C&A Blog

National Patient Safety Goal (NPSG) Standard NPSG.15.01.01 Suicide Prevention

Effective July 1, 2020, National Patient Safety Goal (NPSG) Standard NPSG.15.01.01 Suicide Prevention will apply to Joint Commission–accredited critical access hospitals. Most Critical Access Hospitals have been striving toward achieving this Patient Safety goal for some time now. We want to share this with everyone as Suicide Prevention and Ligature Risk is an extremely high …

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Disparity Rate remains above Allowable Standards for FY 2018

From the Center for Clinical Standards and Quality/Quality, Safety & Oversight Group (Ref: QSO-19-17-AO/CLIA) DATE: August 20, 2019 SUBJECT: FY 2018 Report to Congress (RTC): Review of Medicare’s Program Oversight of Accrediting Organizations (AOs) and the Clinical Laboratory Improvement Amendments of 1988 (CLIA) Validation Program Federal Law allows for a 20% disparity rate between what …

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Omnibus Burden Reduction (Conditions of Participation) Final Rule CMS-3346-F Part 2

The removal of these regulations has been approved as an effort to reduce inefficiencies and improve the delivery of lower cost, high quality care with better patient outcomes. This new rule complies with President Trump’s Executive order directing  healthcare providers to focus on the patient as the priority. The Final rule would reduce burden for …

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Part VI – CMS Immediate Jeopardy Series

How to Address an Immediate Jeopardy Decision?   The survey team leader wants to address an Immediate Jeopardy situation with your leadership.  The surveyor verbally presents the circumstances of the situation, the investigation performed and the decision process.  The specific details, including the individuals at risk is provided before leaving the entity.  What should you do?  …

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CMS Part IV : Acting to Avoid Immediate Jeopardy

How are CMS Immediate Jeopardy Investigations Conducted?  Whether your CMS surveyor is concerned with a failure to protect or prevent harm for a served individual or not, they are always on the lookout for potential abuse or neglect. Circumstances that identify triggers must be investigated to assure there is no risk of harm to individuals under …

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