At the urging of CMS, The Joint Commission has been providing surveyors with extra training on procedures related to investigating possible immediate jeopardy situations, as well as the use of open-ended questions during interviews with hospital staff.
Sterile processing departments have and will continue to receive a lot of scrutiny during surveys. That is also where hospitals can see a lot of high-risk deficiencies or even a ruling of immediate threat to health or safety.
If I have learned nothing over the course of the last little while, it is that the administration of the risk assessment process in any organization is as close to an essential undertaking as any I can think of (beyond “compliance” as a process).
Which would you rather do? Tell someone in the C-suite the hospital is facing a CMS immediate jeopardy ruling because the staff was so overwhelmed by paper drug prescriptions after a ransomware attack shut down computer records that a 3-year-old patient was given five times the prescribed dosage...
Sit down with pharmacy leadership and review section-by-section compliance with the revised U.S. Pharmacopeia (USP) standards on medication compounding because The Joint Commission (TJC), the Accreditation Commission for Healthcare (ACHC), and other accrediting organizations will assess...
After years of changing and adding new Conditions of Participation (CoP), CMS has finally updated its only guidance for surveyors, State Operations Manual, Appendix A (SOM)....
Safety audits are performed in laboratories across the world, but in some of these locations the environment remains very unsafe and performing audits hasn’t made any difference. Mistakes can be made when performing a laboratory audit, and those errors can lead to dangerous situations. While all...
CMS is worried that hospitals have too much advance notice of when surveyors will be on the premises to audit patient safety practices and identify problems, including those found while investigating patient complaints.
