January 12, 2022 7 Min Read
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Five things hospitals should expect from regulators and accreditors in 2022

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2022 regulatory checklist for hospitals

It’s time to dust off my crystal ball and preview hot topics for CMS / State Survey Agencies and The Joint Commission (TJC) for the coming year—and how you can prepare for each.

1. OSHA’s Increasing Profile in Healthcare

The U.S. Department of Labor’s Occupational Health and Safety Administration (OSHA) has been in the background of hospital operations for many years. However, we expect the agency to acquire an even higher profile going forward.

OSHA will be on site and top of mind

There has always been much for OSHA to look for in healthcare since healthcare workers are about six times more likely to be injured on the job than the average worker. But in mid-2021, OSHA became more focused than ever with a new enforcement/emphasis program that targeted healthcare and OSHA’s new COVID-19 rule (based on CDC recommendations). Even though OSHA has a lot on its hands currently, we expect to see them in hospitals more frequently as we move through 2022.

How to prepare:

  • Assess vulnerabilities referencing OSHA’s “Hospitals eTool”

  • Focus on formalizing your written COVID-19 plan

  • Confirm that you’re already compliant with the many other OSHA requirements that have already been assimilated into the hospital routine

Disciplines driving implementation: Environmental Safety, Infection Prevention

See our Comprehensive COVID Regulatory Checklist for Hospital Associate Vaccination guidance, OSHA COVID-19 requirements, data reporting requirements, 1135 Waivers and more.

2. The Healthcare Vaccination Requirement

Stay compliant after the stay lifts

The courts have stayed the implementation of CMS’s new requirement for the vaccination of healthcare workers/associates. Assuming CMS’s vaccination rule (a new provision in the Infection Prevention Condition of Participation for Hospitals) went into effect in January 2022 in most states (several states are currently exempt due to pending litigation with the government), we project it will take the rest of the calendar year for before there is clarity on all aspects of how this requirement will be enforced.

How to prepare: Ensure you’re following the guidance found on our Comprehensive COVID Regulatory Checklist.

Disciplines driving implementation: Infection Prevention, Occupational Health, Medical Staff, C-Suite leaders

3. Healthcare Equity: Improving Maternal Outcomes

Joint Commission expectations for the expecting

The rate of maternal morbidity and mortality varies from state to state and is especially high for underserved populations. TJC’s maternal safety standards became effective in early 2021 (delayed from its original effective date of July 2020). In September 2021, CMS reminded State Survey Agencies that the Emergency Medical Treatment and Labor Act pertained to women in labor. And, finally in December 2021, CMS instructed State Survey Agencies to focus on the “4 R’s” (Readiness, Recognition, Response, and Reporting), especially with respect to maternal hemorrhage.

Ensuring better care for pregnant women

We expect the focus on this issue to increase as we move through 2022, with State Survey Agencies and non-TJC accreditors focusing on Joint Commission expectations to the extent that they have been incorporated into hospital policy.

How to prepare:

  • Ensure obstetrics has approved hemorrhage and hypertension assessment and treatment protocols and case review criteria

  • Have hemorrhage kits immediately available to the emergency department (ED), labor and delivery, and postpartum units

  • Complete hemorrhage and blood pressure management training and periodic/annual retraining of nursing and medical personnel involved in the management of pregnancy, labor, delivery, and postpartum care, including emergency department nursing and emergency medicine

  • Conduct case reviews of significant maternal hemorrhages and hypertensive episodes resulting in the need for critical care using the pre-defined case-review criteria discussed above

  • Be ready to show evidence of improvement when indicated

Disciplines driving implementation: Obstetrics, Perinatal Nursing, Emergency Medicine, ED Nursing, Pathology (blood bank), and Pharmacy

4. New Joint Commission Requirements

Four new sets of hospital requirements went into effect on January 1, 2022:

  • Workplace violence
  • Water management
  • Performance improvement
  • Patient Notification of Information Transmittal

Read on to learn how you can prepare for each new requirement.

Workplace violence

Workplace violence has long been a focus of hospital security management plans. The new requirements necessitate:

  • Leadership’s designation of an individual responsible for the workplace violence program

  • A comprehensive organization-wide education program, taken by all staff and associates

  • The formation of a multidisciplinary group that has overseen a workplace violence assessment (to be completed annually)

  • Actions are taken for issues raised through the assessment, individual significant (and sentinel) workplace violence events, and observed trends or patterns

  • All instances of workplace violence are reported, escalated when indicated, and analyzed

Disciplines driving implementation: Environmental Safety, Security, Environment of Care Committee, Nursing Leadership, Risk Management, Quality and Patient Safety, Clinical Education

Water Management

Water management is not a new requirement, but TJC is just catching up with CDC and others. However, there is one aspect of TJC’s requirement, unlike its CMS predecessor (effective in 2017), that left us scratching our heads: the requirement that the plan account for immunocompromised patients. We’re not entirely sure what this unique requirement related to immunosuppression means for your water safety program. We’ll keep you posted as we work with TJC to clarify.

Disciplines driving implementation: Engineering, Infection Prevention

Performance Improvement

TJC’s new Performance Improvement requirement revisions likely don’t require changes to your annual QAPI. Ensure that your process inventory includes:

  • Requirements/goals that are reviewed/prioritized by leadership at least annually

  • Actions necessary to improve performance and achieve these goals

  • The measurement, analytical, and process change methods that have been or will be used

  • The method(s) that will be used for monitoring ongoing/sustained improvement

  • Assurance that your list of goals demonstrates actual improvement, consistent with CMS regulations.

Disciplines driving implementation: Quality

Patient Notification of Information Transmittal

Patient notification of information transmittal became a requirement through the 21st Century Cures act, specifically automatic notification of primary care and post-hospital care providers through the hospital’s electronic medical record (if it has one). CMS regulations and TJC standards were previously amended to account for this transmittal.

The new requirement for 2022 requires a process to:

  1. Notify patients of this information transmittal upon registration/admission to and discharge/transfer from the hospital’s ED or inpatient service

  2. Take documented action should patients decide against this protected information transmittal

Tip: include this notification along with the notification of rights and allow but not require a patient’s signature. There are many times this form (sometimes erroneously called a general consent for treatment) does not include a signature. The only requirement for documentation, however, is when the patient requests that the information be withheld. In such cases, the hospital’s actions should be captured.

Disciplines driving implementation: Admitting, Nursing, Information Technology

5. Sustained Compliance

Keeping constantly compliant

Although new regulations always draw our attention at years’ end, we expect the issues prevalent in the hospital industry over the past several years to continue to be many of the major challenges the industry faces in 2022.

Before the pandemic, more than half of TJC hospitals had one or more serious (so called “condition-level”) deficiencies during their triennial survey. Most of these condition-level findings related to:

  • Infection prevention – sterilization, disinfection and infection-related environment of care findings, such as temperature, humidity, or air flow

  • Suicide prevention – ligature resistance, assessments/screening, and suicide precautions

Hospitals with serious findings in these or other areas cannot afford another survey with the same issues identified. In theory, a repeat of these serious findings could lead to Preliminary Denial of Accreditation. However, we imagine TJC may be a little forgiving given the current stressors on the hospital industry.

How to prepare for what’s ahead

Feeling overwhelmed? All of these new requirements can feel daunting but take these three action steps to break all of this guidance into manageable tasks.

  • Focus on the 25% or fewer “significant” findings from your last two surveys. These findings include any RFI scored as a pattern of issues with a moderate likelihood of harm or above on the SAFER matrix (Moderate Pattern, Moderate Widespread, High Likelihood to harm regardless of frequency, or findings found to be an Immediate Threat to Life).

  • Take the long view of compliance. Although specific observations related to significant issues can be addressed in 60 days, the underlying systems issues usually take far longer to sustainably improve.

  • Put these few, high-importance systems issues on leadership’s agenda using the methods referenced in the new Performance Improvement standards mentioned earlier.

Greeley has implementation toolkits for all the new TJC hospital requirements. Drop me a note if you’d like to discuss the toolkits or any of these other hot topics for 2022: Leddy@greeley.com

About Our Author

Lisa Eddy
Vice President Clinical Compliance & High Reliability

I have more than 25 years of experience in CMS certification and accrediting agency regulatory compliance. First-hand knowledge at the executive nursing level, hospital operations, quality and risk management and critical care nursing, are all embedded in the guidance I provide to organizations to help them achieve and maintain regulatory compliance.

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