Understanding CoPs’ Role in Healthcare Security

Your security department can help your hospital avoid receiving an immediate jeopardy finding by complying with CMS’ Condition of Participation.

In this continuation from the November 2012 article, Healthcare Security Regulatory Requirements: More Than Just Good Ideas, we will focus on one of the most important agencies regarding regulatory compliance in the healthcare setting, which is the Centers for Medicare and Medicaid Services (CMS). CMS, previously known as the Health Care Financing Administration (HCFA) is a federal agency within the U.S. Department of Health and Human Services, and their primary missions are to work in partnership with state governments to administer Medicare and Medicaid services, State Children’s Health Insurance Programs (SCHIP) and police health insurance portability rules and standards (i.e. oversight of HIPAA). Through the CMS survey and certifications processes, a wide array of healthcare providers have their quality standards assessed, and these include acute care and long term care facilities as well as clinical laboratory settings (under the Clinical Laboratory Improvement Amendments, or CLIA).

As part of this duty, CMS has developed Conditions of Participation (CoPs) and Conditions for Coverage (CfCs), which healthcare organizations must meet in order to participate in Medicare and Medicaid programs. The goal of these health and safety standards is to improve quality and protect the health and safety of patients and clients. At the same time, they ensure that standards of healthcare accrediting organizations (such as the Joint Commission), which are recognized and deemed by CMS, meet or exceed the standards that they set forth.

Noncompliance With CoPs Can Be Costly

As mentioned previously, using a simplified category system of “must have,” “should have” and “nice to have,” compliance with the CoPs is a must. Failure to do so can have dramatically unpleasant consequences for the organization violating them. Failure to meet the CoPs can (and often does) result in a potential immediate jeopardy status for the healthcare provider, which is one of the most serious issues a hospital or facility can face since failure to resolve such situations properly can result in the loss of participation in the Medicare and Medicaid program.

Immediate jeopardy is a situation in which the healthcare provider’s noncompliance with one or more requirements of licensure has caused, or is likely to cause, serious injury or death to the patient. A situation meeting these criteria becomes an immediate jeopardy condition at the time it occurs, and correction of the situation does not mean it is no longer an immediate jeopardy. If, when the situation occurred, it was an immediate jeopardy, the facility can still be cited for the situation at a time after the immediate jeopardy condition has been abated, and the department has completed its investigation and evaluation of the situation. Such abatements can take the form of additional education and training of staff, or the updating of procedures and processes, or changes to the physical environment of the facility (such as the addition of duress alarms for staff). While there are myriad clinical and non-clinical issues that could potentially trigger immediate jeopardy situations, this article will only focus on those more commonly associated with the security function of an organization.  

§482.13(c)(1) – The patient has the right to personal privacy.

While this would not immediately strike many as a security issue, with the increasing installation and ubiquitous use of CCTV and other surveillance devices in the healthcare setting, security practitioners must make sure such equipment, even though it has a legitimate and necessary purpose, does not unintentionally invade the privacy of a patient per CMS CoPs. According to CMS CoPs, video or other electronic monitoring/recording methods should not be used while a patient is being examined without his or her consent. Only in cases where extraordinary measures must be taken, such as when a person must be continuously observed (such as when the patient is restrained or in seclusion, poses an immediate and serious risk to himself, is on suicide precautions or other special observation status) should this type of equipment be considered.

Per the CMS rule, “In most situations, security cameras in non-patient care areas such as stairwells, public waiting areas, outdoor areas, entrances, etc., are not generally affected by this requirement.” If in doubt about the use of CCTV (especially that of covert installations), always involve your risk management and legal departments for their interpretation of the intent and use of the video surveillance, and if “monitored only” or recorded video is the correct option for each patient treatment area.

§482.13(c)(2) – The patient has the right to receive care in a safe setting

 This is a sometimes difficult condition to interpret since a “safe setting” can mean so many different things to different people. From a security standpoint however, a safe setting would include protection of vulnerable patients (i.e. newborns, children) and other high risk  patients (such as behavioral health patients) with reasonable and appropriate security measures and processes. It also provides protection for the patient’s emotional health and safety as well as his or her physical safety (components of this include respect, dignity and comfort).

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