Approved: Hospital Program Revisions to Align with Critical Access Hospital Changes and the Hospital Conditions of Participation
As part of the US Centers for Medicare & Medicaid Services’ (CMS) review of The Joint Commission’s critical access hospital deeming renewal application, The Joint Commission made several changes to its Elements of Performance (EPs) for critical access hospitals, effective August 27, 2023, to better align with CMS Conditions of Participation (CoPs) (see the July issue of Perspectives). The Joint Commission has also made some of the same revisions for hospitals to better align with the Joint Commission requirements for critical access hospitals and the CMS CoPs. The hospital revisions are effective January 1, 2024.
The changes made include the following:
The AEM and manufacturer’s recommendations language was removed from the EPs to clarify that medical and utilities equipment must be maintained, but it is up to the hospital to determine how it will perform that maintenance, whether it be through manufacturer-recommended maintenance activities and schedules or an AEM program. The July 1, 2023, update to the organization Survey Activity Guide will include guidance related to specific requirements for an AEM program.
Prepublication Standards - Effective January 1, 2024