Were You Aware?

1.)  UPDATE!  The following appeared in the November 2009 edition of “Were You Aware:"

"Organizations risk Preliminary Denial of Accreditation if the hospital does not have a current license or certificate as required by its state, or if a component that performs laboratory services (waived or non-waived) does not have a CLIA certificate.  Be sure that all surveyable components have current required licensure or certifications."

In the December edition of The Joint Commission Perspectives, TJC announced a new PDA process for this type of situation, which allows the organization to, through the clarification process, avoid going to the Accreditation Committee for a final decision of PDA if the license or certification is obtained in the interim period.  See Perspectives for the full detail.

2.) On a related note, TJC also announced in the December edition of Perspectives that it has eliminated the PDA rule for organizations that have two consecutive Conditional Accreditation Survey results. 

3.) TJC considers all cellular-based products, both human and non-human, to be under the scope of the tissue and transplant safety standards.  For example, while the FDA considers bovine and porcine heart valves to be “medical devices,” TJC would expect that the requirements under the Transplant Safety (TS) standards be followed for these products.  (Courtesy of a response from the TJC Standards Interpretation Group)

4.) TJC requires that organizations develop plans of action for all partially or fully non-compliant standards identified during the Periodic Performance Review (PPR) process.  (Courtesy of a response from the TJC Standards Interpretation Group)

5.) CMS’ and TJC’s telemedicine requirements apply whenever a Licensed Independent Practitioner (LIP) is providing interpretations, care or directing care for a patient.  If the LIP is simply providing consultative advice to a physician at the originating site and is not actually directing (either in a shared or full manner) the care for the patient, the requirements would not apply.