Below is a sample of records and documents requested during TJC triennial hospital surveys in August, according to Gayle Nash, RN, MPH, CEO of Nash Healthcare Consulting.
Expect The Joint Commission (TJC) to get tougher on water management and infection control, preconstruction risk assessments, workplace violence protections, and kitchen safety. Don’t be surprised if TJC Life Safety Code®(LSC) surveyors go into places you may not have seen...
Over the years, physicians have been frequently accused of resisting change. In the face of tremendous new pressures—ranging from explosive levels of new technology and data to changing regulatory burdens and expectations—it is understandable that care providers may struggle to keep up. Now,...
With temperatures dropping and snow on the way in many states, hospitals and clinics need to create a checklist of winter safety items. We asked Brad Keyes, CHSP, owner of Keyes Life Safety Compliance, about things that should be on that checklist from a life safety standpoint.
Surveys are resuming in areas deemed safe for on-site visits even as the coronavirus pandemic continues its waves of surge and decline. With COVID-19 still on everyone’s mind, expect to be asked for documentation of inspection, testing, and maintenance (ITM) of critical systems and to show...
Be prepared to explain to surveyors how you will catch up with any inspection, testing, and maintenance (ITM) of non-critical systems that had been delayed because of the coronavirus pandemic.
Update logs and records for any ITM done on critical systems, and make sure you can show that...
A pandemic caused by a novel coronavirus was predictable. Yet the experience itself was—and still is for many—unanticipated, says Deanna Scatena, BSN, RN, CCRN,...
In the September issue, we told you about a hospital that responded quickly to threats posed after the nation learned of the 2019 novel coronavirus, but still faced a finding of immediate jeopardy (IJ) to patients and staff from CMS officials.
Always being ready for survey can be one of the greatest challenges, but there are tools. In the following excerpt from HCPro’s recently published Survey Coordinator’s Handbook, 21st Edition, we offer you a look at using tracers to assess how well your team is doing on compliance.
The following information was taken from a CMS Form-2567 “Statement of Deficiencies” posted online by the federal agency under its Quality, Certification and Oversight Reports (QCOR) group.