April 2025 Newsletter

In the News This Month

Happy Spring Everyone!

This month’s focus continues to be on patient safety and risk with the goal of providing organizations with valuable information and strategies to not only be compliant with accreditation and regulatory standards but most importantly prevent unnecessary patient risk and severe harm or even death.

Our first article, “What Happens When Surveyors Declare Immediate Jeopardy,” by Denise Smith, Head of Consulting and Senior Consultant, provides comprehensive information regarding an Immediate Jeopardy citation including an overview of what Immediate Jeopardy is, causes for an organization to be placed under Immediate Jeopardy and steps needed to resolve an Immediate Jeopardy citation.

Our second article, “Procedural Safety – Are Your Teams Focused on Preventing Harm,” written by Christopher Pratt, Senior Consultant & Accredited Provider Program Director, highlights the potential for patient harm with minor procedures outside the surgical realm which are often not considered a top priority for patient safety programs, even though the number of minor procedures is more prevalent. Chris provides key elements to help your organization reduce the risk of procedural patient harm events.

Thank you for taking the time to read our articles. We hope this information is helpful in assisting you with accreditation and regulatory compliance needs. If you have any suggestions for future topics or require our services, please reach out to us at info@courtemanche-assocs.com. Our team is always available and eager to assist you in any way we can.

Immediate Jeopardy risks and preventions

Mar 27 2025

What Happens When Surveyors Declare Immediate Jeopardy?
Well, the surveyors just walked through the door and are getting ready to start your accreditation survey.  You've been doing rounds, tracers, and education. The floors are shining and there is no dust anywhere.  Everyone has their identification badges on and above the waist.  Medical records are audited, and ...
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The Author

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

Denise Smith is Head of Consulting & 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.

Healthcare Accreditation & Regulatory Consultant Denise Smith
Surgeons reviewing procedural checklist before operating on patient.

Mar 27 2025

Procedural Safety – Are Your Teams Focused On Preventing Harm?
Significant focus has been placed on patient safety in the Operating Suites to mitigate vulnerabilities with wrong-site surgery, surgical fire risks, and infection prevention practices. However, the potential for patient harm with minor procedures outside the surgical realm is often not considered a top priority for patient safety programs, ...
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The Author

Christopher Pratt, MS, BSN, RN, HACP-CMS

Chris Pratt is Senior Consultant & Accredited Provider Program Director 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.

Christopher Pratt, Senior Consultant and Accredited Provider Program Director
Tri logos Sayas Alliance parent company and sub division companies.

C&A is a division of SAYAS Alliance. Through our sister company Medical Resources Network, we also offer a range of legal nurse consulting services, including medical record review and analysis, medical chronologies, peer review, retention of medical experts, and adverse event and call center management. Learn more.

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: info@courtemanche-assocs.com

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