Accreditation & Regulatory Journal
March 2023

News You Can Use

March's Compliance Tip of the Month

The compliance tip of the month for March is focused on the patient rights specifically related to the Important Message from Medicare (IMM) that must be provided to patient within 2 days of admission and then again within 2 days of discharge for all Medicare beneficiaries. Surveyors will audit medical records to assure that the IMM is provided to the patient as defined by the regulations.
CMS has recently updated and approved a new version of the Form CMS 10065-IM (Expires 12/31/2025). They have mandated the use of the new form no later than April 27, 2023. The updated forms as well as the instructions are available for download in both English and Spanish at
The CMS regulations are included below. Additionally, the CMS interpretive Guidelines are included for further clarification if available.
§482.13(a) Standard: Notice of Rights
§482.13(a)(1) A hospital must inform each patient, or when appropriate, the patient’s representative (as allowed under State law), of the patient’s rights, in advance of furnishing or discontinuing patient care whenever possible.
Excerpt from CMS Interpretive Guidelines §482.13(a)(1)
In addition, according to the regulation at 42 CFR 489.27(a), (which cross references the regulation at 42 CFR 405.1205), each Medicare beneficiary who is an inpatient (or his/her representative) must be provided the standardized notice, “An Important Message from Medicare” (IM), within 2 days of admission. Medicare beneficiaries who have not been admitted (e.g., patients in observation status or receiving other care on an outpatient basis) are not required to receive the IM. The IM is a standardized, OMB-approved form and cannot be altered from its original format. The IM is to be signed and dated by the patient to acknowledge receipt. See Exhibit 16 for a copy of the IM. Furthermore, 42 CFR 405.1205(c) requires that hospitals present a copy of the signed IM in advance of the patient’s discharge, but not more than two calendar days before the patient’s discharge. In the case of short inpatient stays, however, where initial delivery of the IM is within 2 calendar days of the discharge, the second delivery of the IM is not required.
The hospital must establish and implement policies and procedures that effectively ensure that patients and/or their representatives have the information necessary to exercise their rights.
CIHQ encourages organization to evaluate their policies and documentation mechanisms to assure that they comply to the regulations in order to avoid a deficiency during survey.

CIHQ Applications to CMS as an Accrediting Organization and Expansion of Accreditation Programs - Update

CIHQ has been redesignated by CMS as an approved accrediting organizations for hospitals. We were approved and published in the Federal Register on December 19, 2022. Below is a link for your reference. Federal Register :: Public Inspection: Medicare and Medicaid Programs: Application from the Center for Improvement in Healthcare Quality for Continued Approval of its Hospital Accreditation
The longest designation that CMS can award is for six years. CIHQ was awarded a five-year designation. This was determined based on budgetary issues at CMS. They were not able to shadow a survey which is a part of the application process which prohibited them from awarding the full six years.
CIHQ is expanding its accreditation programs to Critical Access Hospitals. The application process has been completed and approved. The final decision is scheduled to be published on or by May 26, 2023. We are excited about welcoming Critical Access Hospitals to the CIHQ family of accredited organizations.
CIHQ is expanding its accreditation programs to Acute Psychiatric Hospitals.
  • Submission of the Application – Submission is scheduled for February 2023
  • The application, standards and process review will occur. We will complete the five pilot surveys and wish to thank them for allowing us to pilot our process in their hospital.
    • Griffin Memorial Medical Center
    • SD Human Services Center
    • Adventist Health Vallejo
    • East End Behavioral Health Hospital
    • Glendora Hospital – A College Behavioral Health Hospital
  • Next steps will be a virtual office review, and shadow survey (dates to be determined)