The Joint Commission revises credentialing EP for CAHs

July 12, 2013
Credentialing Resource Center Digest

The Joint Commission has revised its Leadership Standard LD.04.01.01, Element of Performance (EP) 5 to clarify the credentialing and quality assurance requirement for Critical Access Hospitals (CAHs). “Although Leadership (LD) Standard LD.04.01.01, Element of Performance (EP) 5, already addresses this requirement, The Joint Commission recently revised the EP to clarify that a critical access hospital can make the agreement with one of the three sources listed rather than having to do so with all of them,” The Joint Commission stated in a standards prepublication update.

According to the Centers for Medicare & Medicaid Services (CMS) Medicare Conditions of Participation (CoP) §485.616(b) Standard: Agreements for Credentialing and Quality Assurance, each CAH that is a member of a rural health network shall have an agreement with:

  • at least one hospital that is a member of the network
  • one Quality Improvement Organization or equivalent entity
  • or one other appropriate and qualified entity identified in the state rural health care plan

The revision to Standard LD.04.01.01, EP 5, is effective immediately and will appear in the next update to the Comprehensive Accreditation Manual for Critical Access Hospitals as well as the fall online update for CAHs.

Found in Categories: 
Credentialing