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The Joint Commission is making several changes to the elements of performance (EPs) for its critical access hospitals (CAHs) to better align with Centers for Medicare & Medicaid Services’ (CMS) Conditions of Participation. The changes are in response to CMS’ review of The Joint Commission’s CAH deeming renewal application and are effective Aug. 27.
Revisions 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 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 CAH 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 a future update to both the surveyor and organization survey activity guides.
The prepublication standards can be viewed online.