Proposed Revisions to USP Compounding General Chapter 797
The latest proposed revisions to USP Chapter 797- Pharmaceutical Compounding Sterile Solutions were released in September 2021 for public comment.
CMS Publishes Expectations- Surveyors Conducting Federal Oversight Work
As Accrediting Organizations begin to conduct On-Site Surveys due to the drop in Omicron infections and the reduced acuity associated with most of those infections, CMS released QSO 22-10- All Vaccine Expectations for Surveyors Performing Federal Oversight.
CMS released QSO 22-07-All – Urgent Reminder
CMS released QSO 22-07-All, and surveyors will begin surveying to these requirements on January 27, 2022.
Safety Alert – Double Check your Respirators
NIOSH, in agreement with the manufacturer, ALG Healthcare, have agreed to rescind the NIOSH approval for specific respirators manufactured by ALG Healthcare.
Ambulatory Care’s Most Challenging Findings
A list of Ambulatory Care’s most challenging findings for 2021 was recently published by The Joint Commission (TJC).
CMS Conditions of Participation FAQs

CMS published several FAQs on the changes made to the Conditions of Participation for Hospitals.
Rights and Responsibilities (RI) Chapter Update- Just Released
The Rights and Responsibilities of the Individual (RI) chapter updates were just released by the Joint Commission. These updates go into effect on July 1, 2022.
FDA Issues Warning Against Certain Imported Medical Gloves

In 2021, The Joint Commission refocused their resources and set forth revisions to the Emergency Management Chapter. There are few items we wish to draw your attention to that are now present in the chapter, and a few areas that we believe are missing from the chapter.
Updates To TJC Emergency Management Standards
On September 1, 2021, The Joint Commission posted the long-awaited Proposed Changes to the Emergency Management Chapter.
New & Revised Requirements Addressing Antibiotic Stewardship
On August 4, 2021, The Joint Commission posted new elements of performance related to MM 09.01.01 Antibiotic Stewardship.
Heads Up! Medication or Not?
Many organizations may be leaving these opportunities for improvement on the table. Did you know that any toothpaste that contains sodium fluoride contains a National Drug Code and is classified as a medication? We recently verified this with The Joint Commission Standards Interpretation Group. Their team advised this would be determined by how they are […]
Covid-19 Resources for Environmental Services
Recently the American Hospital Association, Health Research and Educational Trust and the Center for Disease Control updated their COVID-19 training and education resource for those persons responsible for maintaining the cleanliness of our organizations. While the tool addresses COVID-19, the training is founded in the basic principles of disinfection and contains great infographics that could […]