September 2021 Newsletter

In the News This Month

Greetings Everyone and Happy September. The change in weather and the back to school bustle always brings a rush of excitement!

It should come as no surprise, change continues within the regulatory world as well. Hence, in this month’s newsletter we continue to provide articles and information to assist with your compliance and performance improvement success. This month’s feature, “Treatment Planning”, outlines key elements for an effective plan designed for patient success. These plans form the backbone of a patient’s care regimen and thus are a major focus for survey teams. The second article, "CMS 1754-F Hospice Conditions of Participation Changes" spotlights important information tucked within the adopted changes of the rule.

As autumn approaches this year, C&A has some exciting news of our own to share! Our freshly designed website is up and running with a brand new look, and ease of use. We invite you to share in our excitement at and welcome feedback from you, our readers.

Hope you enjoy this month’s edition and look forward to hearing from you soon.

Are You Meeting the Needs of Your Patients?

Aug 31 2021

Treatment Planning
The overarching goal in treating clients with behavioral health diagnoses is to see them achieve a healthy state where they use robust coping skills for meeting life's challenges.   However, according to Antoine de Saint-Exupery, a famous French writer and aviator, "A goal without a plan is just a wish".  That's why effective treatment planning is vital to helping these clients by charting the pathway to reach their goals. By regulation, a treatment plan is required for all individuals seeking treatment and it must be individualized to their unique needs and situation.  The plan's format is simple, however, it does require ...
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About the Author

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.


Changes for CMS rule 1754-F

Aug 31 2021

CMS 1754-F Hospice Conditions of Participation Changes Finalized- Competency Changes
On July 29, 2021, CMS rule 1754-F was finalized and while it is entitled the 2022 Hospice Payment Rate Update, the rule makes final the proposed changes to the Hospice Conditions of Participation.  This month, our focus is on the adopted changes to the hospice aid competency evaluation changes that are contained within rule 1754-F. While many of you will be focused on the changes in the reimbursement rates and the quality measure changes, there is a small section that will require each organization to evaluate their current competency assessment process to ensure alignment with these new requirements. During the ...
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About the Author

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.


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.

Patient Visitation

Sep 10 2021

Breast Milk Management
This month we are providing you some simple tools related to the management of Breast Milk. So often when we are conducting mock surveys at our client organizations, we encounter issues with the management of Breast Milk. Whether the issue is related to storage, labeling or management of the product by the patient, they can all be tracked back to two issues; staff reliance on memory and/or unsubstantiated competency of the skills needed to manage Breast Milk. We are also providing two CDC published posters that can be posted for staff reference along with the Courtemanche & Associates Breast Milk Management Competency Tool. The posters should be placed in convenient locations such as on or near the Breast Milk storage refrigerator and potentially in each patient room so that the staff and patients can review the safety steps that should be taken when handling breast milk.
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September Focus

Breast Milk Management

This month's package includes:

  • Breast Milk Management Competency Tool
  • CDC Breast Milk Management Poster
  • CDC Poster HUman Milk Storage Guidelines

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:

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