In preparing for your Joint Commission survey, it is always helpful to review the Survey Activity Guides published by the Joint Commission annually. These guides will not only assist you in preparing for survey but will also provide you with an abstract of each survey activity that includes logistical needs, session objectives, an overview of …
Recently there has been a lot of news about cybercrime related to hospital IT systems. The American Hospital Association published a Special Bulletin recently updating hospitals of these attacks and the need to make sure that their IT systems are secure. This information comes from the Cybersecurity and Infrastructure Security Agency, the FBI and the …
On September 25, 2020, the following information was released by The Joint Commission (TJC). TJC has worked closely with certification providers and CMS. Certification providers have stated they do not intend to provide any further extensions on certification card expiration dates. CMS has confirmed there are no waivers for these certifications except for ESRD organizations. …
Are additional waivers available for ACLS, BLS and CPR certifications? Read More »
The Joint Commission will be defining fall events in their Sentinel Event Policy starting January 1, 2021 to help address the need for more preventive fall measures. This new definition will be more closely aligned with established guidelines from the National Database of Nursing Quality Indicators™ and the National Quality Forum. The new definition will …
New Definition for Fall Events Under TJC’s Sentinel Event Policy Read More »
CMS’s recently announced adoption of the final rule that will make changes to several regulatory requirements that affect hospitals, critical access hospitals and/or Ambulatory Surgery Centers. These changes will be phased in over the next two years. The first change removes the current requirements found at 416.52(a) for a H&P within 30 days of the …
History & Physical Requirement Changes – Ambulatory Surgery Centers Read More »
While Covid-19 still dominates our minds and our work, TJC recently shared that their review process for continuing their deemed status authority with CMS continues. As a result of this review, CMS will be requiring The Joint Commission to conduct an Environment of Care/ Life Safety Review at each ambulatory care location that is a …
EXPANSION OF SURVEY- HOSPITAL OWNED AMBULATORY CARE LOCATIONS Read More »
On March 12, the United States Pharmacopeia announced the results of the last minute appeal that was filed earlier this year- just before the anticipated implementation deadline for the updated USP Chapter 795, USP Chapter 797 and brand new USP Chapter 825. To summarize the actions taken, the USP has accepted the appeal for USP …
As children, many of us were keenly aware of the dangers of monsters lurking under our beds and in our closets at night. Age and wisdom (and sometimes a flashlight wielding parent) soon dismissed these creatures as figments of our own imagination. However, as leaders in healthcare, we should realize that there are indeed monsters …
Monsters Under the Bed – The Hidden Danger of Mold Read More »
The relationship between quality in healthcare and money (CMS reimbursement specifically) couldn’t be more relevant than when you consider the ramifications of finding your organization in an immediate jeopardy status and your ability to receive funds through the Centers for Medicare and Medicaid Services (CMS) Value Based Purchasing programs. “Hospital Value-Based Purchasing (VBP) is part …
