6.3 Regulatory Bodies and Accreditation

CMS Conditions of Participation and Deemed Status

The Centers for Medicare & Medicaid Services (CMS) sets the Conditions of Participation (CoPs) — the federal minimum health, safety, and quality standards a hospital must meet to participate in and bill Medicare and Medicaid. The CoPs cover medical records, governance, infection control, patient rights, and more; the HIM department is directly responsible for the medical record CoP (record content, completion timeframes, authentication, retention).

A facility demonstrates CoP compliance one of two ways: through a survey by the state survey agency acting for CMS, or through a CMS-approved accrediting organization (AO) that has been granted deemed status. "Deeming" means CMS has reviewed the AO's standards and survey process and found they meet or exceed the CoPs, so accreditation is deemed to satisfy the federal requirement. Accreditation itself is voluntary — about one-fourth of Medicare hospitals are not accredited and instead undergo direct CMS certification.

The Joint Commission, DNV, and HFAP

The Joint Commission (TJC) is the largest hospital accreditor. It surveys on an unannounced, roughly triennial (every 3 years) cycle and uses tracer methodology — surveyors "trace" an actual patient's experience through the care continuum, examining the record and interviewing staff to verify standards in practice. TJC also operates a sentinel event program. A sentinel event is a patient-safety event reaching the patient that results in death, permanent harm, or severe temporary harm; it signals the need for immediate investigation, a root cause analysis (RCA), and a corrective action plan.

Other deemed AOs include DNV (integrates the ISO 9001 quality framework and surveys annually) and HFAP (the Healthcare Facilities Accreditation Program, the original deemed accreditor). All three offer deemed status, but their methods differ:

Licensure vs. Certification vs. Accreditation

These three terms are frequently confused and frequently tested. They differ by who grants them and whether they are mandatory:

• Licensure — granted by the state; mandatory to legally operate a facility (or, for individuals, to practice). Without a license, the entity cannot open its doors.
• Certification — a determination (by CMS or its agent) that a provider meets the CoPs and is therefore eligible to bill Medicare/Medicaid. It is the gateway to federal reimbursement.
• Accreditation — a voluntary seal from a private, non-governmental body (TJC, DNV, HFAP) attesting that the organization meets that body's standards. Through deemed status, accreditation can satisfy the certification requirement.

A simple way to remember the distinction: licensure = permission to operate (state, required), certification = permission to bill federal programs (CMS), and accreditation = voluntary quality recognition (private). A hospital may hold all three simultaneously, with accreditation feeding certification via deeming.

The same three words apply to individuals and data, which the exam exploits to create distractors. An individual RHIT holds a certification (a voluntary credential from AHIMA), a physician holds a license from a state board, and an EHR product may carry ONC certification. Watch the context: a question about a facility billing Medicare is about CoP certification, while a question about a person's AHIMA credential is about professional certification.

Surveys, Standards, and HIM's Survey Responsibilities

Accreditation surveys are increasingly unannounced to capture day-to-day reality rather than a staged performance. During a TJC tracer, surveyors routinely pull the HIM department into scope: they check that records are complete and authenticated within required timeframes (the medical-staff bylaws and CoPs commonly require history and physical within 24 hours of admission and discharge summaries within 30 days), that delinquent record rates are controlled, and that abbreviation and "do not use" lists are followed.

Key survey-related concepts an RHIT should know:

• Ongoing readiness — TJC expects "continuous survey readiness," not last-minute cramming; the HIM department maintains record-completion metrics year-round.
• Standards vs. Elements of Performance (EPs) — each TJC standard breaks into measurable EPs that surveyors score.
• National Patient Safety Goals (NPSGs) — annually updated priorities (e.g., patient identification) checked during tracers.
• Sentinel Event / RCA — after a qualifying event, the organization performs a root cause analysis and develops an action plan; TJC encourages (and in some cases reviews) the response.

A strong HIM operation turns the record itself into evidence of compliance, so a tracer that follows a patient's documentation finds timely, authenticated, legible entries that substantiate the care delivered.

Beyond Hospitals: Other Bodies and Settings

The oversight landscape extends past acute-care hospitals, and RHITs work across settings. NCQA (National Committee for Quality Assurance) accredits health plans and is closely tied to HEDIS quality measures. CARF accredits rehabilitation and behavioral-health programs. The AAAHC accredits ambulatory and office-based surgery centers. Long-term care, home health, and hospice each have their own CoPs/Conditions for Coverage and corresponding survey processes (e.g., MDS-driven oversight in nursing facilities, OASIS in home health).

Layered on top of all settings are CMS value-based and reporting programs that the HIM record must support — the Hospital Inpatient Quality Reporting (IQR) program, the Hospital-Acquired Condition (HAC) Reduction Program, and readmissions penalties. Accurate, fully documented, and properly coded records are the raw material for every one of these quality and payment determinations, which is why compliance, coding, and accreditation are inseparable in HIM practice.