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ARTICLES IN Inside Accreditation & Quality - VOLUME 6 ISSUE 4 - PRINT FULL ISSUE

Inside Accreditation & Quality

- Volume

Issue

ICYMI: Health equity standards now NPSG; TJC deletes some standards; PHE lives on for now

February 21, 2023

Accreditation & Survey Preparation, Natural & Manmade Disasters, Infection Control

Health equity now NPSG, PHE to end May 11, TJC completes round one standards review. ...

Inside Accreditation & Quality

- Volume

Issue

Horine: ACHC-accredited hospitals met pandemic challenges but still have work to do

January 17, 2023

Accreditation & Survey Preparation

by A.J. Plunkett (aplunkett@decisionhealth.com) Look for the Accreditation Commission for Health Care (ACHC) to continue collaborating with hospitals and other healthcare providers to improve patie...

Inside Accreditation & Quality

- Volume

Issue

CMS final rule on rural emergency hospitals offers flexibility on 24-hour observation limit

January 24, 2023

Accreditation & Survey Preparation

In its final rule, CMS included behavioral health and low-risk maternal labor and delivery on the list of services allowed under the rural emergency hospital (REH) designation. However, some hospitals...

Inside Accreditation & Quality

- Volume

Issue

Joint Commission moves to three-year appointment cycle—now what?

January 31, 2023

Accreditation & Survey Preparation

The Joint Commission’s time frame for evaluating licensed practitioners’ ability to provide care, treatment, and services has been updated from two years to three years, and is intended to better alig...

Inside Accreditation & Quality

- Volume

Issue

Infection control, supply storage, food services top ACHC survey deficiencies

February 07, 2023

Accreditation & Survey Preparation, Infection Control

Beware of repeat deficiencies. CMS is pressing accrediting organizations (AO) to deal more harshly with hospitals that have repeat citations, including elevating a recurring finding to a condition-lev...

Inside Accreditation & Quality

- Volume

Issue

Behavioral health cases in ER may rise if post-pandemic telehealth flexibilities end

February 14, 2023

Behavioral & Mental Health, Infection Control

Expect more patients in the emergency room (ER) seeking help with behavioral health issues when the COVID-19 public health emergency (PHE) ends—especially if the Drug Enforcement Administration (DEA) ...

Inside Accreditation & Quality

- Volume

Issue

Use ACHC survey report to work toward sustained patient safety

March 14, 2023

Accreditation & Survey Preparation

For ambulatory surgery centers (ASC) accredited by the Accreditation Commission for Health Care (ACHC), personnel records, governing body oversight of contractors, generator testing, and emergency pre...

Inside Accreditation & Quality

- Volume

Issue

Hospice interpretive guidelines revised, but still waiting on hospital update

March 21, 2023

Accreditation & Survey Preparation

CMS has revised and updated its State Operations Manual (SOM), Appendix M, on interpretive guidelines for hospice Conditions of Participation (CoP) as well as surveyor training for hospice inspectors....

Inside Accreditation & Quality

- Volume

Issue

ACHC reports top-cited credentialing, medical staff standards

March 13, 2023

Accreditation & Survey Preparation, Policies and Procedures

Ambulatory surgery centers (ASC) accredited by the Accreditation Commission for Health Care (ACHC) are once again being reminded that they must have a completed credentials file for every practitioner...

Inside Accreditation & Quality

- Volume

Issue

More and more hospital surveys may be on-site, depending on conditions

December 19, 2025

Accreditation & Survey Preparation, Infection Control

Be aware: As COVID-19 cases go down, your odds for an on-site reaccreditation survey might go up. CMS is continuing to limit its on-site hospital surveys, except those involving complaints of immed...

ICYMI: Health equity standards now NPSG; TJC deletes some standards; PHE lives on for now

Horine: ACHC-accredited hospitals met pandemic challenges but still have work to do

CMS final rule on rural emergency hospitals offers flexibility on 24-hour observation limit

Joint Commission moves to three-year appointment cycle—now what?

Infection control, supply storage, food services top ACHC survey deficiencies

Behavioral health cases in ER may rise if post-pandemic telehealth flexibilities end

Use ACHC survey report to work toward sustained patient safety

Hospice interpretive guidelines revised, but still waiting on hospital update

ACHC reports top-cited credentialing, medical staff standards

More and more hospital surveys may be on-site, depending on conditions

Resource/w tools selected

STET CMS & tools

OSHA Dental Facilities Update - November 2023

OSHA Medical Facilities Update - November 2023

Tab 2, Medical Facilities OSHA Manual- August 2023

Tab 2, Dental Facility OSHA Manual- August 2023

Chapter 2: Chapter Format and Tracer Planning