National Integrated Accreditation for Healthcare (NIAHO ...

1 National Integrated Accreditation for Healthcare (NIAHO ) . Accreditation Requirements Interpretive Guidelines and Surveyor Guidance for Critical Access Hospitals REV (11/1/2012). DNV Healthcare Inc. 400 Techne Center Drive, Suite 350. Milford, OH 45150. Phone 513-947-8343 Fax 513-947-1250. Copyright 2009-2012 Det Norske Veritas Healthcare , Inc. All Rights Reserved. No claim to Government work. NIAHO Critical Access Hospitals Accreditation Requirements Interpretive Guidelines & Surveyor Guidance Rev Table of Contents PAGE. Use of NIAHO Interpretive Guidelines and Surveyor Guidance 6. Definitions 7. QUALITY MANAGEMENT SYSTEM (QM) 9. Quality Management System 9. ISO 9001 Quality Management System 10. Quality Outline 11.

2 Management Representative 11. Documentation and Management Reviews 12. System Requirements 12. Measurement, Monitoring, Analysis 13. Patient Safety System 16. GOVERNING BODY / CHIEF EXECUTIVE (GB) 17. Legal Responsibility 17. Disclosure 20. Institutional Plan and Budget 21. Agreements 22. Contracted services 23. MEDICAL STAFF (MS) 25. Organized Medical Staff 25. Accountability / Responsibility 26. Physician Assistant, Nurse Practitioner, Clinical Nurse Specialists 28. Medical Staff and Health Professional Participation 28. Medical Staff Bylaws, Rules and Regulations 29. Appointment 30. Performance Data 31. Continuing Education 32. Governing Body / Chief Executive Role 32. Clinical Privileges 33. Temporary Clinical Privileges 34.

3 Corrective or Rehabilitative Action 35. Admission Requirements 36. Medical Record Maintenance 37. History and Physical 38. Consultation 40. Telemedicine 41. NURSING services (NS) 42. Nursing Service 42. Nurse Executive / Leader 45. Assessment and Plan of Care 46. STAFFING MANAGEMENT (SM) 48. Professional Scope 48. Determining and Modifying Staffing 49. Job Description 49. Orientation 50. Staff Evaluations 51. 2. NIAHO Critical Access Hospitals Accreditation Requirements Interpretive Guidelines & Surveyor Guidance Rev PAGE. SERVICE PROVISION (SP) 52. services 52. Committee Involvement 52. Periodic Review 53. SURGICAL services (SS) 54. Organization 54. Staffing and Supervision 56. Practitioner Privileges 57. History and Physical 58.

4 Available Equipment 61. Operating Room Register 61. Post-Operative Care 62. Operative Report 62. Immediate Post-Operative Note 63. ANESTHESIA services (AS) 64. Organization 64. Administration 66. Policies and Procedures 70. EMERGENCY services (ED) 73. Organization 73. Staffing 75. Equipment, Supplies and Medication 77. Blood and Blood Products 79. Emergency Response Systems 79. Off-Campus Departments 80. MEDICATION MANAGEMENT (MM) 80. Management Practices 80. Formulary 85. Scheduled Drugs 86. Medication Orders 87. Review of Medication Orders 89. Oversight 91. Available Information 93. LABORATORY services (LS) 94. services 94. MEDICAL IMAGING (MI) 95. services 95. Radiation Protection 96. Equipment 97. Order 98.

5 Supervision 98. Staff 99. DIETARY services (DS) 99. Organization 99. services and Diets 101. Diet Manual 102. 3. NIAHO Critical Access Hospitals Accreditation Requirements Interpretive Guidelines & Surveyor Guidance Rev PAGE. REHABILITATION services (RS) 103. Organization 103. Management and Support 104. Treatment Plan 105. RESPIRATORY CARE services (RC) 105. Organization 105. Physician Order 106. Policies or Protocols 107. INFECTION CONTROL (IC) 108. Infection Control System 108. DISCHARGE PLANNING (DC) 113. Discharge Planning Evaluation 113. UTILIZATION REVIEW (UR) 115. Utilization Review Process 115. PATIENT RIGHTS (PR) 117. Specific Rights 117. Advance Directive 120. Language and Communication 121. Informed Consent 121.

6 Grievance Procedure 122. Restraint or Seclusion 124. Restraint or Seclusion: Staff Training Requirements 133. Restraint or Seclusion: Report of Death 135. Visitation Rights 136. MEDICAL RECORDS SERVICE (MR) 137. Medical Record System 137. Complete Medical Record 137. Retention 138. Confidentiality 139. Record Content 140. ORGAN, TISSUE AND EYE PROCUREMENT (TO) 143. Process 143. Organ Procurement Organization (OPO) Written Agreement 143. Respect for Patient Rights 146. Documentation 146. PHYSICAL ENVIRONMENT (PE) 147. Facility 149. Life Safety Management 149. Safety Management 152. Security Management 153. Hazardous Material (HAZMAT) Management 154. Emergency Management 156. Medical Equipment Management 158. Utility Management 159.

7 4. NIAHO Critical Access Hospitals Accreditation Requirements Interpretive Guidelines & Surveyor Guidance Rev PAGE. APPENDIX SWING BEDS (SB-A) 162. ADMISSION, TRANSFER AND DISCHARGE (TD) 162. Transfer and Discharge Requirements 162. Documentation 163. Notification 163. Orientation for Transfer or Discharge 164. Change or Room in Composite Distinct Part 165. Discharge Summary 165. PLAN OF CARE (PC) 166. Assessment 166. Care Plan 167. RESIDENT RIGHTS (RR) 169. Exercise of Rights 169. Notice of Rights and services 169. Health Care Decisions 171. Advance Directives 172. Medicaid Benefits 172. Personal Privacy and Confidentiality 173. Restraints 174. Abuse 174. Work 177. FACILITY services (FS) 177. Activities 177.

8 Social services 178. Dental services 180. Specialized Rehabilitative services 181. RESIDENT NUTRITION (RN) 183. Nutritional Status 183. APPENDIX DISTINCT PART UNIT - REHABILITATION UNIT (RU-B) 185. APPENDIX DISTINCT PART UNIT - PSYCHIATRIC UNIT (PU-B) 194. 5. NIAHO Critical Access Hospitals Accreditation Requirements Interpretive Guidelines & Surveyor Guidance Rev Use of NIAHO Interpretive Guidelines and Surveyor Guidance Effective Date These NIAHO Interpretive Guidelines and Surveyor Guidance for Critical Access Hospital document. Revision , Effective Date: November 1, 2012. National Professional Organizations- Standards of Practice Standards of practice of the National professional organizations referenced in this NIAHO Interpretive Guideline and Surveyor Guidance document are consultative and considered in the Accreditation decision.

9 Federal Laws, Rules and Regulations The most current version of Federal law and the Code of Federal Regulations referenced in this NIAHO . Interpretive Guideline and Surveyor Guidance document are incorporated herein by reference and constitute NIAHO . Accreditation requirements. This NIAHO Accreditation Standards Interpretive Guidelines and Surveyor Guidance for Critical Access Hospitals (NIAHO CAH) document is based upon the Centers for Medicare and Medicaid (CMS) Conditions of Participation for Critical Access Hospitals 42 CFR and State Operations Manual Regulations and Interpretive Guidelines for Critical Access Hospitals. These Interpretive Guidelines also are periodically updated based on notices distributed from CMS.

10 Hospitals participating in the Medicare and Medicaid program are expected to comply with current Conditions of Participation. When new or revised requirements are published hospitals are expected to demonstrate compliance in a time frame consistent with the effective date published by CMS in the Federal Register. Life Safety Code . The Life Safety Code of the National Fire Protection Association referenced in this NIAHO Interpretive Guideline and Surveyor Guidance document are incorporated herein by reference and constitute NIAHO Accreditation requirements. 6. NIAHO Critical Access Hospitals Accreditation Requirements Interpretive Guidelines & Surveyor Guidance Rev DEFINITIONS. AOA American Osteopathic Association AMA American Medical Association AORN Association of periOperative Registered Nurses APIC Association of Professionals in Infection Control and Epidemiology ASA American Society of Anesthesiologists CAH Critical Access Hospital CDC Centers for Disease Control and Prevention CNS Clinical Nurse Specialist CEO Chief Executive Officer CFR Code of Federal Regulations CMS Centers for Medicare and Medicaid services CRNA Certified Registered Nurse Anesthetist DEA Drug Enforcement Administration ECFMG Educational Commission for Foreign Medical Graduates FDA Food and Drug Administration HHA Home Health Agency HVAC Heating Ventilating and Air Conditioning ISMP Institute for Safe