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The compliance tip of the month for May is focused on the use of telemedicine to provide care and services to patients. CMS is specific regarding the language that needs to be incorporated into the written agreement

One of the most common deficiencies cited is a lack of all the required language as defined by CMS. Lack of the required language likely results in a standard level deficiency.

The CMS regulations and interpretive guidance are provided below for reference.

§482.22(a)(3) When telemedicine services are furnished to the hospital’s patients through an agreement with a distant-site hospital, the governing body of the hospital whose patients are receiving the telemedicine services may choose, in lieu of the requirements in paragraphs (a)(1) and (a)(2) of this section, to have its medical staff rely upon the credentialing and privileging decisions made by the distant-site hospital when making recommendations on privileges for the individual distant-site physicians and practitioners providing such services, if the hospital’s governing body ensures, through its written agreement with the distant-site hospital, that all of the following provisions are met:

1. The distant-site hospital providing the telemedicine services is a Medicare-participating hospital.
2. The individual distant-site physician or practitioner is privileged at the distant-site hospital providing the telemedicine services, which provides a current list of the distant-site physician’s or practitioner’s privileges at the distant-site hospital.
3. The individual distant-site physician or practitioner holds a license issued or recognized by the State in which the hospital whose patients are receiving the telemedicine services is located.
4. With respect to a distant-site physician or practitioner, who holds current privileges at the hospital whose patients are receiving the telemedicine services, the hospital has evidence of an internal review of the distant-site physician’s or practitioner’s performance of these privileges and sends the distant-site hospital such performance information for use in the periodic appraisal of the distant-site physician or practitioner. At a minimum, this information must include all adverse events that result from the telemedicine services provided by the distant-site physician or practitioner to the hospital’s patients and all complaints the hospital has received about the distant-site physician or practitioner.

Interpretive guidelines §482.22(a)(3)
The hospital’s governing body has the option, when considering granting privileges to telemedicine physicians and practitioners, to have the hospital’s medical staff rely upon the credentialing and privileging decisions of the distant-site hospital for these physicians and practitioners. This process would be in lieu of the traditional process required under §482.22(a)(1) and §482.22(a)(2), whereby the hospital’s medical staff conducts its own review of each telemedicine physician’s or practitioner’s credentials and makes a recommendation based on that individualized review.

In order to exercise this alternative credentialing and privileging option, the hospital’s governing body must ensure through its written agreement with the distant-site hospital that all of the following requirements are met:

• The distant-site hospital participates in the Medicare program. If the distant-site hospital’s participation in Medicare is terminated, either voluntarily or involuntarily, at any time during the agreement, then, as of the effective date of the termination, the hospital may no longer receive telemedicine services under the agreement;
• The distant-site hospital provides to the hospital a list of all its physicians and practitioners covered by the agreement, including their privileges at the distant-site hospital. The list may not include any physician or practitioner who does not hold privileges at the distant-site hospital. The list must be current, so the agreement must address how the distant-site hospital will keep the list current;
• Each physician or practitioner who provides telemedicine services to the hospital’s patients under the agreement holds a license issued or recognized by the State where the hospital (not the distant-site hospital) is located. States may have varying requirements as to whether they will recognize an out-of-state license for purposes of practicing within their State, and they may also vary as to whether they establish different standards for telemedicine services. The licensure requirements governing in the State where the hospital whose patients are receiving the telemedicine services is located must be satisfied, whatever they may be; and
• The hospital has evidence that it reviews the telemedicine services provided to its patients and provides feedback based on this review to the distant-site hospital for the latter’s use in its periodic appraisal of each physician and practitioner providing telemedicine services under the agreement. At a minimum, the hospital must review and send information to the distant-site hospital on all adverse events that result from a physician or practitioner’s provision of telemedicine services under the agreement and on all complaints it has received about a telemedicine physician or practitioner covered by the agreement.

§482.22(a)(4) When telemedicine services are furnished to the hospital’s patients through an agreement with a distant-site telemedicine entity, the governing body of the hospital whose patients are receiving the telemedicine services may choose, in lieu of the requirements in paragraphs (a)(1) and (a)(2) of this section, to have its medical staff rely upon the credentialing and privileging decisions made by the distant- site telemedicine entity when making recommendations on privileges for the individual distant-site physicians and practitioners providing such services, if the hospital’s governing body ensures, through its written agreement with the distant-site telemedicine entity, that the distant-site telemedicine entity furnishes services that, in accordance with §482.12(e), permit the hospital to comply with all applicable conditions of participation for the contracted services. The hospital’s governing body must also ensure, through its written agreement with the distant-site telemedicine entity, that all of the following provisions are met:

1. The distant-site telemedicine entity’s medical staff credentialing and privileging process and standards at least meet the standards at §482.12(a)(1) through (a)(7) and §482.22(a)(1) through (a)(2).
2. The individual distant-site physician or practitioner is privileged at the distant-site telemedicine entity providing the telemedicine services, which provides the hospital with a current list of the distant-site physician’s or practitioner’s privileges at the distant-site telemedicine entity.
3. The individual distant-site physician or practitioner holds a license issued or recognized by the State in which the hospital whose patients are receiving such telemedicine services is located.
4. With respect to a distant-site physician or practitioner, who holds current privileges at the hospital whose patients are receiving the telemedicine services, the hospital has evidence of an internal review of the distant-site physician’s or practitioner’s performance of these privileges and sends the distant-site telemedicine entity such performance information for use in the periodic appraisal of the distant-site physician or practitioner. At a minimum, this information must include all adverse events that result from the telemedicine services provided by the distant-site physician or practitioner to the hospital’s patients, and all complaints the hospital has received about the distant-site physician or practitioner.

Interpretive guidelines §482.22(a)(4)
For the purposes of this rule, a distant-site telemedicine entity is defined as an entity that -- (1) provides telemedicine services; (2) is not a Medicare-participating hospital; and (3) provides contracted services in a manner that enables a hospital using its services to meet all applicable Conditions of Participation, particularly those requirements related to the credentialing and privileging of practitioners providing telemedicine services to the patients of a hospital. A distant-site telemedicine entity would include a distant-site hospital that does not participate in the Medicare program that is providing telemedicine services to a Medicare-participating hospital. (See 76 FR 25553, May 5, 2011)

The hospital’s governing body has the option, when considering granting privileges to telemedicine physicians and practitioners, to have the hospital’s medical staff rely upon the credentialing and privileging decisions of the distant-site telemedicine entity for these physicians and practitioners. This process would be in lieu of the traditional process required under §482.22(a)(1) and §482.22(a)(2), whereby the medical staff conducts its own review of each telemedicine physician’s or practitioner’s credentials and makes a recommendation based on that individualized review.

In order to exercise this alternative credentialing and privileging option, the hospital’s governing body must ensure that its written agreement with the distant-site hospital enables the hospital, as required under the regulation at §482.12(e) governing services provided under arrangement, to comply with all applicable hospital Conditions of Participation. In particular, the written agreement between the hospital and the distant-site telemedicine entity must ensure that all of the following requirements are met:

• The distant-site telemedicine entity utilizes a medical staff credentialing and privileging process and standards that at least meets the standards for the medical staff of a hospital established at §482.12(a)(1) through (a)(7) and §482.22(a)(1) through (a)(2);
• The distant-site telemedicine entity provides a list to the hospital of all physicians and practitioners covered by the agreement, including their privileges at the distant-site telemedicine entity. The list may not include any physician or practitioner who does not hold privileges at the distant-site telemedicine entity. The list must be current, so the agreement must address how the distant-site telemedicine entity will keep the list current;
• Each physician or practitioner who provides telemedicine services to the hospital’s patients under the agreement holds a license issued or recognized by the State where the hospital is located. States may have varying requirements as to whether they will recognize an out-of-state license for purposes of practicing within their State, and they may also vary as to whether they establish different standards for telemedicine services. The licensure requirements governing in the State where the hospital whose patients are receiving the telemedicine services is located must be satisfied, whatever they may be; and
• The hospital has evidence that it reviews the telemedicine services provided to its patients and provides a written copy of this review to the distant-site telemedicine entity for the latter’s use in its periodic appraisal of the physicians and practitioners providing telemedicine services under the agreement. At a minimum, the hospital must review and send information to the distant-site telemedicine entity on all adverse events that result from a physician or practitioner’s provision of telemedicine services and on all complaints, it has received about a telemedicine physician or practitioner.

CIHQ encourages organizations to evaluate their written agreements to assure that they comply with the regulations to avoid a deficiency during survey.

ARS provides the following resources to assist organization with their compliance. These can be found in the ARS Resource Library:

1. #1024 – Tool – Telemedicine Agreement with Distant Site Entity Audit Tool
2. #1025 – Tool – Telemedicine Agreement with Distant Site Hospital Audit Tool
3. #2245 – Tool – Suggested Language for Insertion into Written Agreements with Telemedicine Providers

Webinar Center Archive:

1. 5/26/2022 – Telemedicine in a Regulatory Framework

Continue Education Center:

1. 5/26/2022 – Telemedicine in a Regulatory Framework

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.

A huge thank you to Frio Regional Hospital that so graciously volunteered for the onsite observation survey in February. CMS accompanied the CIHQ team to evaluate the survey process. Our team and the team at Frio did an awesome job and there were no deficiencies cited.

CIHQ is expanding its accreditation programs to Acute Psychiatric Hospitals.

• Submission of the Application – February 2023
• The application was accepted as complete – March 22, 2022
• Next steps will be the standards and process review. We have completed 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
• A virtual office review, and an observation survey (dates to be determined) will be conducted
• Publication in the Federal Register will occur on or by October 19, 2023

An article provided by Kenneth Slifer, VP Compliance Solutions
Last month, more than 200 organizations attended Palooza, RLDatix’s annual user conference, participating in 50+ sessions centered around unlocking the future of safer healthcare.

RLDatix was honored to have Rick Curtis participate and share CIHQ’ vision during their session, “Making the Case for a Culture of Compliance.” With brilliant minds from across the industry coming together to share ideas, we left Palooza excited to take action. Here are the top seven things overheard at Palooza 2023:

1. It’s ALL about culture. Rick Curtis reminded us that success starts at the top, and you cannot change culture without buy-in from staff and physicians. If we want to change more than just processes or technologies, senior leaders must provide direction, advocacy and lead by example.
2. Everyone is being pressed to do more with less – and technology can help. As organizations strive for high reliability and attempt to “hard wire” workflows to meet the growing demands of our ever-changing world, manual processes have become a significant source of administrative harm and an increasingly prohibitive roadblock on the path to high reliability. While it can be hard to adjust to new processes, technology can streamline administrative tasks, as well as help us more effectively address the human side of our work, from diversity, equity and inclusion efforts to peer support and workplace violence response and prevention.
3. Effective staffing is our first line of defense. Customers from Wales joined to share their journey and how they have integrated scheduling with risk to combat workforce woes— ensuring effective staffing and safe care. Effectively measures can help ensure we have the right people in the right place at the right time to ultimately provide safer care for our patients.
4. Change management is most effective when all the right players are involved. Software alone cannot solve the complex problems that we face in today’s healthcare environment. A successful implementation or improvement project requires a cross-functional strategy, so it’s imperative that teams and committees have the appropriate resources, representing stakeholders from across the organization — from front-line staff to IT and data analytics to organizational leadership. On a similar note...
5. Innovation is key, but quality, safety and risk must be part of the conversation. Healthcare is ripe for innovation, and Dr. Vin Gupta highlighted groundbreaking products — including mirrors (and toilet seats!) that can help keep us healthy. Artificial intelligence, disruptive technology and more cost-effective models will transform the way we approach personal and institutional health, but we need to bring all the right people to the table to help make sure that these transformations will enable safer and more accessible care.
6. We can learn from the bad – and the good. In his keynote, Banner Health’s Dr. Vilert Loving shared his system’s Asset Based Quality Improvement (ABQI) approach — “flipping the script” to on root cause analysis (RCA) to identify organizational successes. Rather than only focusing on RCA for adverse events, ABQI looks at the root cause of positive outcomes and helps teams replicate them throughout the organization.
7. We’re better off when we’re sharing information. Over 80 individuals worked tirelessly to share the positive outcomes, lessons learned and battle scars from across accreditation, regulatory, policy management, credentialing, safety and risk functions. Conversations spilled out from sessions and into Palooza’s many social events. People were hungry to connect and learn from one another, and they were eager to bring those learning back to their teams. In addition to all the fun and camaraderie, these connections offered teams an opportunity to integrate lessons learned without having to learn the lessons first-hand.