Having your documentation organized for survey is always a challenge, but especially so when dealing with HR requirements and personnel files. Remember that as of January 1, 2021, The Joint Commission updated its Human Resources standard HR.01.01.01, EP 1 to include the documentation icon.
CMS continues to work with accreditation organizations (AOs) on providing some remote flexibilities in conducting surveys. But only through the COVID-19 public health emergency (PHE).
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.
Your facility will need diagrams or schematics of its water system and a way to address stagnant water under the new requirements set out by a new standard from The Joint Commission (TJC). The new Environment of Care standard EC.02.05.02 requires hospitals to have a water management program “in...
As promised, surveys are resuming across the country. And as promised, one of the main items of discussion is how well organizations have responded to the coronavirus pandemic—including their handling of infection control (IC) and implementation of long-term emergency management (EM) operations...
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...
The Healthcare Facilities Accreditation Program (HFAP), the oldest CMS-approved hospital accreditation program in the nation, has merged with the Accreditation Commission for Health Care (ACHC) in a move designed to expand both organizations’ reach in the compliance world.
Assess your environmental cleaning protocols, ensure staff are trained properly, and verify the effectiveness of both as CMS increases scrutiny of infection prevention and control during the coronavirus pandemic.
Earlier this year CMS cited hospitals for not following their own policies...
