Throughout 2019, Joint Commission surveyors detailed compliance with CMS expectation by CMS-A-tags. Surveyors already maintained a list of medical record documentation requirements they explored this information on tracers. But as of July 2019, the organizational survey activity guide now contains this list. And, although it is similar to the evidence detailed on tracers, we believe CMS A-tags present an opportunity.
CMS A-Tags
In fact, that opportunity is a learning exercise. Ask yourself this question.
“Do we all know how to find evidence of compliance somewhere in the medical record of the units involved in tracers to see if they can find all the required documents?”
In addition, here is one way to answer that question. Conduct a scavenger hunt with your staff. Determine how many documents they can find. Furthermore, engage IT experts or superusers to assist the staff on tracers.
What’s more, taking this approach you will help you better prepare for future surveys.
Christi Chavez Joins Patton Healthcare Consulting as Director of Operations.
Can A tags be cited at critical access hospitals?
Technically the acute hospital A tags cannot be cited in critical access hospitals which are regulated by the C tags for critical access hospitals. However the content in both sets of regulations have many similarities. This content is organized differently by COP’s but many of the general expectations are again similar. In general there is a recognition in the COP’s and C tags that critical access hospitals serve a somewhat different mission in rural communities as compared to larger hospitals in metropolitan areas.
Does an inpatient psychiatric unit have to have a director of social work and/or a licensed therapist? This would be an adult psychiatric unit in an acute care hospital. I can only find this verbiage for an exempt unit.
In the Joint Commission hospital standards manual there is no requirement for an inpatient psychiatric unit in an acute care hospital to have a director of social work and/or a licensed therapist. The requirement for Director of Social Services is in the COP Special Requirements for Psych hospitals. There are requirements for psychiatric hospitals that use accreditation for deemed status. Specifically, LD.04.01.05 EP10 requires the hospital has a director of social work services who monitors and evaluates the social work services furnished. LD.04.03.01 EP14 mandates that psychiatric hospital provides psychological services, social work services, psychiatric nursing, and therapeutic activities.
Regarding your question about the mandate for a licensed therapist there is a requirement that staffing meets the needs of your population served. If there is no therapist on a psychiatric unit, who is providing individual therapy, discharge planning, family therapy? The other consideration is whether the individual providing those services is licensed vs unlicensed. This gets into a scope of practice and billing issue. Unlicensed often need co-sign for payment and scope of practice.