concerning | | | | reducing risk and then assess the parents' |
| a safe environment. Expand your review if you | | | | level of understanding. |
| suspect a problem with safe environment in | | | | |
| the hospitals. | | | | - Attach secure identically numbered bands to |
| | | | the baby (wrist and ankle bands), mother, and |
| - Review QAPI, safety, infection control and | | | | father or significant other immediately after |
| security (or the committee that deals with | | | | birth. |
| security issues) committee minutes and | | | | |
| reports to determine if the hospital is | | | | - Footprint the baby, take a color photograph |
| identifying problems, evaluating those | | | | of the baby and record the baby's physical |
| problems and taking steps to ensure a safe | | | | examination within two hours of birth. |
| patient environment. | | | | |
| | | | - Require staff to wear up-to-date, |
| - Observe the environment where care and | | | | conspicuous, color photograph identification |
| treatment are provided. | | | | badges. |
| | | | |
| - Observe and interview staff at units where | | | | - Discontinue publication of birth notices in |
| infants and children are inpatients. Are | | | | local newspapers. |
| appropriate security protections (such as | | | | |
| alarms, arm banding systems, etc.) in place? | | | | - Consider options for controlling access to |
| Are they functioning? | | | | nursery/postpartum unit such as swipe-card |
| | | | locks, keypad locks, entry point alarms or |
| - Review policy and procedures on what the | | | | video surveillance (any locking systems must |
| facility does to curtail unwanted visitors or | | | | comply with fire codes). |
| contaminated materials. | | | | |
| | | | - Consider implementing an infant security |
| - Access the hospital's security efforts to | | | | tag or abduction alarm system. |
| protect vulnerable patients including | | | | |
| newborns and children. Is the hospital | | | | Material in this brochure provided to |
| providing appropriate security to protect | | | | Accutech-ICS ( by Security Assessments |
| patients? Are appropriate security mechanisms | | | | International, Inc., |
| in place and being followed to protect | | | | |
| patients? | | | | Disclaimer |
| | | | |
| Exceptions: | | | | The information provided by and SAI is in |
| | | | accordance with our understanding of current |
| The use of handcuffs or other restrictive | | | | JCAHO and CMS Regulations. It is intended for |
| devices applied by law enforcement officials | | | | educational purposes only and should not be |
| who are not employed by or contracted by the | | | | considered 'legal' advice. Please consult |
| hospital is for custody, detention, and | | | | with your legal counsel or Compliance Officer |
| public safety reasons, and is not involved in | | | | for clarification of laws and rules related |
| the provision of health care. Therefore, the | | | | to your State when applicable. |
| use of restrictive devices applied by and | | | | |
| monitored by law enforcement officers who are | | | | and SAI are not affiliated with the Joint |
| not employed or contracted by the hospital, | | | | Commission on Accreditation of Healthcare |
| and who maintain custody and direct | | | | Organizations. |
| supervision of their prisoner are not | | | | |