Standards Framework
2026 Revenue Cycle Catastrophic Downtime Standards
An independently developed framework aligned with guidance from The Joint Commission and CMS — 83 standards across 9 hospital departments.
About This Framework
Amelior's Cyber Resiliency Standards represent a comprehensive, department-by-department framework for evaluating and improving hospital readiness for catastrophic EHR downtime events. Each standard is mapped to primary Joint Commission chapters and secondary accreditation references including CMS Conditions of Participation and DNV NIAHO.
These standards serve as the assessment foundation for the Archer platform, enabling organizations to benchmark their current readiness, identify critical gaps, and generate corrective action plans with executive-ready reporting.
Framework Coverage
HIM
Emergency Department
Coding
Pharmacy
Laboratory
Radiology
Outpatient
Inpatient
Patient Access Services
9
Departments Covered
83
Individual Standards
JC + CMS
Regulatory Alignment
Showing 1–15 of 83 standards15 per page
| Department | Standard | JC Reference | Secondary Alignment |
|---|---|---|---|
| HIM HIM Downtime Governance and Leadership | The HIM department maintains a documented downtime plan with a designated Downtime Coordinator or leader responsible for oversight… Expand | LD.04.01.05; IM.01.01.01 | CMS §482.12; DNV NIAHO |
| HIM HIM Training, Education, and Drills | All HIM staff receive formal downtime training at least annually; new hires are trained during onboarding. Training logs are maint… Expand | HR.01.05.03; EM.03.01.03 | CMS §482.41 |
| General Downtime Documentation Standardization and Accessibility | Standardized downtime documentation packets (admission forms, progress notes, MARs, etc.) are available for all clinical units. Fo… Expand | IM.02.02.01 | CMS §482.24 |
| General Secure Record Collection, Transport, and Chain of Custody | HIM maintains secure, auditable processes for collecting, labeling, and transporting paper records from patient care areas daily. … Expand | IM.02.01.01 | CMS §482.24(b) |
| General Scanning, Indexing, and EHR Restoration | HIM has a defined workflow for scanning, indexing, and uploading downtime records into the EHR. Dedicated high-speed scanners must… Expand | IM.02.02.01 | CMS §482.24(c) |
| General Record Reconciliation and Revenue Integrity Readiness | HIM performs post-downtime reconciliation to confirm all forms required for coding, CDI, and billing are present. A documented che… Expand | IM.01.02.01 | CMS §482.24(c) |
| General Compliance, Privacy, and Audit Preparedness | HIM ensures all downtime documentation practices meet HIPAA and legal medical record standards. Policies define retention periods … Expand | IM.02.01.01 | HIPAA / CMS |
| General Continuous Review and Plan Improvement | The HIM downtime plan, forms, and associated policies are reviewed at least annually by HIM leadership, compliance, and legal team… Expand | PI.01.01.01 | DNV NIAHO |
| ED ED Downtime Governance and Leadership | The Emergency Department maintains a documented downtime plan with a designated Downtime Coordinator or leader responsible for act… Expand | LD.04.01.05; EM.01.01.01 | CMS §482.55 |
| ED ED Training, Education, and Drills | All ED staff, including providers, nurses, and registrars, receive formal downtime training at least annually and participate in s… Expand | HR.01.05.03; EM.03.01.03 | CMS §482.41 |
| General Downtime Documentation Standardization and Accessibility | Current, version-controlled downtime documentation packets—including H&P, nursing, medication administration, orders, and discharg… Expand | IM.02.02.01 | CMS §482.24 |
| ED Order Entry, Communication, and Execution | Paper-based lab, imaging, medication, and admission order forms must be available, complete with required identifiers, provider si… Expand | IM.02.02.01 | CMS §482.23 |
| ED Charge Capture and Reconciliation | Professional and facility downtime charge sheets are maintained, mapped to the CDM, reviewed by Revenue Integrity quarterly, and i… Expand | RC.01.01.01 | CMS §482.24(c) |
| ED Labeling, Patient Identification, and Record Tracking | The ED maintains downtime forms and labels with barcodes or patient label fields. Labeling must occur at registration or point of … Expand | NPSG.01.01.01 | CMS §482.13 |
| ED ED Patient Flow and Tracking | A manual downtime whiteboard or log tracks patient movement, room assignment, orders, and disposition. The log is reconciled daily… Expand | PC.01.01.01 | DNV NIAHO |
Disclaimer: Amelior's Cyber Resiliency Standards are independently developed and designed to align with publicly available guidance from The Joint Commission and CMS. These standards have not been reviewed, approved, endorsed, or certified by The Joint Commission, CMS, or any other regulatory or accrediting organization. References to external frameworks are for informational alignment purposes only.
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