| Every healthcare organization/hospital accepting | | | | who are not employed or contracted by the |
| payment for Medicare and Medicaid patients is | | | | hospital, and who maintain custody and direct |
| required to meet certain Federal standards called | | | | supervision of their prisoner are not governed by |
| "Conditions of Participation" (CoPs). | | | | §482.13(f)(l-3). The individual may be the law |
| These Federal requirements are promulgated by | | | | enforcement officer's prisoner but he/she is also |
| the Centers for Medicare and Medicaid to improve | | | | the hospital's patient. The hospital is still responsible |
| quality and protect the health and safety of | | | | for providing safe and appropriate care to their |
| patients. Compliance is based on surveys | | | | patient. The condition of the patient must be |
| conducted by state agencies on behalf of the | | | | continually assessed, monitored and reevaluate. |
| CMS. Conditions of Participation are regulatory | | | | JCAHO - 2006 |
| standards hospitals agree to follow as a condition | | | | (Healthcare Security) |
| 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 accredits |
| licensure agencies conduct surveys of hospitals | | | | more than 18,000 healthcare organizations and |
| and enforce compliance with CoPs and ensure | | | | programs throughout the United States. Hospitals |
| that Conditions of Participation are being practiced. | | | | aggressively seek Joint Commission accreditation |
| Hospitals and other healthcare facilities are subject | | | | to meet Medicare certification and licensure |
| to random onsite reviews. Unannounced surveys | | | | requirements. Accreditation is also a condition of |
| can result from patient or public complaints or | | | | reimbursement for many insurers and other |
| inquiries. Healthcare Security is an important | | | | payers. In addition, JCAHO Accreditation reduces |
| element for the new 2006 Conditions of | | | | the hospital's liability insurance premiums. Beginning |
| Participation. | | | | 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 |
| Centers for Medicare & Medicaid Services | | | | more than 50 years and today accredits over 80 |
| (Healthcare Security) | | | | percent of the nation's hospitals. The Centers for |
| ___________ | | | | Medicaid & Medicare Services (CMS) have |
| A-0038 | | | | required JCAHO accreditation by US hospitals |
| Title 42CFR, Volume 3 - §482.13 Condition of | | | | since 1965 as a 'Condition of Participation' |
| Participation: Patients' Rights | | | | requirement in order for them to receive Medicaid |
| A hospital must protect and promote each | | | | and Medicare reimbursements. |
| patient's rights | | | | The Joint Commission and Healthcare Security |
| Interpretive Guidelines §482.13 | | | | The Joint Commission's Standards address the |
| These requirements apply to all Medicare or | | | | hospital's performance in specific areas, and |
| Medicaid participating hospitals including short-term, | | | | specify requirements to insure that patients are |
| acute care, surgical, specialty, psychiatric, | | | | provided a safe and secure environment. 2006 |
| rehabilitation, long-term, childrens' and cancer, | | | | Environment of Care© requirements include, |
| whether or not they are accredited. This rule | | | | but are not limited to the following: |
| does not apply to critical access hospitals. (See | | | | - Development and maintenance of a written |
| Social Security Act (the Act) §1861(e)). | | | | Security Management Plan to include an |
| These requirements, as well as the other | | | | Emergency Management Plan. |
| Conditions of Participation in 42 CFR §482, | | | | - Conduct an annual Risk Assessment that |
| apply to all parts and locations (outpatient | | | | evaluates the potential adverse impact of the |
| services, provider-based entities, inpatient | | | | external environment on the security of patients, |
| services) of the Medicare participating hospital. | | | | staff, and others coming to the facility. |
| ___________ | | | | - Use the risks identified to select and implement |
| A-0057 | | | | procedures and controls to achieve the lowest |
| Title 42, Volume 3 CFR - §482.13(c)(2) The | | | | potential for adverse impact on security. |
| patient has the right to receive care in a safe | | | | - Identify, as appropriate, patients, staff and other |
| setting. | | | | people entering the facility. |
| Interpretive Guidelines for §482.13(c)(2) | | | | - Access Control / Physical Protection - control |
| The intention of this requirement is to specify | | | | access to and egress from security sensitive |
| that each patient receives care in an environment | | | | areas, as determined by the organization. |
| that a reasonable person would consider to be | | | | - Mitigate Violence in the Emergency Department |
| safe. For example, hospital staff should follow | | | | and other locations. |
| current standards of practice for patient | | | | - Education and Training - staff, licensed |
| environmental safety, infection control and | | | | practitioners, and volunteers have the knowledge |
| security. The hospital must protect vulnerable | | | | and skills necessary to perform their |
| patients, including newborns and children. | | | | responsibilities within the environment. |
| Additionally, this standard is intended to provide | | | | - Develop and implement a proactive infant |
| protection for the patient's emotional health and | | | | abduction prevention plan. |
| 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 potential |
| emotionally safe environment. | | | | abductors/abduction situations (during staff |
| Survey Procedures §482.13(c)(2) | | | | orientation and in-service curriculum programs). |
| - Review and analyze patient and staff incident | | | | - Enhance parent education concerning abduction |
| and accident reports to identify any incidents or | | | | risks and parent responsibility for reducing risk and |
| patterns of incidents concerning a safe | | | | then assess the parents' level of understanding. |
| environment. Expand your review if you suspect | | | | - Attach secure identically numbered bands to the |
| a problem with safe environment in the hospitals. | | | | baby (wrist and ankle bands), mother, and father |
| - Review QAPI, safety, infection control and | | | | or significant other immediately after birth. |
| security (or the committee that deals with | | | | - Footprint the baby, take a color photograph of |
| security issues) committee minutes and reports | | | | the baby and record the baby's physical |
| to determine if the hospital is identifying problems, | | | | examination within two hours of birth. |
| evaluating those problems and taking steps to | | | | - Require staff to wear up-to-date, conspicuous, |
| ensure a safe patient environment. | | | | color photograph identification badges. |
| - Observe the environment where care and | | | | - Discontinue publication of birth notices in local |
| treatment are provided. | | | | newspapers. |
| - Observe and interview staff at units where | | | | - Consider options for controlling access to |
| infants and children are inpatients. Are appropriate | | | | nursery/postpartum unit such as swipe-card locks, |
| security protections (such as alarms, arm banding | | | | keypad locks, entry point alarms or video |
| systems, etc.) in place? Are they functioning? | | | | surveillance (any locking systems must comply |
| - Review policy and procedures on what the | | | | with fire codes). |
| facility does to curtail unwanted visitors or | | | | - Consider implementing an infant security tag or |
| contaminated materials. | | | | abduction alarm system. |
| - Access the hospital's security efforts to protect | | | | Material in this brochure provided to Accutech-ICS |
| vulnerable patients including newborns and children. | | | | ( by Security Assessments International, Inc., |
| Is the hospital providing appropriate security to | | | | Disclaimer |
| protect patients? Are appropriate security | | | | The information provided by and SAI is in |
| mechanisms in place and being followed to protect | | | | accordance with our understanding of current |
| patients? | | | | JCAHO and CMS Regulations. It is intended for |
| Exceptions: | | | | educational purposes only and should not be |
| The use of handcuffs or other restrictive devices | | | | considered 'legal' advice. Please consult with your |
| applied by law enforcement officials who are not | | | | legal counsel or Compliance Officer for clarification |
| employed by or contracted by the hospital is for | | | | of laws and rules related to your State when |
| custody, detention, and public safety reasons, and | | | | applicable. |
| is not involved in the provision of health care. | | | | and SAI are not affiliated with the Joint |
| Therefore, the use of restrictive devices applied | | | | Commission on Accreditation of Healthcare |
| by and monitored by law enforcement officers | | | | Organizations. |