August 2023 Newsletter

In the News This Month

Greetings Everyone,

We hope you and your family are enjoying a fun and safe summer. It's hard to believe it is August already!

This month's newsletter edition features a look at the Top Deficiencies noted by CMS on their Quality, Certification and Oversight Reports (QCOR).  Author, Anne Kelly, Associate Consultant provides details for each of these deficiencies including prevention strategies for eliminating harm to patients and staff while gleaning the benefits of a robust regulatory plan.

Also, this month we look at Root Cause Analysis, authored by Patricia Cook, Senior Consultant and Head of Consulting Services, defining what it is, why it's important and providing tips for implementing a successful process.

We hope you find these articles informative and helpful in assisting you with your ongoing regulatory readiness. Please feel free to reach out to us at with any topics you would like to see featured or for any service needs you may have.

CMS surveyor writing notes on clipboard

Aug 1 2023

Is Your Hospital at Risk for a Top CMS Deficiency?
Maintaining continuous compliance with multiple regulatory requirements can be challenging for even the most seasoned hospital teams. We are frequently asked for current survey trends and effective strategies to prevent regulatory issues. In this article, top CMS deficiencies are shared, as noted on the CMS Quality, Certification, and Oversight ...
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About the Authors

Anne Kelly, EdD, BSN

Anne Kelly is an Associate Consultant with Courtemanche and Associates. In this role, she is responsible for assessing healthcare organizations’ readiness for licensing, accreditation, and regulatory compliance. Anne is trained in the survey process, auditing approach and survey outcome determination utilized by The Joint Commission, Centers for Medicare and Medicaid Services (CMS), and other regulatory agencies and accrediting organizations. She assists organizations with pre-survey, intra-survey and post-survey activitieseducation, patient safety strategies, and quality improvement initiatives.

With more than 30 years of clinical and leadership experience working in varying healthcare positions, Anne has held various Quality, Accreditation and Patient Safety leadership positions. As Chief Quality and Compliance Officer with Acadia Healthcare, a leading provider of Behavioral Health services in the United States, she led the enterprise-wide Corporate Compliance Program and quality initiatives.

Anne Kelly, EdD, BSN, Associate Consultant
Root Cause Analysis Diagram

Aug 1 2023

Root Cause Analysis – Does it Really Work?
All of the Regulatory and Accreditation agencies have some type of expectation for the conduct of Root Cause Analysis. It is inherent in our human nature to want to understand what happened, and it is what we need to have peace of mind. Our electric bill has increased by ...
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About the Authors

Patricia Cook, B.S., R.Ph, HACP, GRCP

Pat Cook is a Senior Consultant and Head of Consulting Services at Courtemanche & Associates. Working in collaboration with the C&A Leaders, Pat manages Courtemanche & Associate’s business development initiatives and oversees the clinical delivery of services and support. With her extensive healthcare experience, Pat serves as a knowledgeable resource to new and existing clients, helping to guide them through their accreditation and regulatory needs.

Patricia Cook Consultant & Author

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The Joint Commission® is a registered trademark of Joint Commission on Accreditation of Healthcare Organizations. Courtemanche & Associates has no affiliation with this entity.

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