February 2022 Newsletter

In the News This Month

Compliance with CMS Conditions of Participation is the foundation for regulatory readiness and is critical for your organization's participation in the Medicare and Medicaid programs. But more importantly, it frequently stems from a patient safety concern which likely had detrimental outcomes. Are you aware of what an immediate jeopardy citation is and how to avoid one? Our feature this month, “Immediate Jeopardy - Risks and Prevention Strategies” by Denise Smith identifies hazards that can lead to an immediate jeopardy citation and strategies for how your team can prevent it.

In addition to complying with CMS, staying up to date with all the healthcare regulatory requirements can be a struggle for many organizations, especially during these trying times of staff shortages and increasing patient loads. Have you considered the benefits a mock survey can provide to help your team identify risk areas and opportunities for improvement? Chris Pratt's article, “Mock Surveys: Determining Your Regulatory Alignment and Safe Patient Care Vulnerabilities” outlines the benefits a Mock Survey can provide your organization as well as what to expect surrounding the process.

We hope you find these articles informative and helpful in assisting you with your ongoing regulatory readiness. Please reach out to us at info@courtemanche-assocs.com for additional information or any service needs you may have.

Immediate Jeopardy risks and preventions

Feb 1 2022

Risks and Prevention Strategies for Immediate Jeopardy
What is Immediate Jeopardy? Immediate Jeopardy defined by CMS , within their Core Guidelines is "a situation in which the provider's noncompliance with one or more requirements of participation has caused or is likely to cause serious injury, harm, impairment, or death to a resident."  The Core Guidelines for Determining ...
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About the Authors

Denise Smith, RN, MS, CLNC, HACP

Denise Smith is a Senior Consultant with Courtemanche & Associates. In this role she is responsible for assessing healthcare organizational readiness for licensing, certification, accreditation, and regulatory compliance. She has extensive knowledge in the requirements of The Joint Commission, DNV, and Centers for Medicare and Medicaid services including knowledge in their survey process, auditing approach and survey outcome determination. She also has knowledge and experience in AAHC and other regulatory and accreditation organizations. She assists organizations with survey preparation, educational needs, post survey activities, patient safety strategies and quality improvement initiatives. Denise has more than 40 years of experience and expertise in Infection Prevention, Sterile Processing, Legal Nurse Consulting, Quality and Resource Management, Clinical Education, in acute inpatient and outpatient care settings.

Healthcare Accreditation & Regulatory Consultant Denise Smith
Mock Surveys Determining Your Regulatory Alignment & Safe Patient Care Vulnerabilities

Feb 1 2022

Mock Surveys: Determining Your Regulatory Alignment
A mock survey is an excellent way to check your alignment with regulatory requirements and ensure your survey readiness.  It involves having unbiased, skilled reviewers, often an external third party, to look at your systems, processes, practices, and documentation to ensure that they address the requirements of your regulatory ...
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About the Authors

Christopher Pratt, MS, BSN, HACP

Chris Pratt is a Senior Consultant with Courtemanche and Associates with more than 33 years in clinical and leadership experience working in varying healthcare positions from the bedside to the Boardroom. In this role, he is responsible for assessing healthcare organizations’ readiness for licensing, accreditation, and regulatory compliance. He is trained in the survey process, auditing approach and survey outcome determination utilized by The Joint Commission, DNV, Centers for Medicare and Medicaid Services (CMS), and other regulatory agencies and accrediting organizations. He assists organizations with post-survey activities, education, patient safety strategies, and quality improvement initiatives and has experience in various health care settings including acute care, behavioral health, and ambulatory care settings.

Courtemanche & Associates Healthcare Consultant Chris Pratt

C_APPS 2021

Fresh from the Field

Our C_APPS membership provides monthly offerings January through November including regulatory & accreditation tools, resources, tracers, policy checklists, and other key aids to facilitate ongoing success with changing expectations.

C_APPS Healthcare Accreditation Tools & Resources 2022

Jan 7 2022

CMS Final Guidance Co-Located Hospitals
This month focuses on the newly released QSO from CMS that provides guidance on Co-Located Hospitals. While the QSO is specific to the co-location of hospitals, more commonly known as a hospital within a hospital, we believe many of the principles and circumstances outlined within the QSO would apply to other types of facilities with co-location as well.
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January Focus

CMS Final Guidance Co-Located Hospitals

This month's package includes:

  • C&A's Co-Located Hospitals Gap Analysis Sample Tool
  • Clinical Contract Sample Evaluation Form
  • Medical Staff New Appointment Sample Checklist
  • Medical Staff Re-Appointment Sample Checklist
  • Revised QSO 19-13-Hospital

C_Apps Resources & Tools

C_APPS is an Exclusive Membership Service resource developed by Courtemanche & Associates that provides monthly offerings of regulatory and accreditation tools, resources, tracers, policy checklists or other key aids to facilitate ongoing success with changing expectations.

Disclaimer: The information on this website is published in good faith for general information purposes only. This website does not make any warranties about the completeness, reliability and accuracy of this information.

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

Courtemanche & Associates | (704)-573-4535 | Email: info@courtemanche-assocs.com

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