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CMS and JCAHO Healthcare Security Requirements Summary - Articles Surfing

Every healthcare organization/hospital accepting payment for Medicare and Medicaid patients is required to meet certain Federal standards called 'Conditions of Participation' (CoPs).

These Federal requirements are promulgated by the Centers for Medicare and Medicaid to improve quality and protect the health and safety of patients. Compliance is based on surveys conducted by state agencies on behalf of the CMS. Conditions of Participation are regulatory standards hospitals agree to follow as a condition for receiving federal funding through the Medicare program.

Under an agreement with CMS, State healthcare licensure agencies conduct surveys of hospitals and enforce compliance with CoPs and ensure that Conditions of Participation are being practiced. Hospitals and other healthcare facilities are subject to random onsite reviews. Unannounced surveys can result from patient or public complaints or inquiries. Healthcare Security is an important element for the new 2006 Conditions of Participation.

Department of Health & Human Services
Centers for Medicare & Medicaid Services
(Healthcare Security)


Title 42CFR, Volume 3 - '482.13 Condition of Participation: Patients' Rights

A hospital must protect and promote each patient's rights

Interpretive Guidelines '482.13

These requirements apply to all Medicare or Medicaid participating hospitals including short-term, acute care, surgical, specialty, psychiatric, rehabilitation, long-term, childrens' and cancer, whether or not they are accredited. This rule does not apply to critical access hospitals. (See Social Security Act (the Act) '1861(e)).

These requirements, as well as the other Conditions of Participation in 42 CFR '482, apply to all parts and locations (outpatient services, provider-based entities, inpatient services) of the Medicare participating hospital.



Title 42, Volume 3 CFR - '482.13(c)(2) The patient has the right to receive care in a safe setting.

Interpretive Guidelines for '482.13(c)(2)

The intention of this requirement is to specify that each patient receives care in an environment that a reasonable person would consider to be safe. For example, hospital staff should follow current standards of practice for patient environmental safety, infection control and security. The hospital must protect vulnerable patients, including newborns and children. Additionally, this standard is intended to provide protection for the patient's emotional health and safety as well as his/her physical safety. Respect, dignity and comfort would be components of an emotionally safe environment.

Survey Procedures '482.13(c)(2)

' Review and analyze patient and staff incident and accident reports to identify any incidents or patterns of incidents concerning a safe environment. Expand your review if you suspect a problem with safe environment in the hospitals.

' Review QAPI, safety, infection control and security (or the committee that deals with security issues) committee minutes and reports to determine if the hospital is identifying problems, evaluating those problems and taking steps to ensure a safe patient environment.

' Observe the environment where care and treatment are provided.

' Observe and interview staff at units where infants and children are inpatients. Are appropriate security protections (such as alarms, arm banding systems, etc.) in place? Are they functioning?

' Review policy and procedures on what the facility does to curtail unwanted visitors or contaminated materials.

' Access the hospital's security efforts to protect vulnerable patients including newborns and children. Is the hospital providing appropriate security to protect patients? Are appropriate security mechanisms in place and being followed to protect patients?


The use of handcuffs or other restrictive devices applied by law enforcement officials who are not employed by or contracted by the hospital is for custody, detention, and public safety reasons, and is not involved in the provision of health care. Therefore, the use of restrictive devices applied by and monitored by law enforcement officers who are not employed or contracted by the hospital, and who maintain custody and direct supervision of their prisoner are not governed by '482.13(f)(l-3). The individual may be the law enforcement officer's prisoner but he/she is also the hospital's patient. The hospital is still responsible for providing safe and appropriate care to their patient. The condition of the patient must be continually assessed, monitored and reevaluate.

JCAHO ' 2006
(Healthcare Security)


The Joint Commission on Accreditation of Healthcare Organizations evaluates and accredits more than 18,000 healthcare organizations and programs throughout the United States. Hospitals aggressively seek Joint Commission accreditation to meet Medicare certification and licensure requirements. Accreditation is also a condition of reimbursement for many insurers and other payers. In addition, JCAHO Accreditation reduces the hospital's liability insurance premiums. Beginning in 2006 JCAHO will conduct all surveys without prior notice.

The Joint Commission has accredited hospitals for more than 50 years and today accredits over 80 percent of the nation's hospitals. The Centers for Medicaid & Medicare Services (CMS) have required JCAHO accreditation by US hospitals since 1965 as a 'Condition of Participation' requirement in order for them to receive Medicaid and Medicare reimbursements.

The Joint Commission and Healthcare Security

The Joint Commission's Standards address the hospital's performance in specific areas, and specify requirements to insure that patients are provided a safe and secure environment. 2006 Environment of Care© requirements include, but are not limited to the following:

' Development and maintenance of a written Security Management Plan to include an Emergency Management Plan.

' Conduct an annual Risk Assessment that evaluates the potential adverse impact of the external environment on the security of patients, staff, and others coming to the facility.

' Use the risks identified to select and implement procedures and controls to achieve the lowest potential for adverse impact on security.

' Identify, as appropriate, patients, staff and other people entering the facility.

' Access Control / Physical Protection ' control access to and egress from security sensitive areas, as determined by the organization.

' Mitigate Violence in the Emergency Department and other locations.

' Education and Training ' staff, licensed practitioners, and volunteers have the knowledge and skills necessary to perform their responsibilities within the environment.

' Develop and implement a proactive infant abduction prevention plan.

' Include information on visitor/provider identification as well as identification of potential abductors/abduction situations (during staff orientation and in-service curriculum programs).

' Enhance parent education concerning abduction risks and parent responsibility for reducing risk and then assess the parents' level of understanding.

' Attach secure identically numbered bands to the baby (wrist and ankle bands), mother, and father or significant other immediately after birth.

' Footprint the baby, take a color photograph of the baby and record the baby's physical examination within two hours of birth.

' Require staff to wear up-to-date, conspicuous, color photograph identification badges.

' Discontinue publication of birth notices in local newspapers.

' Consider options for controlling access to nursery/postpartum unit such as swipe-card locks, keypad locks, entry point alarms or video surveillance (any locking systems must comply with fire codes).

' Consider implementing an infant security tag or abduction alarm system.

Material in this brochure provided to Accutech-ICS (www.Accutech-ICS.com) by Security Assessments International, Inc., www.saione.com


The information provided by Accutech-ICS.com and SAI is in accordance with our understanding of current JCAHO and CMS Regulations. It is intended for educational purposes only and should not be considered 'legal' advice. Please consult with your legal counsel or Compliance Officer for clarification of laws and rules related to your State when applicable.

Accutect-ICS.com and SAI are not affiliated with the Joint Commission on Accreditation of Healthcare Organizations.

Accutech-ICS.com and SAI - ©January, 2006

Submitted by:

Karl Radke

Karl Radke is the director of sales and marketing at Innovative Control Systems, Inc (ICS) headquartered in Franklin, Wisconsin. Karl has been vital to the marketing and development of the Accutech product line. Accutech is recognized as the market leader in infant and pediatric security while maintaining a strong role in long-term care and assisted living markets.

For more information about Accutech, visit http://www.Accutech-ICS.com or e-mail Karl at karlr@accutech-ics.com.



Copyright © 1995 - Photius Coutsoukis (All Rights Reserved).


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