Accreditation & Regulatory Journal
November 2023

News You Can Use

November’s Compliance Tip of the Month

November’s compliance tip of the month is around the requirement of an organization to have an institutional plan and budget.
Surveyors will cite organizations if an organization is unable to demonstrate that it has both an operational and capital expenditure budget as well as the requirement for the governing body to review and approve the budgets annually.
CMS is prescriptive in the requirements around budgeting and capital expenditure planning. The expectation for surveyors is only to verify that the organization has the documents and that they have been submitted for review to the specific planning agency and that the governing body has reviewed and approved the budgets annually. Surveyors are not expected to review the specifics nor to make judgments on the budgeting process.
The CMS regulations are below for your reference.
(Rev. 37, Issued: 10-17-08; Effective/Implementation Date: 10-17-08)
§482.12(d) Standard: Institutional Plan and Budget
The institution must have an overall institutional plan that meets the following conditions:
  1. The plan must include an annual operating budget that is prepared according to generally accepted accounting principles.
  2. The budget must include all anticipated income and expenses. This provision does not require that the budget identify item by item the components of each anticipated income or expense.
  3. The plan must provide for capital expenditures for at least a 3-year period, including the year in which the operating budget specified in paragraph (d)(2) of this section is applicable.
  4. The plan must include and identify in detail the objective of, and the anticipated sources of financing for, each anticipated capital expenditure in excess of $600,000 (or a lesser amount that is established, in accordance with section 1122(g)(1) of the Act, by the State in which the hospital is located) that relates to any of the following:
    1. Acquisition of land;
    2. Improvement of land, buildings, and equipment; or
    3. The replacement, modernization, and expansion of buildings and equipment.
Survey Procedures §482.12(d)
Verify that an institutional plan and budget exist, includes items 1-4, and complies with all items in this standard. Do not review the specifics or format in the institutional plan or the budget.
(Rev. 37, Issued: 10-17-08; Effective/Implementation Date: 10-17-08)
§482.12(d)(5) The plan must be submitted for review to the planning agency designated in accordance with section 1122(b) of the Act, or if an agency is not designated, to the appropriate health planning agency in the State. (See Part 100 of this title.)
Survey Procedures §482.12(d)(5)
Determine that the hospital’s plan for capital expenditures has been submitted to the planning agency designated to review capital expenditures. In certain cases facilities used by HMO and CMP patients are exempt from the review process.
(Rev. 37, Issued: 10-17-08; Effective/Implementation Date: 10-17-08)
§482.12(d)(5) (
A capital expenditure is not subject to section 1122 review if 75 percent of the health care facility’s patients who are expected to use the service for which the capital expenditure is made are individuals enrolled in a health maintenance organization (HMO) or competitive medical plan (CMP) that meets the requirements of section 1876(b) of the Act, and if the Department determines that the capital expenditure is for services and facilities that are needed by the HMO or CMP in order to operate efficiently and economically and that are not otherwise readily accessible to the HMO or CMP because—
  1. The facilities do not provide common services at the same site;
  2. The facilities are not available under a contract of reasonable duration;
  3. Full and equal medical staff privileges in the facilities are not available;
  4. Arrangements with these facilities are not administratively feasible; or
  5. The purchase of these services is more costly than if the HMO or CMP provided the services directly.
(Rev. 37, Issued: 10-17-08; Effective/Implementation Date: 10-17-08)
§482.12(d)(6) The plan must be reviewed and updated annually.
Survey Procedures §482.12(d)(6)
Verify that the plan and budget are reviewed and updated annually.
(Rev. 37, Issued: 10-17-08; Effective/Implementation Date: 10-17-08)
§482.12(d)(7) The plan must be prepared—
  1. Under the direction of the governing body; and
  2. By a committee consisting of representatives of the governing body, the administrative staff, and the medical staff of the institution.
Survey Procedures §482.12(d)(7)
Verify that the governing body, administrative staff, and medical staff have participated in the development of the institutional plan and budget.
CIHQ encourages organizations to make available both the operating and capital budgets during survey to eliminate the potential for a deficiency to be cited.

Meeting Patient Expectations with Excellence

Community Hospital Corporation
PLANO, Texas, Oct. 11, 2023 /PRNewswire/ -- Community Hospital Corporation (CHC) is proud that its eight owned Long-Term Acute Care Hospitals (LTACHs) – under the name ContinueCARE Hospitals – hold accreditation by the Center for Improvement in Healthcare Quality (CIHQ). Six of those have received CIHQ Center of Excellence designations, while the remaining two are working toward that achievement.
The importance of healthcare excellence cannot be overstated as it fosters trust and confidence in healthcare providers, reassuring individuals that their well-being is top priority.
"The pursuit of excellence matters," said Sally Parnell, VP Clinical Services Post-Acute Services for CHC. "Despite the challenges, many health care professionals exceed expectations every day. Our LTACHs go well beyond providing routine care for our patients."
LTACHs serve the needs of patients with medically complex conditions, especially those suffering from multisystem failures and needing continued highly specialized intensive acute care – a hospital stay that is often 25 days or more. A patient is admitted to an LTACH from a short-term acute-care hospital.
"ContinueCARE Hospitals uphold a tradition of providing comprehensive, multidisciplinary care across skilled teams of physicians, nurses, therapists, dietitians, social workers, case managers, pharmacists, and other professionals," Parnell added. "CIHQ Center of Excellence recognizes exemplary performance and measures the use of standards and outcomes to promote quality of care and services."
CHC's LTACHs accredited by CIHQ that have also earned Center of Excellence in LTACH, Nursing and Respiratory for their facility include:
  • ContinueCARE Hospital at Hendrick Medical Center, Abilene, Texas - just earned the Centers of Excellence
  • Tyler ContinueCARE Hospital at Mother Frances Hospital, Tyler, Texas
  • ContinueCARE Hospital at Medical Center, Odessa, Texas
  • ContinueCARE Hospital at Baptist Health Corbin, Corbin, Ky.
  • ContinueCARE Hospital at Baptist Health Paducah, Paducah, Ky.
  • Carolinas ContinueCARE Hospital at Pineville, Pineville, N.C.
CHC's LTACHs accredited by CIHQ and working on center of excellence milestones include:
  • ContinueCARE Hospital at Palmetto Health Baptist, Columbia, S.C.
  • ContinueCARE Hospital at Baptist Health Deaconess Madisonville, Madisonville, Ky.
Parnell added, "We are pleased to work with partner CIHQ and their commitment to furthering quality." CIHQ is a membership-based organization serving acute care hospitals, critical access hospitals and acute psychiatric hospitals.
About Community Hospital Corporation – HELP WHERE HOSPITALS NEED IT®
Community Hospital Corporation owns, manages, and consults with hospitals through CHC Hospitals, CHC Consulting and CHC ContinueCARE. Visit

CIHQ Accredited Hospital Extranet Site Gets a Facelift

The accreditation division of CIHQ is always working behind the scenes to improve our systems and more importantly our client’s experience. As a result, the hospital’s extranet site has undergone a facelift and will now begin a beta testing period. Once the testing period has been conducted, everyone will be switched over to the new site.
While the look and feel may be a bit different the content and information remain unchanged. Below is a snapshot of what a hospital will see in the current version and then what it will look like in the new version.
New Version
Current Version
So, what is different?
In the new version access to information has been relocated to the blue navigation bar at the top of the page instead of having all the boxes and sections of the site to navigate.
Your online standards and resources are now accessed via the following:
Lists & Archives – Quick Links, Contains Accredited Hospital Listing, Notification Archive, Past Survey Report Archive and ARS Mock Survey Requests
Standards & Resources – Online Standard Manuals, Glossary, Standards Interpretation and Download Standards, Policies & More
Libraries – What’s New on the Website, Resource Library, Reference Library, Regulatory Alert Library and Survey Preparation Library
Education – Webinar Center, Continuing Education Center and Staff Training Library
Partners & Sponsors
The quick links button on the navigation bar under Lists & Archives will provide you with all the resources in a list on the screen and you will be able to enter each one from there if you wish.
What you will see on your extranet landing page is:
  • Important Actions Required. This will still turn red when you have a corrective action plan to enter.
  • Standards, Policies & More – Policies and Survey Tools, Survey Activity Guides and Center of Excellence and Disease Specific Manuals and Information
  • Past Survey Reports – This will contain any survey information for the past 18 months. Any surveys done prior to that they are located under the Lists & Archives under Past Survey Report Archive
  • Miscellaneous Important Notifications – This will contain all notifications posted for the past 90 days. Any notification posted prior to the 90 days can be accessed under Lists & Archives under Notification Archive
There is also a new and improved site directory at the bottom of the screen to help you navigate your extranet page. As always, we welcome your feedback so when you begin to use the new site, please provide us any ideas, suggestions, or comments to Traci at

CIHQ Expansion of Accreditation Programs – Update

CIHQ is expanding its accreditation programs to Acute Psychiatric Hospitals. The application has been approved and the virtual office review has been completed. The final decision to accept the application was published in the Federal Register on September 29, 2023.
We are excited about welcoming Acute Psychiatric Hospitals to the CIHQ family of accredited organizations. You can find this exciting announcement in the Register at
Will you be the first acute psychiatric hospital to be accredited by CIHQ? You can open an account and apply today at Select Hospital Programs-United States, click on Acute Psychiatric Hospital and then Apply for Accreditation in the blue navigation bar.
Our standards, policies and survey activity guide are available free of charge on our website.

Misinformation about Accrediting Bodies

This article has been provided to CIHQ by COLA
Dear Colleague,
We understand that recent communications from other accrediting organizations have caused confusion within the clinical laboratory community. We would like to clarify that the Centers for Medicare & Medicaid Services (CMS) has the sole authority to grant CUA-deemed status to laboratory accrediting organizations. COLA, the first accrediting organization to receive deemed status, has proudly held that authority for over 30 years. Hospital accrediting organizations. Such as The Joint Commission (TJC). do not have the authority to remove CMS-deemed status from any laboratory accrediting organizations.
We want to assure you that COLA maintains its deemed status from CMS and remains a premier physician­ led laboratory accreditor with a 98% customer satisfaction rate. We are committed to accrediting clinical laboratories of all sizes and types throughout the country. Our Board of Directors includes representatives from some of the largest physician member organizations in the U.S., namely the American Medical Association (AMA). American Academy of Family Physicians (AAFP) and American College of Physicians (ACP). Asa physician-directed organization. COLA promotes health and safety through accreditation and educational programs.
Our team at COLA consists of highly experienced professionals who bring a wealth of expertise10 the table. COLA employs professional surveyors who are dedicated medical laboratory scientis1s with a minimum of 10 years of bench experience, eliminating the need for laboratories 10perform reciprocal surveys. This ensures consistent and standardized surveys as well as fairness and reliability across all assessments. We strive for high customer satisfaction by providing accessible technical advisors who can be reached throughout the accreditation cycle via email, phone, chat, and our customer portal.
We greatly appreciate the opportunity to serve you. We hope that our educational, consistent approach to accreditation has been beneficial for your laboratory and patients.
If you are not currently a COLA-accredited laboratory and would like to learn more about our excellent laboratory accreditation program, please reach out to us.
Nancy Stratton
Chief Executive Officer
p:(800) 981-9883
w: e:
It is the position of CIHQ that we will accept COLA accreditation for laboratories.

2023 Fall Educational Conference & Expo

CIHQ appreciates the work of rehabilitation hospitals, and attended AMRPA’s annual conference October 15-18, 2023, in Dallas. AMRPA hosted an IRF Boot Camp before the conference to provide rehabilitation managers and medical directors with fundamental knowledge.
The conference program focused on innovative strategies to keep rehabilitation professionals ahead of the curve and providing the highest quality of care, advocacy efforts in the interest of inpatient rehabilitation hospitals and units, outpatient rehabilitation centers, and other rehabilitation providers.
As always it was a great event and a great time to connect with old friends and make some new ones. The partnership with AMPRA has proven to be a valuable one. We look forward to next year’s conference.