Blogs

Time Sensitive New Survey Guidance from CMS- Survey Suspensions

On January 20, 2021 CMS issued QSO 20-13 announcing new limitations to the conduct of allegation, accreditation and certification surveys. Accrediting Organizations are being advised to suspend their accreditation certification activities for the next 30 days at which point CMS will reevaluate and could extend the suspension for an additional 30-day period. Click here to […]

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Get Ready for Your Next Survey

In preparing for your Joint Commission survey, it is always helpful to review the Survey Activity Guides published by the Joint Commission annually. These guides will not only assist you in preparing for survey but will also provide you with an abstract of each survey activity that includes logistical needs, session objectives, an overview of

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Suicide Prevention – Are You Addressing the Risk?

January 2021 marks eighteen months since changes were initiated with more focus on NPSG 15.01.01, Reducing the risk of suicide. The changes in focus were in response to devastating statistics showing a trend of increasing rates of suicide. According to the Centers for Disease Control and Prevention (CDC) WISQARS Leading Causes of Death Reports, in

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Cybercrime – Is Your IT System Secure?

Recently there has been a lot of news about cybercrime related to hospital IT systems. The American Hospital Association published a Special Bulletin recently updating hospitals of these attacks and the need to make sure that their IT systems are secure. This information comes from the Cybersecurity and Infrastructure Security Agency, the FBI and the

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The TJC and CMS Update 2020

While we have been dealing with Covid for the majority of 2020, some important information about CMS’s expectations of Accreditation Organizations (AOs) with Deeming Authority has come to light and while Covid remains a significant health risk, there are other patient safety focused standards that were slated for implementation in 2020 that were delayed to

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Patient Fall Prevention – Are You Addressing the Risk?

[vc_row type=”in_container” full_screen_row_position=”middle” scene_position=”center” text_color=”dark” text_align=”left” overlay_strength=”0.3″][vc_column column_padding=”no-extra-padding” column_padding_position=”all” background_color_opacity=”1″ background_hover_color_opacity=”1″ column_shadow=”none” width=”1/1″ tablet_text_alignment=”default” phone_text_alignment=”default” column_border_width=”none” column_border_style=”solid”][vc_column_text]How is your organization doing in addressing fall risks for your patients? Patient falls are among the most reported patient safety incident. Recent data from the Agency for Healthcare Research and Quality (AHRQ) estimates that 700,000 to 1 million

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Credentialing: How to Succeed

Credentials are documented evidence of licensure, education, training, experience, or other qualifications. Credentials can be in the form of a certificate, letter, official identification, or experience that confirms a practitioner is qualified to perform specific procedures or services. Once credentials are submitted along with the application and all other requested paperwork, the organization needs to

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Are additional waivers available for ACLS, BLS and CPR certifications?

On September 25, 2020, the following information was released by The Joint Commission (TJC). TJC has worked closely with certification providers and CMS. Certification providers have stated they do not intend to provide any further extensions on certification card expiration dates. CMS has confirmed there are no waivers for these certifications except for ESRD organizations.

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Are Daily Anesthesia Machine Checks Needed?

To provide safe and reliable anesthesia to all patients undergoing surgery it is important to make sure that the anesthesia machine used is working properly.  Anesthesia outcome claims have decreased over the past two decades to less than 1% of claims according to the American Society of Anesthesiology (ASAHQ), with the most recent data publicized

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Emergency Preparedness Part III – Can Disasters Be Managed Through a Lens of High Reliability?

By James Ballard, MBA, CPHQ, CPPS, HACP and Christopher Pratt, MS, BSN, RN A Futuristic Perspective for Incident Management In Parts I and II of Emergency Preparedness, we provided an overview of what happens when disaster strikes and a process to trace your current procedure. In Part III, we offer a futuristic viewpoint on High

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