A close look at the top five standards cited during the Joint Commission (TJC) surveys from January 1, 2012, through December 31, 2012, revealed similarities between those found in 2012 and those found in 2011. According to the Joint Commission’s report, the most challenging requirements for 2012 were the following: RC.01.01.01. The hospital maintains complete [...]
In April 2013, the Centers for Medicare and Medicaid Services (CMS) issued two survey and certification letters to State Agencies with instructions relative to performing complaint surveys in response to sequestration budget reductions. The first letter, issued on April 5, 2013, instructed State Agencies to limit the on-site investigations to “those allegations that, if substantiated, would [...]
In Part I of this series, “It’s Time to Sound the Alarm About Medical Device Safety,” we began to examine The Joint Commission’s (TJC) guidelines for medical device safety in hospitals focusing on the safety of alarm-equipped medical devices. In Part II, we continue our examination of these recommendations—including guidelines for alarm settings and processes for [...]
On April 8, 2013, the Joint Commission issued a Sentinel Event Alert on medical device alarm safety in hospitals. This series of articles examines how to improve safety related to alarm-equipped medical devices and thereby improve an organization’s ability to provide safe, quality care. Have you ever bought a new car with all the latest [...]
In our recent article, “CMS and TJC Survey Preparation: Is There a Difference?” we explained some differences in how Joint Commission (TJC) standards cross-walk to the Centers for Medicare and Medicaid Services (CMS) Conditions of Participation (CoPs). Here’s an example of how these standards can differ: CMS Tag A-0131, §482.13(b)(2), relates to informed consent. Although [...]
Have you evaluated what readmissions will cost your organization? Have you implemented any plans to address readmissions? The readmissions penalty is not going away and CMS likely will expand the program as it enters its second year. The time to act is now.
READ “Hospital Readmissions: How to Stop the Pain,” by Compass Clinical’s Terri Marshall, RN, on Hospital & Health Networks magazine.
Last week, the Centers for Medicare and Medicaid Services (CMS) unveiled its new searchable hospital inspection report database to the public. Now, anyone—patients, news media, lawyers, and hospital critics—can easily access reports detailing violations found in hospital operations. To make matters worse, the part of the database that is supposed to include hospital-submitted corrective action plans [...]
Our previous article, “Does increased Infection Control scrutiny leave you feeling exposed?” discussed the growing trend of increased scrutiny in the areas of Infection Control. To help you prepare for survey, we included lists of Infection Control findings being cited at other organizations. The next step is to identify where the gaps are in your [...]
Results of recent surveys by both regulatory and accrediting agencies confirm the continued trend of an intense focus on Infection Control practices throughout the healthcare system. In particular, surveyors are looking to see if Infection Control practices and training are consistent across all settings, including off-site locations. Does the surveillance plan address infections identified in [...]
Hospitals that are accredited by the Joint Commission (TJC) know the value of continued survey readiness. However, when it comes to preparing for a Centers for Medicare and Medicaid Services (CMS) survey, many hospitals utilize the same approach as they would for TJC survey. This is a mistake. Although TJC standards are reflective of the CMS [...]
Welcome to Compass Clinical Consulting's Hospital Accreditation and Compliance Journal!
"No recent Twitter posts." — compasscc
