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November 2025 Newsletter
In the News This Month
Greetings Everyone,
The Joint Commission shared their Top Scoring Clinical Findings observed during survey. Many of these observations have been on previous years’ lists, indicating that organizations continue to struggle to mitigate these challenges. This month’s article, “2025 Top Scoring Clinical Findings Part 1,” written by Christopher Pratt, Senior Consultant & Accredited Provider Program Director, highlights in detail the top findings outlining mitigation strategies recommended for improvement.
Active shooter events are unpredictable and evolve rapidly. Teri Reinhartsen, Associate Consultant’s article, “Is Your Staff Prepared for an Active Shooter?” emphasizes the importance of implementing thorough procedures while providing strategies with necessary elements to include that lay out a proactive approach consisting of education, simulation, and clear communication.
Thank you for taking the time to read our articles. We hope this information is helpful in assisting you with accreditation and regulatory compliance needs. For future topics or should you require our services, please reach out to us at info@courtemanche-assocs.com. Our team is always available and eager to assist you in any way we can.
- By Christopher Pratt, MS, BSN, HACP-CMS, Senior Consultant & Accredited Provider Program Director
The Joint Commission shared their Top Scoring Clinical Findings observed during survey. Learn what to look for and mitigation strategies
The Author
Christopher Pratt MS, BSN, RN, HACP-CMS
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
- By Teri Reinhartsen, RN, MS, CPHRM
Does your organization have an approach to an active shooter situation? Learn strategies to incorporate an effective procedure.
The Author
Teri Reinhartsen is an Associate Consultant with Courtemanche and Associates with 30 years of clinical and leadership experience working in varying healthcare positions from the bedside to the Boardroom. In this role, she is responsible for assessing healthcare organizations’ readiness for licensing, accreditation, and regulatory compliance, and 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. She 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. Throughout her career, Teri has held a variety of Patient Safety, Risk Management and Regulatory Compliance leadership positions for several large healthcare systems. These experiences provided her with a wealth of knowledge in these areas as well as Root Cause Analysis and High Reliability Concepts. Teri has been the lead on mock surveys where she has worked and conducted educational programs related to her areas of expertise. She has also participated in and assisted in DOH/CMS investigations. Clinically, Teri has expertise in the Peri Operative area.
October Spotlight Observations
C&A is a division of SAYAS Alliance. Through our sister company Medical Resources Network, we also offer a range of legal nurse consulting services, including medical record review and analysis, medical chronologies, peer review, retention of medical experts, and adverse event and call center management. Learn more.
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