Informational Notice: Forthcoming Integration of the Psychiatric Hospital Program into the Hospital Program and State Operations Manual (SOM) Changes

To improve the identification of quality issues, the Centers for Medicare & MedicaidServices (CMS) is in the process of integrating the psychiatric hospital programsurvey into the hospital program survey: Currently the hospital and psychiatrichospital programs are reviewed separately for compliance with the Conditions ofParticipation. Our intent is to ensure psychiatric hospital services are evaluated in thecontext of the overall hospital program to better identify systemic quality issues. •Update and relocation of the Interpretive Guidelines for Psychiatric Hospitals: Theinterpretive guidelines in SOM Appendix AA for the special psychiatric Conditions ofParticipation (CoPs) will be updated and relocated in the interpretive guidance forHospitals in Appendix A. Appendix AA will be deleted. •Develop training to provide the necessary competencies for all State Survey Agencysurveyors to evaluate compliance with the psychiatric hospital CoPs: CMS isdeveloping training to assist surveyors in identifying compliance with the specialpsychiatric hospital CoPs. Currently, the SA surveys the hospital requirements in all non-deemed psychiatric hospitals as well as during validation and complaint surveys ofdeemed psychiatric hospitals. Once the psychiatric program is moved to the hospitalprogram, the hospital survey team will assess compliance with all requirements. Allinterpretive guidelines and survey procedures will be located in Appendix A.