October 2023 Newsletter

In the News This Month

Greetings Everyone,

As we approach the end of the year, this is the time when The Centers for Medicare and Medicaid Services (CMS) and other accrediting organizations review the regulatory standards and look for ways to improve upon patient safety and care. This month’s articles highlight two different areas of focus.

On July 17, 2023, CMS released a memorandum highlighting the requirements for ligature risk and assessment in hospitals. When considering ligature risk in your organization, how thoroughly is your team addressing this in an ongoing and persistent manner? Anne Kelly’s article, “Ligature Risk and Assessments as a Hospital Priority,” addresses key CMS guidelines and best practices for how to manage Ligature Risk in healthcare settings.

Our second article, “Assessing your Dental Services for Compliance,” is the first in a two-part series, focusing on regulatory compliance standards in Dental Services. Author, Denise Smith presents a comprehensive look at a multitude of areas in dental practices that can be a patient safety concern while providing key strategies for safe practice and regulatory compliance for each.

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 info@courtemanche-assocs.com with any topics you would like to see featured or for any service needs you may have.

Patient Safety Healthcare Concept

Sep 28 2023

Ligature Risk and Assessments as a Hospital Priority
The Centers for Medicare and Medicaid Services (CMS) regulations cover a wide range of expectations in the provision of safe, quality patient care. On July 17, 2023, CMS released a memorandum highlighting the requirements for ligature risk and assessment in hospitals. Psychiatric hospitals encounter heightened ligature risks due to ...
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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
Dental assistant cleaning equipment

Sep 28 2023

Assessing Your Dental Services for Compliance
First in a series on Regulatory Compliance for Dental Services! When performing dental services, you first need to identify the types of procedures that will be performed in the organization or office. This includes the type of anesthesia that will be offered to the patients as well as the ...
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About the Authors

Denise Smith, RN, BS, MS, CLNC, HACP-CMS

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 AAAHC 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.

Denise Smith, Senior Consultant

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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.

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

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