ACCREDITATION- DEEMED STATUS Anita Laumann, RN, BSN  Nurse Consultant Lead Cindy Deporter,  Acting Assistant Section Chief  Division of Health Service Regulation Acute and Home Care Section Anita Laumann, RN, BSN  Nurse Consultant Lead Cindy Deporter,  Acting Assistant Section Chief  Division of Health Service Regulation Acute and Home Care Section

Laws and Regulations “Section 1865(a)(1) of the Social Security Act (the Act) permits providers and suppliers ‘accredited’ by an approved national organization(AO)to be exempt from routine surveys by State survey agencies to determine compliance with Medicare conditions. Accreditation by an AO is voluntary and is not required for Medicare certification.”

CMS-Approved Accrediting Organizations for Home Health and Hospice Agencies  Accreditation Commission for Health Care, Inc. (ACHC)  Community Health Accreditation Program (CHAP)  The Joint Commission (TJC)  Accreditation Commission for Health Care, Inc. (ACHC)  Community Health Accreditation Program (CHAP)  The Joint Commission (TJC)

Deemed Status Agencies  State Agency (SA) does not conduct a survey to initially certify or recertify compliance with the Medicare Condition of participation (CoPs)  Deemed agencies are under the jurisdiction of the Accrediting (AO), not the SA, for oversight of ongoing compliance  The SA may conduct a Validation survey at the direction of CMS  State Agency (SA) does not conduct a survey to initially certify or recertify compliance with the Medicare Condition of participation (CoPs)  Deemed agencies are under the jurisdiction of the Accrediting (AO), not the SA, for oversight of ongoing compliance  The SA may conduct a Validation survey at the direction of CMS

Validation Surveys Validation surveys are intended to furnish information on the validity of the survey process of accrediting organizations for compliance with the CoPs A validation survey provides a process for a “look behind” of an AO A “look behind” is 2-fold.  Validating the AO’s compliance with the survey process  Validating the agency’s compliance with the CoPs Validation surveys are intended to furnish information on the validity of the survey process of accrediting organizations for compliance with the CoPs A validation survey provides a process for a “look behind” of an AO A “look behind” is 2-fold.  Validating the AO’s compliance with the survey process  Validating the agency’s compliance with the CoPs

DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES AUTHORIZATION FOR STATE AGENCY HOME HEALTH AGENCY VALIDATION SURVEY 1. NAME AND ADDRESS OF STATE AGENCY NAME AND ADDRESS OF HOME HEALTH AGENCY CMS CERTIFICATION NUMBER: _______________________________ THIS HHA IS CURRENTLY DEEMED BY (NONE OR MORE THAN 1 MAY BE CHECKED): ACHC CHAP TJC NONE THIS VALIDATION SURVEY IS BASED ON A SAMPLE SELECTION. PLEASE CONDUCT A FULL VALIDATION SURVEY FOLLOWING THE PROTOCOLS AND PROCEDURES FOR A MEDICARE CERTIFICATION SURVEY WITHIN 60 CALENDAR DAYS OF _________________________ (ENTER AO NAME) ACCREDITATION SURVEY END DATE. THE SCHEDULED END DATE OF THE ACCREDITATION SURVEY IS: _______________

Categories for Complaint Intakes  Immediate Jeopardy (IJ)-“ The regulations at 42 CFR define immediate jeopardy as, ‘A situation in which the provider’s noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment, or death to a resident [patient].’”  Non-IJ High- ‘’ Intakes are assigned a “high” priority if the alleged noncompliance with one or more requirements may have caused harm that negatively impacts the individual’s mental, physical and/or psychosocial status and are of such consequence to the person’s well being that a rapid response by the SA is indicated.  Non IJ Medium-” the incident or complaint, if found to be true and uncorrected, would not result in a determination of substantial non-compliance”  Non-IJ Low-” Intakes are assigned this priority if the alleged noncompliance with one or more standards within a Condition of Participation, Coverage or Certification may have caused physical, mental and/or psychosocial discomfort that does not constitute injury or damage.”  Immediate Jeopardy (IJ)-“ The regulations at 42 CFR define immediate jeopardy as, ‘A situation in which the provider’s noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment, or death to a resident [patient].’”  Non-IJ High- ‘’ Intakes are assigned a “high” priority if the alleged noncompliance with one or more requirements may have caused harm that negatively impacts the individual’s mental, physical and/or psychosocial status and are of such consequence to the person’s well being that a rapid response by the SA is indicated.  Non IJ Medium-” the incident or complaint, if found to be true and uncorrected, would not result in a determination of substantial non-compliance”  Non-IJ Low-” Intakes are assigned this priority if the alleged noncompliance with one or more standards within a Condition of Participation, Coverage or Certification may have caused physical, mental and/or psychosocial discomfort that does not constitute injury or damage.”

 IJ Intakes- Non-DEEMED agencies: Survey must begin within 2 working days of receipt of the complaint DEEMED agencies: o To be submitted to the Regional Office (RO) promptly with a request for survey authorization o Survey must begin within 2 working days of receipt of the RO authorization  IJ Intakes- Non-DEEMED agencies: Survey must begin within 2 working days of receipt of the complaint DEEMED agencies: o To be submitted to the Regional Office (RO) promptly with a request for survey authorization o Survey must begin within 2 working days of receipt of the RO authorization Federal Triaging Criteria for Complaints

Cont.  Non-IJ High Intakes- o Non-DEEMED agencies: o Survey must begin within 45 calendar days of prioritization  DEEMED Agencies: o To be submitted to the AO promptly with a request for survey authorization o Survey must begin within 45 calendar days of receipt of the RO authorization  Non-IJ High Intakes- o Non-DEEMED agencies: o Survey must begin within 45 calendar days of prioritization  DEEMED Agencies: o To be submitted to the AO promptly with a request for survey authorization o Survey must begin within 45 calendar days of receipt of the RO authorization

Cont.  Non-IJ Medium Intakes-  Non-DEEMED agencies: o Must be investigated no later than the next on-site visit (recertification or complaint )  DEEMED agencies: o Complainants are to be advised that the complaint does not meet criteria for a Federal investigation o The SA is to provide the complainant information regarding where to submit a complaint to the applicable AO  Non-IJ Medium Intakes-  Non-DEEMED agencies: o Must be investigated no later than the next on-site visit (recertification or complaint )  DEEMED agencies: o Complainants are to be advised that the complaint does not meet criteria for a Federal investigation o The SA is to provide the complainant information regarding where to submit a complaint to the applicable AO

Cont.  Non-IJ Low Intakes-  Non-DEEMED agencies:  To be reviewed, with tracking of possible trends in the nature of the complain, to determine if common themes that may suggest a focused survey be conducted with the next on-site survey  DEEMED agencies: o Complainants are to be advised that the complaint does not meet criteria for a Federal investigation o The SA is to provide the complainant information regarding where to submit a complaint to the applicable AO  Non-IJ Low Intakes-  Non-DEEMED agencies:  To be reviewed, with tracking of possible trends in the nature of the complain, to determine if common themes that may suggest a focused survey be conducted with the next on-site survey  DEEMED agencies: o Complainants are to be advised that the complaint does not meet criteria for a Federal investigation o The SA is to provide the complainant information regarding where to submit a complaint to the applicable AO

NC State Agency Compliance  Maintains systems for tracking survey workload (Initial Certifications, Recertifications, Validations and Complaint Investigations)  Complaints are received from the Complaint Intake Department ( )  Complaints are triaged by Home Care Branch for Home Health and Hospice  Maintains systems for tracking survey workload (Initial Certifications, Recertifications, Validations and Complaint Investigations)  Complaints are received from the Complaint Intake Department ( )  Complaints are triaged by Home Care Branch for Home Health and Hospice

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