CMS and JCAHO Healthcare Security Requirements Summary

Every healthcare organization/hospital acceptingwho are not employed or contracted by the
payment for Medicare and Medicaid patients ishospital, and who maintain custody and direct
required to meet certain Federal standards calledsupervision 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 byenforcement officer's prisoner but he/she is also
the Centers for Medicare and Medicaid to improvethe hospital's patient. The hospital is still responsible
quality and protect the health and safety offor providing safe and appropriate care to their
patients. Compliance is based on surveyspatient. The condition of the patient must be
conducted by state agencies on behalf of thecontinually assessed, monitored and reevaluate.
CMS. Conditions of Participation are regulatoryJCAHO - 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 healthcareHealthcare Organizations evaluates and accredits
licensure agencies conduct surveys of hospitalsmore than 18,000 healthcare organizations and
and enforce compliance with CoPs and ensureprograms throughout the United States. Hospitals
that Conditions of Participation are being practiced.aggressively seek Joint Commission accreditation
Hospitals and other healthcare facilities are subjectto meet Medicare certification and licensure
to random onsite reviews. Unannounced surveysrequirements. Accreditation is also a condition of
can result from patient or public complaints orreimbursement for many insurers and other
inquiries. Healthcare Security is an importantpayers. In addition, JCAHO Accreditation reduces
element for the new 2006 Conditions ofthe hospital's liability insurance premiums. Beginning
Participation.in 2006 JCAHO will conduct all surveys without
CONDITIONS of PARTICIPATIONprior notice.
Department of Health & Human ServicesThe Joint Commission has accredited hospitals for
Centers for Medicare & Medicaid Servicesmore 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-0038required JCAHO accreditation by US hospitals
Title 42CFR, Volume 3 - §482.13 Condition ofsince 1965 as a 'Condition of Participation'
Participation: Patients' Rightsrequirement in order for them to receive Medicaid
A hospital must protect and promote eachand Medicare reimbursements.
patient's rightsThe Joint Commission and Healthcare Security
Interpretive Guidelines §482.13The Joint Commission's Standards address the
These requirements apply to all Medicare orhospital'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 rulebut 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 otherEmergency Management Plan.
Conditions of Participation in 42 CFR §482,- Conduct an annual Risk Assessment that
apply to all parts and locations (outpatientevaluates the potential adverse impact of the
services, provider-based entities, inpatientexternal 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-0057procedures and controls to achieve the lowest
Title 42, Volume 3 CFR - §482.13(c)(2) Thepotential 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 specifyaccess to and egress from security sensitive
that each patient receives care in an environmentareas, 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 followand other locations.
current standards of practice for patient- Education and Training - staff, licensed
environmental safety, infection control andpractitioners, and volunteers have the knowledge
security. The hospital must protect vulnerableand 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 andabduction prevention plan.
safety as well as his/her physical safety. Respect,- Include information on visitor/provider
dignity and comfort would be components of anidentification 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 orrisks and parent responsibility for reducing risk and
patterns of incidents concerning a safethen 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 andor 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 reportsthe 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 appropriatenursery/postpartum unit such as swipe-card locks,
security protections (such as alarms, arm bandingkeypad 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 thewith 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 protectMaterial in this brochure provided to Accutech-ICS
vulnerable patients including newborns and children.( by Security Assessments International, Inc.,
Is the hospital providing appropriate security toDisclaimer
protect patients? Are appropriate securityThe information provided by and SAI is in
mechanisms in place and being followed to protectaccordance 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 devicesconsidered 'legal' advice. Please consult with your
applied by law enforcement officials who are notlegal counsel or Compliance Officer for clarification
employed by or contracted by the hospital is forof laws and rules related to your State when
custody, detention, and public safety reasons, andapplicable.
is not involved in the provision of health care.and SAI are not affiliated with the Joint
Therefore, the use of restrictive devices appliedCommission on Accreditation of Healthcare
by and monitored by law enforcement officersOrganizations.