Effective Aug. 27, The Joint Commission is making several changes to the elements of performance (EPs) for its accredited critical access hospitals (CAHs) to better align with Centers for Medicare & Medicaid Services’ (CMS) Conditions of Participation (CoPs).
The changes — which were part of CMS’ review of The Joint Commission’s CAH deeming renewal application — include:
- New EPs to address CMS’ definitions of rural health network and personnel qualifications.
- New EPs addressing the expectation for compliance with the Life Safety Code (NFPA 101-2012) and the Health Care Facilities Code (NFPA 99-2012).
- Revisions to the Environment of Care (EC) chapter removing the references to alternative equipment maintenance (AEM) programs and manufacturer’s recommendations from the requirements for equipment maintenance. The AEM and manufacturer’s recommendations language was removed from the EPs to clarify that maintenance of medical and utilities equipment must be performed, but it is up to the critical access hospital to determine how it will perform that maintenance, whether it be through manufacturer-recommended maintenance activities and schedules or the use of an AEM program. Guidance related to the specific requirements for an AEM program will be added in the July 1 update to both the surveyor and organization survey activity guides.
View the prepublication standards.
The Joint Commission, in collaboration with the Alzheimer’s Association, launched Memory Care Certification for Assisted Living Communities (ALCs) on July 1. The voluntary, specialty certification recognizes Joint Commission-accredited ALCs that meet its standards to support the delivery of high-quality care for residents diagnosed with Alzheimer’s disease or other forms of dementia.
The new certification requirements:
- Reflect current evidence-based practices in memory care.
- Align with the Alzheimer’s Association Dementia Care Practice Recommendations.
- Build on existing requirements for The Joint Commission’s Assisted Living Community Accreditation Program.
The requirements received feedback and expert guidance from a review panel and public field review. The standards specifically address the needs of residents living with dementia, including environment of care requirements that organizations provide visual cues or landmarks in the physical environment to assist with wayfinding, as well as provide an environment in which noises that may overstimulate or distress residents are minimized. Additional requirements address the following domains: human resources; information management; leadership; medication management; the provision of care, treatment and services; and the record of care, treatment and services.
“Approximately 34% of assisted living community residents have Alzheimer’s disease or other dementias — impacting residents, families and healthcare workers across the nation,” said Gina Zimmermann, executive director, Nursing Care Center and Assisted Living Community Services, The Joint Commission, in a news release. “It is key that assisted living communities provide these residents with specialized care to meet their unique needs. Memory Care Certification for Assisted Living Communities provides a unique opportunity to recognize those organizations meeting state-of-the-art standards and implementing best practices for dementia care."
Nearly 50 ALCs across the United States have committed to undergo the optional certification process. ALCs that achieve the certification will be recognized on The Joint Commission’s website and on the Alzheimer’s Association and AARP Community Resource Finder.
The Advanced Certification in Heart Failure addresses care, treatment, and services for all types of heart failure, including new onset heart failure, acute-on-chronic heart failure, and decompensated heart failure, across the continuum of care provided by a robust interdisciplinary team. The requirements for the interdisciplinary team members have been expanded to include emergency room physicians, advanced practice providers (if used by the organization), hospitalists, pharmacists, and cardiologists/heart failure specialists. The revised requirements include more specificity for developing certified organizations’ written protocols, such as utilizing the new heart failure definitions and criteria for assessing, diagnosing, classifying, and staging heart failure through the continuum of care.
The revised requirements also emphasize how using a variety of assessments, such as patient-reported outcomes and assessing health-related social needs, aligns the individualized plan of care with the patient’s goals and supports healthy lifestyle changes.
View the prepublication standards.
“As leading quality organizations, the National Committee for Quality Assurance, The Joint Commission, and the National Quality Forum are committed to collaborating with the Office of the National Coordinator for Health Information Technology (ONC), the Centers for Medicare and Medicaid Services (CMS), and the U.S. Department of Health and Human Services (HHS) to specify, harmonize, and mature interoperability standards and guidance. We believe alignment across measurement organizations is essential as standards evolve, and each organization has carefully reviewed the USCDI+ Quality – Draft Data Element List.
“Collectively, we recognize the USCDI+ Quality – Draft Data Element List is an important first step to establish a minimum data set for use in digital quality measurement and reporting systems.
“In future iterations, we encourage ONC and CMS to engage measure developers, quality and safety organizations, and other industry partners in earlier stages of health data standards development. In particular, we highly recommend transparent and collaborative engagement of measure developers and quality measurement organizations seeking to advance interoperable data for measures.
“We also recommend that ONC and CMS develop with broad stakeholder engagement a more detailed strategic digital quality framework to support advancement and implementation of USCDI+.
“Successful implementation of USCDI+ will require intentional and iterative collaboration across federal and industry stakeholders. We recognize HHS’s national leadership in standards-setting and are eager to engage with ONC as key stakeholders to inform, support, and advance the transition to digital quality measurement.”