From time to time, we update our readers on standards compliance requirements related to commonly challenging issues we see coming up on surveys. So, take a look at the following and make sure these don’t become survey pitfalls for you:

Vaccine Storage

TJC agrees with the CDC recommendation not to store vaccines in a dormitory style refrigerator and has cited this method of storage as non-compliant on surveys. A dormitory style refrigerator is a combination refrigerator/freezer unit with one exterior door and an evaporator plate (cooling coil) which is usually located inside an ice maker compartment (freezer) within the refrigerator. These types of units have demonstrated significant temperature instability throughout the entire unit and are thus not considered appropriate for vaccines. In addition, CDC recommends that temperatures for vaccine storage units be monitored twice a day so be sure to make that part of your procedure. For more information on this topic, see the CDC Vaccine Storage and Handling Toolkit.

Vaccines Exempt from 28 Day Rule for Multi-dose Vials

Everyone is aware that multi-dose vials must be labeled with a 28 day discard date once opened. However, also be aware that vaccines are exempt from this requirement. The CDC recommends that vaccines be discarded according to the manufacturer’s expiration date and TJC is applying this approach during surveys.

CLIA Certificates for Outpatient Sites

If your organization does waived testing at outpatient sites, be sure you have the appropriate CLIA certificate for that site. We have found that in some states the CLIA certificate for the main organization applies to all outpatient sites as well. In other states, this is not the case and each outpatient site must obtain its own CLIA certificate. So, be sure to check with your State Agency to determine what rules apply in your state. Also, be aware that you must notify your State Agency of any changes to the location or the name of the director on your CLIA certificate within 30 days of such a change. State Agency contact information is found on the CMS CLIA internet page.

Timing of Fire Drills

Remember that the timing of quarterly fire drills should be varied and should not occur on the same day of the week, month, or time of day each quarter. Some organizations have been cited on survey for having all of their dire drills consistently occur at the same time over several quarters; e.g. the drill for the first shift always occurred at 7:15 a.m. So, be sure to develop a schedule for varying the timing of your fire drills. See EC.02.03.03 EP 3 in both the Hospital and BH manuals for details.

Documentation of Continuing Medical Education

The minimal TJC requirement for documentation of CME is that there be an attestation by the licensed independent practitioner of attendance at CME programs that relate to their area of practice with the stipulation that proof of attendance and program content will be submitted upon request. Beyond that, it is up to the organization to determine whether they will require copies of program certificates or other documentation of the CME. Remember, the surveyors will survey against your organizational policy.

Texting of Orders

TJC has stated their position that the use of secure text messaging for patient care orders is not acceptable. This is in agreement with CMS’ position on this issue and is a reversal of the earlier TJC position published in May 2016. For full coverage of this topic, see the clarification in the December 2016 issue of TJC Perspectives.


A Mission for Michael Receives Gold Standard of Joint Commission Accreditation Revisions to BH Standards Effective July 1, 2017