Comparison and contrast of the licensure, certification and accreditation requirements of the services of long-term care contiinuum
Without certification by the federal government, a hospital cannot receive payment for services provided to Medicare or Medicaid beneficiaries. The Joint Commission on Accreditation of Health Care Organizations (JCAHO) determines that hospitals accredited by this body meet or exceed JCAHO standards and that they also meet federal certification standards.
To be certified and accredited according to JCAHO standards, a hospital must invite agents of the Center of Medicare and Medicaid Services (CMS) for inspection of its facilities. Before the hospital is granted certification, the working condition of these facilities must meet federal standards. Such facilities as may be subjected to inspection include rural health centers, end stage renal disease facilities, ambulatory signal centers, and facilities for persons with developmental disabilities.
A second very important segment of the continuum of long term care is nursing homes. A facility must meet Medicare requirements to qualify for reimbursement. Nursing homes are highly regulated at both federal and state levels. To be reimbursed by Medicare or Medicaid, a nursing home must be certified.
Certification: To be certified by JCAHO, nursing homes must meet the two basic stipulations of the Omnibus Budget Reconciliation Act of 1987 (OBRA, 1987). These stipulations are that:
i. There shall be no compromise on the quality of staff employed in nursing homes;
ii. All the medical, dietary, pharmaceutical, psychological, physical and mental-ill-health services, must meet definite standards.
Besides, an on-site inspection is carried out on the site of the nursing homes, to ascertain the quality of:
i. Residential care processes;
ii. Staff/resident interaction;
iii. environmental condition
The inspection is to determine whether individual resident meets are met, whether the interaction between staff and resident is satisfactory with respect to the purpose of an ideal nursing home, and whether environmental sanitation and health standards are complied with, regarding cleanliness, safe storage and preparation of food, protection from physical and mental abuse, and adequate care practices.
Licensure: The licensing requirements of nursing home are established by the congress. In general, to be issued a license, a nursing home must be staffed with sufficient and qualified personnel and must meet the physical plant standards of the federal safety codes.
Home Health Agencies
Licensure: Most states license Medicare certified home health agencies as a health care provide. This is done under the jurisdiction of the states health department.
Certification: Home health care agencies must be certified in order to obtain Medicare reimbursement. The major licensing requirement for home health agencies is that:
Agencies “shall be governed by a governing authority, “shall maintain an active professional advisory committee, and shall “be directed by an administrator and operate any services offered in compliance with these regulations.”
This governing authority must have full legal authority and responsibility for the operation of the agency “which shall adopt bylaws and rules that are periodically reviewed…” The professional body, on the other hand, must be appointed by the governing authority and must consist of at least one physician, one public health nurse, one therapist representative, and one social worker.
Certification: The certification requirements are inherent in the conditions of participation (COP’s) of home health agencies in the delivery of health care services according to standards, in the Omnibus Budget Reconciliation Act of 1989( OBRA, 1989), and in the Outcome Assessment and Information (OASIS) system. The OBRA, 1989, stipulates a “periodicity schedule”, which is a mandatory regular delivery of definite kind of standard services. It “schedules for Periodic Screening, Vision, and Hearing services must be provided at intervals that meet reasonable standards of medical practice. …”. OASIS forms the basis for what is called “patient outcomes’, which is a means of uplifting the quality of services based on the quality of treatment and results patients receive and evidence.
“The OASIS is a key component of Medicare’s partnership with the home care industry to foster and monitor improved home health care outcomes and is proposed to be an integral part of the revised Conditions of Participation for Medicare-certified home health agencies.”
“Any HHA seeking Medicare certification is required to meet the Medicare condition of Participation (COPs) prior to certification. This includes compliance with the OASIS collection and transmission requirements .New HHAs must demonstrate they can transmit OASIS data prior to initial certification . Specifically, new HHAs must apply for temporary user identification number and passwords from the state agency (OASIS) automation coordinator ( OAC).”
Accreditation: To be accredited, home health agencies must comply with JCAHO’s ORYX. This is “a data collection of clinical measures”, which provides information on the clinical performances of the home health agency seeking accreditation.
Licensure: Licensure is by state. Almost all states recognize hospice as a distinct category. In states without licensure programs, hospices are allowed to operate with Medicare certification and sometimes are also licensed as home health agency, nursing home, or hospital.
Certification: To receive payment from Medicare or Medicaid, hospices must meet federal certification requirements. Medicare has extensive conditions of participation, and Medicaid regulations mirror those of Medicare. Hospices certified by Medicare serve Medicare enrollees, who must meet Medicare’s eligibility criteria to receive the benefit, but may also serve others, such as those whose care is paid by commercial insurance, managed care, or out of pocket. . Accreditation: The joint commission on accreditation of health care organizations (JCAHO), the community health accreditation program, (CHAP), and the Accreditation commission for home care all accredit hospices in the United States. JCAHO & CHAP have deemed status to grant Medicare certification along with accreditation.
Adult Day Services
Licensure: Most states currently require some kind of licensing for ADS programs. The department regulating day care programs may be the state’s department of aging, health care, social services, or other department. Licensing regulations are likely to be minimum but may dictate the qualifications of staff, services offered, participant to staff ratio, physical facility specifications, participant’s rights, admissions process, and required documentation.
Certification: Since Medicare does not pay for ADS, Medicare certification is not applicable. However a number of states do pay for, and thus certify/ license, ADS through the Medicaid program. To be certified, an ADS must contact the relevant Department of state to schedule an appointment for inspection visit. Based on the verdicts of the inspectors, the ADS will be required to fill in an assessment form citing standards as “met” or “unmet”. With “Unmet” citations, certification is denied.
Accreditation: Accreditation is also not required by state or federal government. It is voluntary. However, an Accreditation program and standards were developed in the late 1990’s by the Commission for the Accreditation of rehabilitation facilities (CARF). The Commission for the Accreditation of rehabilitation facilities (CARF) and the National Adult Day Services Association (NADSA), formerly the National Institute for Adult Day Services (NIAD), of the National Council on the Aging (NCoA). Accreditation began in 1999. Accreditation is a positive step toward quality assessment and standardization for a care model that has a great deal of variability and relatively little external regulation.
The accreditation of ADS involves inspection of services and interviewing of patients to ensure approximation to Medicare standards.
COMPARISON AND CONTRAST
From the foregoing, it is inferable that:
1. Licensure and certification requirements are generally mandatory, while accreditation requirements, being voluntary, affords the health care organization the privilege of volunteering.
2. Licensure, certification and accreditation all involve issuance of documents of attestation.
3. Accreditation, unlike licensure and certification, is a periodic process of ascertaining standard growth. It recurs at given (or arbitrary) intervals as developments and innovations occur.
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