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Did you know a federal jury in Ft. Lauderdale, Florida has convicted Gail Russ, Cassandre Jean, and Vilaire Duroseau of wire fraud and conspiracy to commit wire fraud for their roles in a fraudulent nursing diploma scheme. These individuals were part of a larger operation involving 27 defendants, known as Operation Nightingale. They sold over 7,600 fake nursing diplomas from the Palm Beach School of Nursing and Quisqueya School of Nursing LLC. The fraudulent diplomas allowed buyers to sit for the national nursing board exam, obtain licenses, and secure nursing jobs across the U.S. Eleven other defendants pleaded guilty to conspiracy charges. The case was investigated by the FBI and HHS-OIG, with additional support from other federal and state agencies.

The  Accreditation Commission for Health Care (ACHC) standards for hospital providers require verification of qualifications for all licensed personnel. This includes:

  1. Standard 01.00.04 Licensure of Personnel: Ensuring personnel are licensed or meet applicable state or local standards (§482.11(c)).
  2. Standard 04.00.02 Licensure: Verifying that all employees meet licensure and employment standards, including certification, qualifications, training, education, and necessary permits. This applies to both hospital employees and contract staff (§482.11(c)).

These standards apply to all healthcare professionals who require certification, licensure, or registration and must act within their state-defined scope of practice. This includes nurses, doctors, physician assistants, dietitians, and various therapists.

Hospitals must establish verification mechanisms (via mail, electronic communication, or phone) with licensing agencies to confirm that all licenses and certificates are valid. Practicing without appropriate licensure may lead to loss of accreditation.

Tips For Compliance

  • Include processes for verifying credentials at hiring and renewal in hospital policies.
  • Outline steps to handle suspended or revoked licenses.
  • Maintain evidence of credential verification in personnel files.
  • Develop a tracking system to monitor credential expiration and revalidation dates.

Tips for Successful Navigation of Clinical Records During a Survey

Our next accreditor update details tips the Center for Improving Healthcare Quality (CIHQ) provides for skillfully navigating electronic clinical records during an accreditation survey.

The varied interfaces and real-time navigation challenges of electronic medical records (EMRs) can complicate the review process if your staff is not proficient in using these systems. This can result in hospitals facing unwarranted deficiencies due to unclear compliance documentation.

To manage modern medical record reviews effectively:

  1. Clarify Formats: Know what information is on paper and what is electronic, ensuring both are accessible for the surveyor. Ensure all EMR components are accessible from the same device.
  2. Create a Suitable Environment: Provide a quiet, spacious area near the care unit for record review, avoiding cramped or busy spaces.
  3. Utilize Super Users: Have a sufficient number of knowledgeable “super users” available to assist both staff and surveyors, assigning one per surveyor if possible.
  4. Provide Cheat Sheets: Develop and distribute laminated cheat sheets to help staff navigate the EMR, particularly for cross-disciplinary entries.
  5. Resolve Information Gaps: If information is missing during a survey, collect necessary patient details and ensure the record is reviewed internally. Arrange for a super user to demonstrate the entry to the surveyor if found.

Implementing these strategies can help hospitals successfully navigate medical record reviews during surveys.

 

Cybersecurity

In 2023 there were 450 security breaches that impacted providers? Although healthcare organizations are making progress, with the average amount of breaches trending down slightly in 2024, it pays to be vigilant.

DNV Healthcare (DNV)  is introducing an Advanced Healthcare Cybersecurity Certification to help hospitals and healthcare organizations enhance patient data security amid these cyber threats. This certification aims to safeguard sensitive patient information, ensure regulatory compliance, and mitigate the financial and operational risks associated with data breaches and cyberattacks.

Importance of Cybersecurity in Healthcare

  • Safeguards sensitive patient information used for treatment.
  • Avoids disruptions in healthcare services.
  • Upholds trust in healthcare providers.
  • Alleviates the financial risks from data breaches.

Certification Benefits

  • Recognizes cybersecurity applications and risks within healthcare organizations.
  • Provides organizations with tools and knowledge to protect patient data.
  • Warrants compliance with standards like HIPAA, GDPR, and HITECH.
  • Improves incident response plans.
  • Promotes a culture of cybersecurity awareness among staff.

Certification Standards Cover

  • Distinctive cybersecurity challenges in healthcare.
  • Leading practices for securing electronic health records (EHRs).
  • Accreditation compliance standards and CMS requirements.
  • Threat response and cyber risk mitigation strategies.
  • Staff education and awareness.

Additionally, DNV will soon offer a healthcare cybersecurity training course for all healthcare professionals to further support cybersecurity management in the industry.  Contact DNV to download the standards.

 

Joint Commission Field Review: Infection Prevention and Control (IC) Chapter Requirements for Behavioral Health Care Organizations

Infection prevention and control is the final topic in our accreditor update. The Joint Commission is proposing revisions to the “Infection Prevention and Control” (IC) chapter for Behavioral Health Care organizations. Key points include:

  • The IC chapter has been fully revised and will replace current requirements starting July 1, 2025.
  • The new IC chapter is more streamlined, emphasizing essential structures and processes to support quality and safety.
  • The revisions align requirements more closely with laws, regulations, and CDC Core Infection Prevention and Control Practices for Safe Healthcare Delivery in all settings.

Two Standards are open to the public for Field Review and comment.  These standards are summarized below.  Please use the following link to access the full standards and EPs Proposed Infection Prevention (IC) Chapter for Behavioral Health Care and Human Services (BHC) Program

IC.04.01.01 Summary

The organization establishes processes to prevent and control infections and communicable diseases. This includes assigning qualified individuals to oversee the infection control program, maintaining a sanitary environment, developing and implementing infection control activities, monitoring compliance, and ensuring adherence to local health authority requirements. Policies and procedures align with laws, regulations, and evidence-based guidelines, including standard precautions such as hand hygiene and use of PPE. The organization provides job-specific infection control training to staff and supplies necessary for infection control activities.

IC.06.01.01 Summary

The organization implements activities to prevent and control infections and communicable diseases. It identifies infection risks based on the services provided and relevant public health issues and reviews these risks at least annually. The organization uses standard precautions and develops action plans to address infection control issues. It also ensures proper handling, storage, processing, and transportation of linens according to regulations.

Barrins and Associates

Barrins stays up to date with current accreditor changes. By conducting mock surveys, we enable your organization to remain in continuous compliance with accreditation and regulatory requirements. Contact us today to schedule a 2024 Mock Survey.

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