CurrentBlue Cross Blue Shield - MarylandPolicy 11.01.01

MDH Healthcare System Facility Accreditation and Licensure Policy

Establishes mandatory continuous accreditation and licensure requirements for all MDH Healthcare System hospitals and facilities, specifying required accreditors and state/federal licensures and assigning roles for compliance and oversight.

Policy Summary

PayerBlue Cross Blue Shield - Maryland

PolicyMDH Healthcare System Facility Accreditation and Licensure Policy

Policy CodePolicy 11.01.01

Change TypeInitial issuance

Effective Date3/24/2026

Next Review Date

Key ActionEnsure facilities meet accreditation/licensure standards, maintain readiness for unannounced surveys, and respond to non-compliance and critical incident recommendations.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

11MDH facilities required

TJC, CMS, OHCQ, CARFRecognized accreditors

1.0Document version

3/24/2026Effective

Accreditation and Licensure Requirements

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Facility-specific accreditation and licensure requirements

All MDH HCS hospitals and facilities must maintain continuous accreditation or licensure as specified for each facility.

Clifton T. Perkins Hospital Center (Adult Psychiatric) must maintain: TJC (Hospital) and OHCQ (Hospital).

Eastern Shore Hospital Center (Adult Psychiatric) must maintain: TJC (Hospital), OHCQ (Hospital), and CMS.

Spring Grove Hospital Center (Adult Psychiatric) must maintain: TJC (Hospital), OHCQ (Hospital), and CMS.

Springfield Hospital Center (Adult Psychiatric - Hospital) must maintain: TJC (Hospital), OHCQ (Hospital), and CMS.

Springfield Hospital Center (ALP) must maintain: TJC (Behavioral Health Care and Human Services) and OHCQ (Assisted Living Program).

Thomas B. Finan Center (Hospital) must maintain: TJC (Hospital), OHCQ (Hospital), and CMS; and (ALP) must maintain: TJC (Behavioral Health Care and Human Services) and OHCQ (Assisted Living Program).

John L. Gildner RICA (Rockville) must maintain: TJC (Behavioral Health Care and Human Services) and OHCQ (Residential Treatment Center).

RICA-Baltimore (residential) must maintain: TJC (Behavioral Health Care and Human Services) and OHCQ (Residential Treatment Center).

Potomac Center (ICF/IID) must maintain: OHCQ (ICF-IID) and CMS.

Holly Center (ICF/IID) must maintain: OHCQ (ICF-IID) and CMS.

Deer's Head Hospital Center (Chronic Care) must maintain: TJC (Hospital; Nursing Care), OHCQ (Freestanding Renal Dialysis Center; Hospital; Long Term Care Facility), CMS, and Maryland Commission on Kidney Disease.

Western Maryland Hospital Center (Chronic Care) must maintain: TJC (Hospital; Nursing Care), OHCQ (Hospital; Long Term Care Facility), CMS, and CARF.

Facility Compliance and Survey Readiness

Documentation Required

Maintain accreditation/licensure readiness and respond to non‑compliance

Hospital and Facility CEOs must ensure continuous compliance with accreditation and licensure requirements, maintain readiness for unannounced surveys, and respond promptly to non‑compliance and critical incident recommendations.

Ensure the facility meets all TJC survey requirements and maintains accreditation.
Maintain readiness for unannounced surveys and ensure all staff are trained on TJC National Patient Safety/Performance Goals.
Comply with OHCQ licensure standards and respond promptly to any additional recommendations regarding a critical incident.
Ensure applicable CMS standards and criteria are met; respond to questions or challenges with non‑compliance in a timely manner.

Definitions and Accrediting Bodies

CARF International

DefinitionCARF International (Commission on Accreditation of Rehabilitation Facilities): the independent, nonprofit accreditor of health and human services.

ScopeApplies to accreditation of rehabilitation and community-based health and human services programs overseen by MDH facilities.

Role in policyNamed as an accepted accreditor for specific MDH facilities that require CARF designation.

CMS

DefinitionCenters for Medicare & Medicaid Services (CMS): the federal agency within HHS that administers the Medicare program and partners with states to administer Medicaid.

AuthoritySets federal Conditions of Participation and regulatory requirements applicable to Medicare/Medicaid–funded facilities.

Policy relevanceRequired designation for certain MDH facilities to maintain CMS certification in addition to state licensure/accreditation.

Maryland Commission on Kidney Disease

DefinitionMaryland Commission on Kidney Disease: the state body responsible for the certification and inspection of dialysis centers within Maryland facilities.

FunctionCertifies freestanding and hospital-based renal dialysis centers to ensure safe outpatient dialysis services.

Policy relevanceNamed licensure/certification authority for dialysis services at MDH facilities requiring renal dialysis oversight.

OHCQ

DefinitionOffice of Health Care Quality (OHCQ): the MDH agency charged with monitoring the quality of care in Maryland's health care facilities and community-based programs.

ResponsibilityProvides state licensure, inspection, and oversight for hospitals, long-term care, residential programs, and other licensed facilities.

Policy roleOHCQ licensure is required for MDH facilities alongside applicable accreditations named in the policy.

Hospital

DefinitionHospital: an institution with a group of at least five physicians organized as a medical staff that provides diagnostic and treatment services and admits or retains individuals for overnight care.

CharacteristicsMaintains facilities to provide supervised diagnostic/treatment services for two or more unrelated individuals; includes TJC Hospital Program standards.

Policy implicationMDH-operated hospitals must maintain required accreditations and state licensure to meet policy criteria.

ICF/IID

DefinitionIntermediate Care Facility for Individuals With Intellectual Disabilities (ICF/IID): an institution that meets CMS Federal Conditions of Participation and provides health or rehabilitation services to individuals with intellectual disabilities eligible for Medicaid.

Service focusRequires provision of active treatment and therapeutic interventions to support community reintegration for residents.

Funding/eligibilityICF/IID designation ties to Medicaid eligibility when CMS CoPs are met.

Residential Treatment Center

DefinitionResidential Treatment Center: a non-hospital psychiatric institution providing campus-based intensive and extensive evaluation and treatment of children and adolescents with severe and chronic emotional disturbances.

Program featuresProvides a self-contained therapeutic, educational, and recreational program in a residential setting for youth requiring intensive services.

LicensureSubject to OHCQ residential treatment center licensure and may also require TJC behavioral health standards where applicable.

Nursing Care Center Program (TJC)

DefinitionNursing Care Center Program (TJC): The Joint Commission standards for long-term and rehabilitative care (Nursing Care Center Program).

ScopeApplies to nursing homes and long-term care settings providing non-acute inpatient care and rehabilitative services.

Policy relevanceNamed as an accepted accreditation standard for MDH long-term and chronic care facilities requiring TJC Nursing Care Center designation.

Behavioral Health Care and Human Services (TJC)

DefinitionBehavioral Health Care and Human Services (TJC): The Joint Commission standards for residential and community-based behavioral health care settings.

ApplicationUsed to accredit residential and community-based behavioral health programs within MDH facilities.

Policy roleRequired TJC behavioral health designation is listed for specific MDH residential and behavioral facilities in the policy.