A transplant program must establish and implement written policies to address and document adverse events that occur during any phase of an organ transplantation case. [72 FR 15273, Mar. (2) The hospital must develop and maintain mutually agreed upon protocols that address the duties and responsibilities of the hospital, each transplant program, and the OPO for the DSA where the hospital is situated, unless the hospital has been granted a waiver to work with another OPO, during an emergency. Potentially HIV infectious blood and blood components are prior collections from a donor. Condition of participation: Radiologic services. All patients have the right to be free from physical or mental abuse, and corporal punishment. (i) If the hospital allows a patient to self-administer specific hospital-issued medications, then the hospital must have policies and procedures in place to: (A) Ensure that a practitioner responsible for the care of the patient has issued an order, consistent with hospital policy, permitting self-administration. To file a complaint or grievance for care received at a physicians office or medical practice (non-hospital setting), patients are encouraged to address their concerns directly with the Medical (ii) Multidisciplinary discharge planning for post-transplant care. If you want to ask for a review (appeal) of Mercy Cares action, follow the directions in your notification letter. (4) Include a unified and integrated emergency plan that meets the requirements of paragraphs (a)(2), (3), and (4) of this section. At 85 FR 86303, Dec. 29, 2020, this section was amended, effective Dec. 4, 2020; however, due to a publication error, the amendments were codified at 86 FR 33902, June 28, 2021. (1) The hospital must have a full-time employee who. (ii) A fully funded plan to transfer these records to another hospital or other entity if such hospital ceases operation for any reason. (1) The program must include, but not be limited to, an ongoing program that shows measurable improvement in indicators for which there is evidence that it will improve health outcomes and identify and reduce medical errors. Medical records must be accurately written, promptly completed, properly filed and retained, and accessible. (2) The nursing service must have a procedure to ensure that hospital nursing personnel for whom licensure is required have valid and current licensure. (1) The medical staff must be organized in a manner approved by the governing body. If the blood collecting establishment (either internal or under an agreement) notifies the hospital of the reactive HIV or HCV screening test results, the hospital must determine the disposition of the blood or blood product and quarantine all blood and blood components from previous donations in inventory. (4) To the extent permissible under applicable federal and state law and regulations, and not inconsistent with the patient's expressed privacy preferences, the system sends notifications directly, or through an intermediary that facilitates exchange of health information, either immediately prior to, or at the time of: [72 FR 60788, Oct. 26, 2007, as amended at 84 FR 51821, Sept. 30, 2019; 85 FR 19292, Apr. The transplant program must identify a multidisciplinary transplant team and describe the responsibilities of each member of the team. (2) If a patient on the waiting list is removed from the waiting list for any reason other than death or transplantation, the transplant program must document in the patient's record that the patient (and in the case of a kidney patient, the patient's usual dialysis facility) was notified no later than 10 days after the date the patient was removed from the waiting list. Choosing an item from (ii) Staff who provide support services for the hospital that are performed exclusively outside of the hospital setting and who do not have any direct contact with patients and other staff specified in paragraph (g)(1) of this section. (vi) All practitioners' orders, nursing notes, reports of treatment, medication records, radiology, and laboratory reports, and vital signs and other information necessary to monitor the patient's condition. Original medical records must be released by the hospital only in accordance with Federal or State laws, court orders, or subpoenas. (a) Standard: Eligibility and process for appointment to medical staff. (b) Standard: Dialysis services. No hospital that provides transplantation services shall be deemed to be out of compliance with section 1138(a)(1)(B) of the Act or this section unless the Secretary has given the OPTN formal notice that he or she approves the decision to exclude the transplant hospital from the OPTN and also has notified the transplant hospital in writing. (6) The hospital's discharge planning process must require regular re-evaluation of the patient's condition to identify changes that require modification of the discharge plan. (B) If the hospital experiences an actual natural or man-made emergency that requires activation of the emergency plan, the hospital is exempt from engaging in its next required full-scale community-based exercise or individual, facility-based functional exercise following the onset of the emergency event. (2) All orders, including verbal orders, must be dated, timed, and authenticated promptly by the ordering practitioner or by another practitioner who is responsible for the care of the patient only if such a practitioner is acting in accordance with State law, including scope-of-practice laws, hospital policies, and medical staff bylaws, rules, and regulations. (10) Notification to legal representative or relative. (B) A drug or medication when it is used as a restriction to manage the patient's behavior or restrict the patient's freedom of movement and is not a standard treatment or dosage for the patient's condition. As used in this subpart, the following definitions apply: Adverse event means an untoward, undesirable, and usually unanticipated event that causes death or serious injury, or the risk thereof. (1) The radiologist or other practitioner who performs radiology services must sign reports of his or her interpretations. (e) Standard: Discharge planning and discharge summary. The hospital must develop, implement, and maintain an effective, ongoing, hospital-wide, data-driven quality assessment and performance improvement program. We want to ensure that you are receiving the care and services you need. (2) Facilities, supplies, and equipment must be maintained to ensure an acceptable level of safety and quality. (xii) NFPA 110, Standard for Emergency and Standby Power Systems, 2010 edition, including TIAs to chapter 7, issued August 6, 2009. A kidney transplant program must have written policies and procedures for ongoing communications with dialysis patients' local dialysis facilities. You may have a problem with You may also request a 14 calendar day extension if you need more time to gather information for the appeal. This page provides basic information about being certified as a Medicare Critical Access Hospital (CAH) provider and includes links to applicable laws, will bring you to those results. It is not an official legal edition of the CFR. (4) Nuclear medicine services must be ordered only by practitioner whose scope of Federal or State licensure and whose defined staff privileges allow such referrals. (ii) The patient's admission to the hospital's inpatient services (if applicable). (2) Inform each patient (or support person, where appropriate) of the right, subject to his or her consent, to receive the visitors whom he or she designates, including, but not limited to, a spouse, a domestic partner (including a same-sex domestic partner), another family member, or a friend, and his or her right to withdraw or deny such consent at any time. (1) The governing body must ensure that the services performed under a contract are provided in a safe and effective manner. (1) The governing body must ensure all of the following: (i) Systems are in place and operational for the tracking of all infection surveillance, prevention, and control, and antibiotic use activities, in order to demonstrate the implementation, success, and sustainability of such activities. According to the Managed Care Reform Act, there are two ways by which a patient can challenge decisions made by their managed care plan. (iii) Affect health outcomes, patient safety, and quality of care. (ii) If the blood collecting establishment notifies the hospital that the result of the supplemental, (additional, more specific) test or other follow-up testing required by FDA is positive, the hospital must, (A) Dispose of the blood and blood components; and. Staff must be trained and able to demonstrate competency in the application of restraints, implementation of seclusion, monitoring, assessment, and providing care for a patient in restraint or seclusion. (ii) Each entry must document the patient's name, date of birth, date of death, name of attending physician or other licensed practitioner who is responsible for the care of the patient, medical record number, and primary diagnosis(es). The fastest way to report a grievance is to call Mercy Care GrievanceSystem Department Monday through Friday8 a.m. to5 p.m. at 602586-1719 or 18663865794 (TTY/TDD 711). Condition of participation: Special staff requirements for psychiatric hospitals. Family and Medical Leave Act (FMLA) FMLA applies to any public or private employer with 50 or more employees, as well as to all public agencies, and public and private elementary and secondary schools, regardless of number of employees. This contact form is only for website help or website suggestions. (3) A center that performs 50 percent or more of its transplants on pediatric patients in a 12-month period is not required to meet the clinical experience requirements prior to its request for approval as a pediatric transplant center. (v) The prevention and control of HAIs, including auditing of adherence to infection prevention and control policies and procedures by hospital personnel. Filing a grievance will not affect your future health care or the availability of services. (iv) Competency-based training and education of hospital personnel and staff, including medical staff, and, as applicable, personnel providing contracted services in the hospital, on the practical applications of antibiotic stewardship guidelines, policies, and procedures. (a) Standard: Discharge planning process. The hospital must maintain, or have available, radiologic services according to needs of the patients. You will get a letter (Notice of Adverse Benefit Determination) when a service has been denied or changed. Network organization means the administrative governing body to the network and liaison to the Federal government. Sometimes, we may need more information to make a decision. 1302, 1395hh, and 1395rr, unless otherwise noted. At a minimum, this direct consultation must occur periodically throughout the fiscal or calendar year and include discussion of matters related to the quality of medical care provided to patients of the hospital. The hospital must maintain and demonstrate evidence of its QAPI program for review by CMS. (iii) Within 3 calendar days after the blood collecting establishment supplied blood and blood components collected from an infectious donor, whenever records are available. (ii) By trained staff using both video and audio equipment. Grievance - Glossary | HealthCare.gov (i) If the blood collecting establishment notifies the hospital that the result of the supplemental (additional, more specific) test or other follow-up testing required by FDA is negative, absent other informative test results, the hospital may release the blood and blood components from quarantine. If your grievance was reviewed by our Quality Management department, you will get the resolution in writing. (5) The operating room register must be complete and up-to-date. website belongs to an official government organization in the United States. Patient selection criteria must ensure fair and non-discriminatory distribution of organs. (ii) Drugs listed in Schedules II, III, IV, and V of the Comprehensive Drug Abuse Prevention and Control Act of 1970 must be kept locked within a secure area. (1) CMS will compare each transplant program's observed number of patient deaths and graft failures 1-year post-transplant to the center's expected number of patient deaths and graft failures 1-year post-transplant using the data contained in the most recent Scientific Registry of Transplant Recipients (SRTR) program-specific report. The hospital must require appropriate staff to have education, training, and demonstrated knowledge based on the specific needs of the patient population in at least the following: (i) Techniques to identify staff and patient behaviors, events, and environmental factors that may trigger circumstances that require the use of a restraint or seclusion. (ii) Understanding of the potential impact of family and other external pressures on the prospective living donor's decision whether to donate and the ability to discuss these issues with the donor. (3) Except as specified in paragraph (e) of this section, reviews may be conducted on a sample basis. (ii) The Secretary may impose additional requirements if they are found necessary in the interest of the health and safety of the individuals who are furnished services in hospitals. contact the publishing agency. (b) Standard: Discharge of the patient and provision and transmission of the patient's necessary medical information. (2) Periodic inspection of equipment must be made and hazards identified must be promptly corrected. (d) Standard: Records. (a) Standard: Pharmacy management and administration. Condition of participation: Laboratory services. (4) All records must document the following, as appropriate: (A) A medical history and physical examination completed and documented no more than 30 days before or 24 hours after admission or registration, but prior to surgery or a procedure requiring anesthesia services, and except as provided under paragraph (c)(4)(i)(C) of this section. 42 CFR 482.61 The hospital must also provide such data directly to the Department when requested by the Secretary. A hospital must protect and promote each patient's rights. 482.62 Condition of participation: Special staff requirements for psychiatric hospitals. The hospital is not required to review an extended stay that does not exceed the outlier threshold for the diagnosis. Outpatient services must be appropriately organized and integrated with inpatient services. The transplant program must ensure that all individuals who provide services and/or supervise services at the program, including individuals furnishing services under contract or arrangement, are qualified to provide or supervise such services. The organization of the nuclear medicine service must be appropriate to the scope and complexity of the services offered. If the director does not hold a masters degree in social work, at least one staff member must have this qualification. 30, 2007, as amended at 84 FR 51822, 51824, Sept. 30, 2019]. (b) Standard: Transplant surgeon and physician. Grievance in the context of health care means a complaint about the manner in which medicare health plan gives care. We are committed to resolving your concerns as quickly as possible and in no more than 90 calendar days from the date you submitted your grievance. HHAs must request to be listed by the hospital as available. (3) The type or technique of restraint or seclusion used must be the least restrictive intervention that will be effective to protect the patient, a staff member, or others from harm. In most cases, we will resolve your appeal within 30 calendar days. (3) Radiation workers must be checked periodically, by the use of exposure meters or badge tests, for amount of radiation exposure. You will get a letter (Notice of Adverse Benefit Determination) when a service has been denied or changed. (1) Drugs and biologicals must be prepared and administered in accordance with Federal and State laws, the orders of the practitioner or practitioners responsible for the patient's care, and accepted standards of practice. (1) All rehabilitation services orders must be documented in the patient's medical record in accordance with the requirements at 482.24. is available with paragraph structure matching the official CFR Complaints for all the licensing and If we deny your appeal, you may request that AHCCCS look at our decision through a State Fair Hearing. 482.100 Condition of participation: Organ procurement. (iv) TIA 124 to NFPA 99, issued March 7, 2013. (4) Section 1883 of the Act sets forth the requirements for hospitals that provide long term care under an agreement with the Secretary. (i) This list must only be presented to patients for whom home health care post-hospital extended care services, SNF, IRF, or LTCH services are indicated and appropriate as determined by the discharge planning evaluation. 7, 1988; 68 FR 1386, Jan. 10, 2003; 69 FR 49267, Aug. 11, 2004; 70 FR 15238, Mar. Hospitals that maintain an onsite fuel source to power emergency generators must have a plan for how it will keep emergency power systems operational during the emergency, unless it evacuates. The hospital must not specify or otherwise limit the qualified providers or suppliers that are available to the patient. (3) Document that the living donor has given informed consent, as required under 482.102. (1) The director of the social work department or service must have a master's degree from an accredited school of social work or must be qualified by education and experience in the social services needs of the mentally ill. (c) A center that performs 50 percent or more of its transplants in a 12-month period on pediatric patients must be approved to perform pediatric transplants in order to be approved to perform adult transplants. (3) A postanesthesia evaluation completed and documented by an individual qualified to administer anesthesia, as specified in paragraph (a) of this section, no later than 48 hours after surgery or a procedure requiring anesthesia services. 30, 2007, as amended at 79 FR 27155, May 12, 2014; 81 FR 79880, Nov. 14, 2016; 84 FR 51822, Sept. 30, 2019]. Community Legal Aid has a grievance procedure if you are not satisfied with the service provided. (2) The hospital must measure, analyze, and track quality indicators, including adverse patient events, and other aspects of performance that assess processes of care, hospital service and operations. (b) Standard: Delivery of service. 482.30 Condition of participation: Utilization review. (3) The patient has the right to be free from all forms of abuse or harassment. Condition of participation: Infection prevention and control and antibiotic stewardship programs. (2) The provision of care and the personnel qualifications must be in accordance with national acceptable standards of practice and must also meet the requirements of 409.17 of this chapter. Simultaneous restraint and seclusion use is only permitted if the patient is continually monitored, (i) Face-to-face by an assigned, trained staff member; or. eCFR This function may be delegated to the hospital's organized pharmaceutical service. (c) Standard: Content of record. (3) The UR committee must make the periodic review no later than 7 days after the day required in the UR plan. (1) There must be emergency power and lighting in at least the operating, recovery, intensive care, and emergency rooms, and stairwells. (ii) Conduct an additional annual exercise that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or an individual, facility-based functional exercise; or. (i) Each order for restraint or seclusion used for the management of violent or self-destructive behavior that jeopardizes the immediate physical safety of the patient, a staff member, or others may only be renewed in accordance with the following limits for up to a total of 24 hours: (A) 4 hours for adults 18 years of age or older; (B) 2 hours for children and adolescents 9 to 17 years of age; or, (C) 1 hour for children under 9 years of age; and. 42 CFR 482.60 If your provider agrees, we will expedite the resolution of your appeal. There must be a director of social services who monitors and evaluates the quality and appropriateness of social services furnished. For distant-site physicians and practitioners requesting privileges to furnish telemedicine services under an agreement with the hospital, the criteria for determining privileges and the procedure for applying the criteria are also subject to the requirements in 482.12(a)(8) and (a)(9), and 482.22(a)(3) and (a)(4). (c) Standard: Orders for outpatient services. (iii) Other practitioner, or other practice group or entity, identified by the patient as the practitioner, or practice group or entity, primarily responsible for his or her care. (ii) When verbal orders are used, they must only be accepted by persons who are authorized to do so by hospital policy and procedures consistent with Federal and State law. (c) Standard: Facilities. (1) Except as specified in paragraphs (b) (2) and (3) of this section, the UR committee must be one of the following: (i) A staff committee of the institution; (A) Established by the local medical society and some or all of the hospitals in the locality; or. The nursing care plan may be part of an interdisciplinary care plan. (1) The patient has the right to personal privacy. or Condition of participation: Quality assessment and performance improvement program. (2) The number of qualified therapists, support personnel, and consultants must be adequate to provide comprehensive therapeutic activities consistent with each patient's active treatment program. (2) If a program performs living donor transplants, each living donor is under the care of a multidisciplinary patient care team coordinated by a physician throughout the donor evaluation, donation, and discharge phases of donation.