TJC recently published data on the “Top Ten” compliance issues for the first half of 2015. For hospitals, it was notable that the # 2 issue is the improper cleaning and disinfection of medical equipment, devices, and supplies. 54% of hospitals were cited for this...
read moreAlthough it is not a part of the formal agenda, most TJC surveys typically include a review of a sample of closed records in addition to the open record review that takes place during tracer activities. There are specific elements that surveyors are evaluating when...
read more“How do you know this clinician is competent to run these groups?” That was the question asked by the nurse surveyor during the Human Resources interview on a psychiatric hospital survey. She was reviewing the file of an inpatient therapist who was a licensed clinical...
read moreWe still sometimes see organizations (both psychiatric hospitals and behavioral health organizations) receiving TJC survey findings related to waived testing. So, this month, we are recapping the requirements for waived testing and answering some frequently asked...
read moreIn October 2014, CMS distributed the final version of the three worksheets to be used by the State Survey Agencies (SAs) when conducting their surveys. The worksheets are for Infection Control, Discharge Planning, and Quality Assessment/Performance Improvement (QAPI)....
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