Monday, April 30, 2007

A New Client from Texas writes…

Friday, April 27, 2007 @ 11:10 AM and I quote the Client stating:


"I interviewed two Texas based companies, one Florida based company and one North Carolina based company and yours. You basically went out of your way to answer my questions without making me feel like a novice (which I am) I felt comfortable calling and emailing you with any information I needed. I am glad you got the gig. Very deserving, I look forward meeting you and working with you" D. d. -nursing director


Thank you D.D. for such nice words and examples of our efforts. Here at The Compliance Doctor, LLC we value our clients with each individual's needs as special as they are. No two clients have the same level of understanding likewise no two clients have the same level of appreciation or need to understand some of the processes we must employ in order for you to be happy with the accreditation of your facility. It is very much a pleasure to work with all types in our client base; you are special and have the desire to learn this work. We appreciate your eagerness in understanding it all and look forward to working with you as you mature into the awareness and understanding as to what it really means to "do the right thing from the very beginning". Thank you again, Troy Lair, Chief Consultant and CEO- the Compliance Doctor, LLC


Sunday, April 15, 2007

How can we change the very thing we know to be a reality, as pathetic as it is?

OSHA Morale Improvement 








you spend the majority of your time in a 10X10 cell


you spend the majority of your time in an 6X6 cubicle /office

you get three meals a day fully paid for


you get a break for one meal and you have to pay for it

you get time off for good behavior


you get more work for good behavior

the guard locks and unlocks all the doors for you


you must often carry a security card and open all the doors for yourself

you can watch TV and play games


you could get fired for watching TV and playing games 

you get your own toilet


you have to share the toilet with some people who pee on the seat 

they allow your family and friends to visit


you aren't even supposed to speak to your family

all expenses are paid by the taxpayers with no work required


you get to pay all your expenses to go to work, and they deduct taxes from your salary to pay for prisoners

you spend most of your life inside bars wanting to get out


you spend most of your time wanting to get out and go inside bars

you must deal with sadistic wardens


they are called managers


Now get back to work. You're not getting paid to read this!

Wednesday, April 11, 2007

A great resource and excellent educational tool provided:

Accreditation Agencies in

United States

This section provides you with an overview of major accreditation agencies in the United States.

The Joint Commission On Accreditation Of Healthcare

"The mission of the Joint Commission on Accreditation of Healthcare Organizations is to continuously improve the safety and quality of care provided to the public through the provision of health care accreditation and related services that support performance improvement in health care organizations." JCAHO

A little history of the JCAHO Quality Standards:

Similar "quality assurance" standards for five Joint Commission accreditation programs (hospital, psychiatric, long term care, and ambulatory healthcare) were adopted between 1979 and 1981. Revisions were adopted in 1984 to add a requirement for monitoring and evaluation. Then in 1990 the ten-step monitoring and evaluation process was added to the manuals. In 1992 there were major changes with the expansion in language and standards to quality assessment and improvement. In 1994 the hospital standards were reorganized into functional chapters and "performance improvement" language replaced QA & I. The ambulatory care manual was likewise reorganized into functional standards and began using PI terms and processes for improving organization-wide performance in 1996. The home care and "- behavioral health care manual conversions to functional standards took place in 1997.

Beginning in 2003, all accredited organizations must meet all approved National Patient Safety Goals and the accompanying recommendations (as applicable) to avoid a Requirement for Improvement.

A new accreditation process called "Shared Visions-New Pathways" became effective in January 2004. It is intended to shift the focus from survey preparation to continuous improvement. The vision shared with healthcare organizations, oversight bodies, and the public is to "bridge what has been called a gap or chasm between the current state of health care and the potential for safer, higher quality care" [Source: "Facts about Shared Visions-New Pathways," www.icaho.orq/accredited+organizations/svnp  ]

Joint Commission on Accreditation of Healthcare Organizations (Joint Commission or JCAHO): Multiple accreditation programs

  • Hospital Accreditation Services (HAS)
  • Accreditation Program/Behavioral Health Care (AP/BHC), with program for Managed Behavioral Health Care (AP/MBHC)
  • Accreditation Program/Long term Care (AP/L TC) .

Hospital Accreditation Program (HAP)

The acute hospital Joint Commission standards seem to set the precedent for standards in other settings, and they are now quoted in the judgments of many civil malpractice cases. Conversely, changes in the standards are generally consistent with changes in federal regulation and precedent-setting court cases. Similarly, changes in the standards reflect recent national concerns, as expressed in media coverage (e.g., sentinel events) or major reports (e.g., the 10M report on medical errors). This makes the Joint Commission standards an important resource in establishing quality strategies and performance improvement processes. Hospital standards are referenced in this Handbook the most, as they are the first to change and are the most comprehensive of all the Joint Commission programs. Behavioral Care Program The Comprehensive Accreditation Manual for Behavioral Health Care (CAMBHC) is used for healthcare organizations that provide mental health or chemical dependency/ other addictive behavior services to adults, adolescents, or children; or that provide mental retardation/developmental disability, foster care, corrections, forensic, or other psychosocial services in most settings. Hospitals providing inpatient and/or residential mental health programs for children and adolescents may be surveyed under the CAMBHC if third party reimbursement requires; otherwise, such programs are surveyed under the hospital standards (CAMH). Each facility is evaluated individually for determination of eligibility for survey based on the behavioral health care standards, hospital standards, or a combination.

Long Term Care (LTC) and Assisted Living (AL Programs)

The long term care program has been in place since 1966. The Comprehensive Accreditation Manual for Long Term care (CAML TC) applies to nursing homes and skilled nursing facilities, as well as facilities now providing sub-acute care. The newer assisted living program began in 2000 and uses standards in the Accreditation Manual for Assisted Living (AMAL).

Joint Commission on Accreditation of Healthcare Organizations

(Joint Commission or JCAHO) Multiple accreditation programs

  • Accreditation Program/Ambulatory Care (AP/AC)
  • Accreditation Program/Home Care (AP/HC)
  • Office-Based Surgery Accreditation Program, subset of ambulatory care standards .

Ambulatory Care Program

The Comprehensive Accreditation Manual for Ambulatory Care (CAMAC) is used for any ambulatory healthcare organization meeting eligibility criteria. Types of ambulatory care organizations include:

  • Clinics, health service centers, and primary care centers
  • Ambulatory surgery centers
  • College, community, and correctional health centers
  • Medical groups and solo practice o Armed Services programs
  • Ambulatory specialty testing/treatment centers, e.g., ambulatory infusion centers o Urgent/emergency care centers
  • Physical rehabilitation centers
  • Staff and group model practices in managed care organizations
  • The Accreditation Program/Home Care (AP/HC), available since 6/88, is approved by CMS for deemed status with annual onsite surveys (perhaps unannounced). The similar Accreditation program offered by the Community Health Accreditation Program (CHAP) also carries deemed status. The Joint Commission Home Care Program began accrediting Hospice Programs in 1994. The AP/HC Standards apply to: o Both freestanding and hospital-based programs o Home health services, including skilled intermittent home health agencies o Hospice programs o Home personal care and support services o Home medical equipment services also providing maintenance and monitoring, including clinical respiratory services and rehabilitation technology o Pharmacy, pharmacy dispensing, long term care pharmacy services, and clinical/consultant pharmacist services o Freestanding ambulatory infusion services
  • Accreditation Program/Health Care Networks (AP/HCN), with customized evaluation programs for health plans, integrated delivery systems (lDSs) and preferred provider organizations (PPOs)
  • Accreditation Program/Laboratory and Point-of-Care Testing (a separate program to meet CLIA requirements every 2 years)
  • Multiple accreditation programs
  • Accreditation Program/Critical Access Hospitals (AP/CAH)
  • Accreditation Program/Assisted Living (AP/AL)
  • Disease-Specific Care (DSC) Certification Program: Almost all chronic conditions and disease states; criteria based on the Chronic Care Model, 

National Committee for Quality Assurance

"Our goal is to increase the value of NCQA accreditation both to organizations pursuing accreditation and to the audiences who seek help in assessing the quality of health care provided by those organizations. " Margaret E. O'Kane President.

The National Committee for Quality Assurance (NCQA) works with managed care organizations, healthcare purchasers, state regulators, and consumers to develop standards and performance measures (Health Plan Employer Data Information Set or HEDIS~ that effectively evaluate the structure and functions of medical and quality management systems in managed care organizations.

In 1990, when JCAHO dropped their Managed Care Accreditation Program, they turned those managed care organizations that were currently accredited over to NCQA. NCQA is now an independent body originally founded in 1979 by the then Group Health Association of America (now the American Association of Health Plans) and the American Managed Care Review Association. Standards were finalized 7/1/91, with revisions approximately every two years since then.

Current NCQA programs:

  • Accreditation of managed care organizations (MCOs)
  • Accreditation of managed behavioral healthcare organizations (MBHOs)
  • Accreditation of preferred provider organizations (PPOs)
  • Accreditation of new health plans (NHPs)
  • Accreditation program for human research protection (VA system)
  • Partnership for Human Research Protection, Inc., Accreditation Program (PHRP) with JCAHO
  • Disease management (DM) accreditation/certification
  • Certification of credentials verification organizations (CVOs)
  • Certification of physician organizations (POC)
  • Organization certifications: Credentialing (CR) and utilization management (UM), for PPO networks and others, using standards adapted from the PPO plan accreditation program
  • Privacy Certification for Business Associates (HIPAA compliance) - Heart/Stroke Recognition Program (HSRP)
  • Physician Practice Connections (PPC)-physician assessment program for Bridges to Excellence rewards program www.bridaestoexcellence.ora

US Accrediting Agencies

  • Joint Commission on Accreditation of Healthcare Organizations (Joint Commission or JCAHO): Multiple accreditation programs
  • National Committee for Quality Assurance (NCQA): Managed care organizations
  • American Osteopathic Association (AOA): Osteopathic hospitals
  • The American Osteopathic Association's Healthcare Facilities Accreditation Program (HFAP) has been providing medical facilities with an objective review of their services since 1945. The program is recognized nationally by the federal government, state governments, insurance carriers and managed care organizations.

History of the AOA Healthcare Facilities Accreditation Program

The AOA accreditation program was developed in 1943 and 1944 and implemented in 1945. Under this program hospitals were surveyed each year. In this manner the AOA was able to assure that osteopathic students received their training through rotating internships and residencies in facilities which provided a high quality of patient care. In 1965 Medicare and Medicaid were introduced and the American Osteopathic Association and the American Osteopathic Hospital Association applied to the Health Care Financing Administration (HCFA), now CMS, for deeming authority to survey hospitals under the Medicare Conditions of Participation. In 1995 the AOA applied for and received deeming authority to accredit laboratories within AOA accredited hospitals under the Clinical Laboratory Improvement Amendments of 1988 (CLIA).

The AOA has also developed accreditation requirements for ambulatory care/surgery, mental health, substance abuse, and physical rehabilitation medicine facilities. HFAP Recognition

The AOA program has been granted "Deeming Authority" to conduct accreditation surveys of acute care hospitals by the Centers for Medicare & Medicaid Services (CMS). (Section 1865 of the Social Security Act and implementing regulations 42 CFR 488.5.) This means that a hospital accredited by the AOA is deemed to comply with the Medicare Conditions of Participation for Hospitals as published by CMS.

The AOA program has been granted "Deeming Authority" from CMS to survey hospital laboratories under the Clinical Laboratory Improvement Amendments of 1988 (CLIA) as published in the Federal Register, Vol. 60, No. 140, page 37657, Friday, July 21, 1995. The program is a recognized alternative to accreditation by CMS or the Joint Commission on Accreditation of Healthcare Organizations (JCAHO). The laboratory accreditation program is a recognized alternative to accreditation by the College of American Pathologists (CAP) or JCAHO. According to the National Committee for Quality Assurance, "NCQA does not require managed care organizations (MCOs) to accept specific accrediting bodies. An MCO makes the final determination about which accrediting bodies are acceptable." An MCO can decide to accept the AOA as their preferred accrediting agency.

US Accrediting Agencies

  • Community Health Accreditation Program, Inc. (CHAP), a subsidiary of the National League of Nursing :(NLN) Home care and community health organizations .
  • Accreditation Commission for Health Care, Inc. (ACHC): Home care services
  • Continuing Care Accreditation Commission (CCAC): Continuing care retirement communities
  • Commission for Accreditation of Rehabilitation Facilities (CARF): Hospital-based or freestanding medical rehabilitation centers, adult day services, assisted living The Community Health Accreditation Program, Inc. (CHAP) is an independent, non-profit accrediting body which was established in 1965. CHAP accreditation publicly certifies that an organization has voluntarily met the highest standards of excellence for home and/or community-based health care. Additional benefits of accreditation by CHAP include management consultation of the highest quality, access to a broad network of professional resources, and guidance critical to building intra and inter-organizational collaboration and strength. The Accreditation Commission for Health Care, Inc. (ACHC) is an independent, private, not-for-profit corporation established in 1986. The North Carolina Association for Home Care created the program, Inc. in response to provider concerns for quality in-home aide services and the desire for an alternative program. ACHC accredits home health agencies, home infusion companies, home care aide programs, home medical equipment suppliers, specialty pharmacies, hospices and companies that specialize in services and products for post breast surgery patients. The Continuing Care Accreditation Commission (CCAC), which was acquired by the Commission on Accreditation of Rehabilitation Facilities (CARF) in 2003, is the nation's only accrediting body for continuing care retirement communities (CCRCs) and other types of continuums of care that we refer to as aging services networks.
  • CARF is an international nonprofit accrediting body. CARF provides accreditation in the human services field—focusing on the areas of rehabilitation, employment and community, child and family, and aging services. The mission of CARF is to promote the quality, value, and optimal outcomes of services through a consultative accreditation process that centers on enhancing the lives of the persons served
  • American College of Surgeons Commission on Cancer (ACS-CoC): Cancer treatment programs in hospitals, outpatient centers, and freestanding facilities
  • Council on Accreditation (COA): Council on Accreditation (COA): Outpatient mental health, residential treatment centers, alcohol and other substance abuse treatment centers, therapeutic foster care
  • Accreditation Association for Ambulatory Health Care (AAAHC): Ambulatory surgery centers, medical and dental group practices, community and university , student health centers, diagnostic imaging centers
    • What is the Commission on Cancer? The CoC is a consortium of professional organizations dedicated to reducing the morbidity and mortality of cancer through education, standard-setting, and the monitoring of quality care. History Established by the American College of Surgeons (ACoS) in 1922, the multi-disciplinary Commission on Cancer (CoC) sets standards for quality multidisciplinary cancer care delivered primarily in hospital settings; surveys hospitals to assess compliance with those standards; collects standardized and quality data from approved hospitals to measure treatment patterns and outcomes; and uses the data to evaluate hospital provider performance and develop effective educational interventions to improve cancer care outcomes at the national and local level.

The Council on Accreditation (COA) is an international, independent, not-for-profit, child- and family-service and behavioral healthcare accrediting organization. Founded in 1977 by the Child Welfare League of America and Family Service America, COA partners with human service organizations worldwide to improve service delivery outcomes by developing, applying, and promoting accreditation standards. In 2004, COA accredited or was in the process of accrediting more than 1,500 private and public organizations that serve more that 7 million individuals and families in North America, England and the Philippines.

As the leader in ambulatory health care accreditation, the Accreditation Association for Ambulatory Health Care (Accreditation Association/AAAHC) has been setting the standard for quality in ambulatory health care for over 25 years. The AAAHC accreditation certificate has become a symbol that an organization is committed to providing the highest level of quality health care possible.

The Accreditation Association currently accredits over 2200 organizations in a wide variety of ambulatory health care settings, including ambulatory and office based surgery centers, managed care organizations, as well as Indian and student health centers, among others. With a single focus on the ambulatory care community, the Accreditation Association offers organizations a peer-based, relevant, and cost-effective approach to accreditation.

  • American Association for Accreditation of Ambulatory Surgery Facilities (AAAASF)
    • It is the mission of the American Association for Accreditation of Ambulatory Surgery Facilities, Inc. (AAAASF) to develop and implement standards of excellence to ensure the highest quality of patient care through an accreditation program that serves both the medical community and the public interest by establishing a means for measuring medical competence and providing an external source for evaluating patient safety in the ambulatory surgery setting.
  • The Medical Quality Commission (TMQC), a separate organization associated with the American Medical Group Association (AMGA): Prepaid group practices
  • Utilization Review Accreditation Commission (URAC)/American Accreditation Health Care Commission (AAHCC): Voluntary accreditation for private UM organizations, case management organizations, health plans and networks, worker's compensation UM and network organizations, and three others
    • URAC, an independent, nonprofit organization, is well-known as a leader in promoting health care quality through its accreditation and certification programs. URAC offers a wide range of quality benchmarking programs and services that keep pace with the rapid changes in the health care system, and provide a symbol of excellence for organizations to validate their commitment to quality and accountability. Through its broad-based governance structure and an inclusive standards development process, URAC ensures that all stakeholders are represented in establishing meaningful quality measures for the entire health care industry. To promote continuous improvement in the quality and efficiency of health care delivery by achieving a common understanding of excellence among purchasers, providers, and patients through the establishment of standards, programs of education and communication, and a process of accreditation. In the late 1980's concerns grew over the lack of uniform standards for utilization review (UR) services. UR is the process where organizations determine whether health care is medically necessary for a patient or an insured individual. As a result, URAC's first mission was to improve the quality and accountability of health care organizations using UR programs. In later years, URAC's mission expanded to cover a larger range of service functions found in various health care settings including the accreditation of integrated systems such as health plans to smaller organizations offering specialty services. Now, in its 14th year of operation, URAC has over 16 accreditation and certification programs.
  • College of American Pathologists (CAP), Commission on Inspections and Accreditation: Clinical laboratories
    • The goal of the CAP Laboratory Accreditation Program is to improve the quality of clinical laboratory services through voluntary participation, professional peer review, education, and compliance with established performance standards. Upon successful completion of the inspection process, the laboratory is awarded CAP accreditation and becomes part of an exclusive group of more than 6,000 laboratories worldwide that have met the highest standards of excellence.
  • Commission on Office Laboratory Accreditation (COL ards for Blood Banks and Transfusion Services"
    • COLA is a physician-directed organization whose purpose is to promote excellence in laboratory medicine and patient care through a program of voluntary education, consultation, and accreditation. Services are designed to improve your clinical laboratory as a whole, giving confidence that the facility provides the best patient care. COLA's accreditation program means the clinical laboratory is in compliance with CLIA, and is recognized by the Joint Commission on Accreditation of Healthcare Organizations (JCAHO). COLA accredit the following types of laboratories: Physician Office, Community Hospitals, Mobile Clinics, Veterans Administration Department of Defense

The AABB Accreditation Program strives to improve the quality and safety of collecting, processing, testing, distributing and administering blood and blood products. The Accreditation Program assesses the quality and operational systems in place within the facility. The basis for assessment includes compliance with Standards, Code of Federal Regulations and federal guidance documents. This independent assessment of a facility's operations helps the facility to prepare for other inspections and serves as a valuable tool to improve both compliance and operations. Accreditation is granted for collection, processing, testing, distribution, and administration of blood and blood components; hematopoietic progenitor cell activities; cord blood activities; perioperative activities; parentage testing activities; immunohematology reference laboratories and SBB schools. Contact the Accreditation Department at or call (301) 215-6492.

  • American Society for Histocompatibility and Immunogenetics (ASHI)
    • ASHI Accreditation Mission, Purpose and Goal The mission is to promote quality practice in Histocompatibility and Immunogenetics through the objective and consistent evaluation of compliance with ASHI standards. The purpose of the accreditation program is to evaluate laboratory personnel, procedures and facilities to determine if they are in compliance with those published standards of ASHI and with those standards of organizations by which ASHI is deemed and which apply to the activities of that laboratory. Laboratories will be evaluated for the technology utilized and, if applicable, the clinical services provided.
  • American College of Radiology (ACR)
    • The American College of Radiology's history of developing and administering accreditation programs that assess the quality of imaging facilities dates back to 1963. In 1987, the ACR introduced the Mammography Accreditation Program. This program attracted widespread, voluntary participation from facilities wanting to be recognized for performing quality mammography. In 1992, the federal government mandated that all mammography facilities be accredited. Accreditation Program for Lithotripsy Organizations
  • American Lithotripsy Society (ALS)
    • The Accreditation Association for Ambulatory Health Care, Inc. (AAAHC) and the American Lithotripsy Society (ALS) is pleased to announce the formation of the Accreditation Program for Lithotripsy Organizations (APLO) - a voluntary, joint accreditation program that combines an expertise of the society with the experience of a national accrediting organization - for those organizations offering lithotripsy services. Under this new program, eligible organizations will be reviewed for compliance with AAAHC standards, as well as additional ALS requirements that address the unique components of lithotripsy services. Those organizations found to be substantially compliant with AAAHC and ALS standards will be awarded a combined AAAHC/ALS accreditation.
  • Commission on Accreditation of Ambulance Services (CAAS)
    • The Commission on Accreditation of Ambulance Services was established to encourage and promote quality patient care in America's medical transportation system. Based initially on the efforts of the American Ambulance Association, the independent Commission established a comprehensive series of standards for the ambulance service industry. Accreditation signifies that your service has met the "gold standard" determined by the ambulance industry to be essential in a modern emergency medical services provider. These standards often exceed those established by state or local regulation. The process includes a comprehensive self-assessment and an independent outside review of the EMS organization. This independent process provides verification to your Board of Directors, city council, medical community and others that quality care is provided to the community. All ambulance systems are eligible for the three-year accreditation including private, public, fire department and hospital-based
  • National Commission for Correctional Health Care (NCCHC)
    • With more than 450 institutions of all shapes and sizes participating, NCCHC's voluntary health services accreditation program is well-known and well-respected among the nation's prisons, jails and juvenile detention facilities Established in the 1970s, it's a process of external peer review in which NCCHC, a private, not-for-profit organization, grants public recognition to correctional institutions that meet its nationally accepted Standards for Health Services. Through the accreditation process, NCCHC renders a professional judgment regarding health services provided and assists correctional facilities in their continued improvement.

Developed by experts from the professions of health, law and corrections, separate standards exist for health care delivery in jails, prisons, and juvenile detention and confinement facilities. The areas covered by the Standards include:

  • Facility governance and administration
  • Maintaining a safe and healthy environment
  • Personnel and training
  • Health care services support
  • Inmate care and treatment
  • Health promotion and disease prevention
  • Special inmate needs and services
  • Health records
  • Medical-legal issue
  • QM standards Electronic Healthcare Network Accreditation Commission (EHNAC): Entities that send or receive HIPAA-regulated transactions or transport or process ED transactions
  • EHNAC accredits entities engaged in ehealth activities of electronic healthcare transactions and management of healthcare information on their ability to meet high quality performance standards in the areas of privacy, security, technical performance, and business practice. EHNAC's self-assessment and site review processes assist entities in meeting industry-defined performance standards, which include, but are not limited to, Administrative Simplification provisions of the Health Insurance Portability and Accountability Act of 1996 (HIPAA).

Government In Health Care

The Federal Government and the Provision of Health Services

• The U.S. Department of Health and Human Services (USDHHS) is the most important federal actor in health care.

• Other federal agencies with major health services roles include:

- Department of Veterans Affairs

- Department of Defense

- Department of Agriculture (nutrition policy, meat and poultry inspection, food stamps)

- Environmental Protection Agency

- Department of Labor which administers

Occupational Safety and Health Act


Protect and promote the health, social and economic well-being of all Americans and in particular those least able to help themselves—children, the elderly, persons with disabilities and the disadvantaged—by helping them and their families develop and maintain, productive, and independent lives. (1996)


Administration for Children and Families (ACF)

Administration on Aging (AoA)

Agency for Healthcare Research and Quality (AHRQ)

Agency for Toxic Substances and Disease Registry (ATSDR)

Centers for Disease Control and Prevention (CDC)

Centers for Medicare & Medicaid Services (CMS)

Food and Drug Administration (Food and Drug Administration)

Health Resources and Services Administration (HRSA)

Indian Health Service (IHS)

National Institutes of Health (NIH)

Program Support Center (PSC)

Substance Abuse and Mental Health Services Administration (SAMHSA)

Centers for Medicare & Medicaid Services

The Centers for Medicare & Medicaid Services (CMS) administers the

Medicare program and works in partnership with the States to administer:

• Medicaid,

• The State Children's Health Insurance Program (SCHIP), and

• Health insurance portability standards.

In addition to these programs, CMS has other responsibilities, including:

• The administrative simplification standards from the Health Insurance Portability and Accountability Act of 1996 (HIPAA),

• Quality standards in health care facilities through its survey and certification activity, and clinical laboratory quality standards.

o Medicare

o Medicaid

o State Children's Health Insurance Program (SCHIP)

o The Health Insurance Portability and Accountability Act of 1996 (HIPAA)

o Clinical Laboratory Improvement Amendments (CLIA)

The Medicare Program

Medicare (Title XVIII) is a social insurance a program for people age 65Ø and older and for some disabled people under 65

Mandated by 1965 Social
Ø Security Act and administered by DHHHS


- Part A – Hospital Insurance – pays for medically necessary inpatient hospital care, inpatient care in a skilled nursing facility after a hospital stay, home-health care, and hospice care

- Part B – Outpatient Care

The Medicaid Program

Medicaid eligibility is limited to individuals who fall into specified categories:

• Pregnant women,

• children and teenagers,

• individuals who are aged, blind, or disabled.

The rules for counting income and resources vary from State to State and from group to group.

States have a wide degree of flexibility in designing their programs.

The portion of the Medicaid program that is paid by the Federal Government is known as the Federal Medical Assistance Percentage.

Certification under Medicare/Medicaid

Certification and/or recertification means that an agency can bill Medicare and/or Medicaid for the services provided if the patient is covered by Medicare and/or Medicaid (publicly funded insurance programs)

The federal regulations become the standards that an institution must meet if it wishes to participate in Medicare and /or Medicaid programs

The standards are known as the Conditions of Participation

Medicare/Medicaid Conditions of Participation

The Conditions of Participation are part of the Code of Federal Regulations, last revised by HCFA in 1986 (final rule published June 17, 1986, in the Federal Register, Volume 51, No. 116, pp. 22010-22052).

Hospitals must meet the Conditions established by Medicare and Medicaid to receive reimbursement for treating program beneficiaries.

The Conditions of Participation are part of the Code of Federal Regulations, last revised by HCFA in 1986 (final rule published June 17, 1986, in the Federal Register, Volume 51, No. 116, pp. 22010-22052).

Hospitals must meet the Conditions established by Medicare and Medicaid to receive reimbursement for treating program beneficiaries.

Conditions related to these services or functions must be met by all hospitals participating in Medicare and Medicaid programs:

• Governing body

• Patients' rights

• Quality assessment and performance improvement

• Medical staff

• Nursing services

• Medical record services

• Pharmaceutical services

• Radiological services (contract service OK)

• Laboratory services (contract service OK)

• Food and dietetic services (contract service OK)

• Utilization review

• Physical environment

• Infection control

• Discharge planning .

Conditions for optional services are applicable if the institution offers such services:

- Organ, tissue, and eye procurement

- Surgical services

- Anesthesia services

- Nuclear medicine

- Outpatient services

- Emergency services

- Rehabilitation services

- Respiratory care services

Swing beds (between acute and skilled services)

Special conditions apply to psychiatric hospitals, related to

• Medical record requirements

• Staffing requirements

The conditions:

  • Require services to be organized, leaving the details to the institutions;
  • Specify credentials for directors of services that involve direct patient care activities, leaving most non-director and non-patient care staff qualification and staffing level determinations to the institution consistent with the institution's scope of services;
  • Specify standards on the delivery of services (e.g., scope, restrictions, safety, etc; and
  • Specify records that must be maintained.

Aspects of Federal Standards

o Surveyors of health care facilities are concerned with three aspects of standards:

o Capacity concerns the physical plant—the professional and nonprofessional staff and equipment

o Performance refers to how the capacity of the facility is used and is a much more complex judgment for the surveyor than capacity

o Product is based on the maintenance of the patient's well-being

Medicare Legislation of 1965

• Granted "deemed status" to any hospital accredited by the Joint Commission on Accreditation of Hospitals.

• Deemed status is a legal term meaning in accordance with federal law, agencies accredited by certain bodies are in automatic compliance with all the conditions of participation in the Federal Registry for that particular type of agency.

• The Joint Commission is the only organization with deemed status for the accreditation of hospitals.

• Accreditation is a voluntary process.

• DHHS conducts validation surveys on 10% of all Joint Commission accredited hospitals each year.

Role Of CSM In Quality Improvement





Recently Asked Questions

Ask a question and we will answer it within the next 48 hours.  If you have no questions, please review the answer to the questions asked by others: 


Question:  1. Does JCAHO have jurisdiction and render accreditation surveys overseas i.e. international since US healthcare organizations are buying and operating hospitals abroad? 2. Since most accreditation surveys are good for a period of 3 years, do you think the length of time between assessments is optimal to promote patient safety? 3. What is the rationale for having accreditation process dependent on voluntary participation and why US accreditation agencies have limited enforcement ability?   Answer:  1. Joint Commission International (JCI) extends the Joint Commission's (JCAHO) mission worldwide. Through international consultation, accreditation, publications and education, Joint Commission International helps to improve the quality of patient care in many nations. Joint Commission International has extensive international experience working with public and private health care organizations and local governments in more than 60 countries. For more information please check JCI web site at : 2. Despite the fact that JCAHO accreditation is good for 3 years, however the new survey process requires a continuous state of readiness thorough the periodic performance review. Also, starting 2006, the visit will be unannounced during the year of the survey. JCAHO can perform unannounced surveys at any time in between the visits. 3. The rational to have accreditation as voluntary process is that it is not governmental licensure that is required by law. It is an approach to improve quality within the healthcare organization and to maintain it. Accreditation gets its power from the consumer who trusts the accrediting agency. It has become almost impossible to survive in the healthcare industry without accreditation due to the fact that it is required by patients, CMS, health plans and all managed care companies.

Question:  Since JCAHO is the only organization with deemed status for accreditation of hospitals does AAAHC grant deemed status to outpatient hospitals and are the same conditions of participation apply as well?  Answer:  It is not clear from the published information that AAAHC is granted deemed status to outpatient hospitals. For CMS conditions of participation please check the following web site

Question:  Does the section on AOA tell us that AOA does not go out and do the accreditation visits and does it tell us that COA does the accrediting of psychiatric facilities for AOA? Thank you AnswerUnfortunately, the instructor for this course is not available until the summer to answer the questions posted on the web.

Question:  Explain how licensure, certification (for Medicare) and accreditation for healthcare organizations are similar and how they are different?  Answer:  Please take a look at

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Providers and suppliers can apply to enroll in the Medicare program using one of the following two methods:   Internet-based Provider Enrol...

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