August 2023 Newsletter

In the News This Month

Greetings Everyone,

We hope you and your family are enjoying a fun and safe summer. It's hard to believe it is August already!

This month's newsletter edition features a look at the Top Deficiencies noted by CMS on their Quality, Certification and Oversight Reports (QCOR).  Author, Anne Kelly, Associate Consultant provides details for each of these deficiencies including prevention strategies for eliminating harm to patients and staff while gleaning the benefits of a robust regulatory plan.

Also, this month we look at Root Cause Analysis, authored by Patricia Cook, Senior Consultant and Head of Consulting Services, defining what it is, why it's important and providing tips for implementing a successful process.

We hope you find these articles informative and helpful in assisting you with your ongoing regulatory readiness. Please feel free to reach out to us at info@courtemanche-assocs.com with any topics you would like to see featured or for any service needs you may have.

CMS surveyor writing notes on clipboard

Aug 1 2023

Is Your Hospital at Risk for a Top CMS Deficiency?
Maintaining continuous compliance with multiple regulatory requirements can be challenging for even the most seasoned hospital teams. We are frequently asked for current survey trends and effective strategies to prevent regulatory issues. In this article, top CMS deficiencies are shared, as noted on the CMS Quality, Certification, and Oversight ...
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About the Authors

Patricia Cook, B.S., R.Ph, HACP, GRCP

Pat Cook is a Senior Consultant at Courtemanche & Associates. She has four decades of healthcare administrative and regulatory experience where she served in multiple leadership positions including Drug Distribution Supervisor, Assistant Director of Pharmacy and Director of Pharmaceutical Care. Her experience with regulatory compliance, licensure and accreditation spans over 30 years and involved survey coordination and survey readiness and response across hospital, long term care, ambulatory care, behavioral health, and home care practice settings. Prior to joining the C&A team, Pat’s most recent healthcare experience was serving as System Vice President of Accreditation and Licensure for RWJ Barnabas Health. where Additionally, she also holds the following certifications, Six Sigma Green Belt, Certified Healthcare Accreditation Professional (HACP), and is a Master Trainer in TeamSTEPPS.

Anne Kelly, EdD, BSN, Associate Consultant
Root Cause Analysis Diagram

Aug 1 2023

Root Cause Analysis – Does it Really Work?
All of the Regulatory and Accreditation agencies have some type of expectation for the conduct of Root Cause Analysis. It is inherent in our human nature to want to understand what happened, and it is what we need to have peace of mind. Our electric bill has increased by ...
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About the Authors

The C&A Consulting Team

Our healthcare accreditation & regulatory compliance team are experts in the healthcare industry and collectively sharing more than two centuries of healthcare knowledge, wisdom & guidance. Our core team along with our top-notch partners provide a wealth of knowledge, wisdom and guidance to assist you with performance improvement and regulatory success.

Patricia Cook Consultant & Author

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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