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

Inside Accreditation & Quality

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Follow these tips for storing holiday decorations to avoid problems later

December 18, 2025

Accreditation & Survey Preparation, Fire & Life Safety

Decorations around the hospital can bring joy to patients and staff. But they also can bring citations from CMS, accrediting organizations, or the fire marshal’s office. Ensure that the next holiday g...

Inside Accreditation & Quality

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Keyes offers workshops on emergency preparedness, fire safety compliance

January 04, 2023

Accreditation & Survey Preparation

by A.J. Plunkett (aplunkett@decisionhealth.com) Brad Keyes, CHSP, a Life Safety Code® expert and longtime contributor to Healthcare Safety Leader, Healthcare Life Safety Compliance and other HCPro ...

Inside Accreditation & Quality

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Issue

Check splash guards, update to latest infection control practices

January 10, 2023

Accreditation & Survey Preparation

Ensure safeguards against sink splash in areas designated for clean medication preparation or face potential citations from surveyors, especially now that the problem has been called out in recently u...

Inside Accreditation & Quality

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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

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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

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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

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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

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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

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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

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Ask the expert: Answers to recurring EMTALA and HIPAA questions

February 28, 2023

Accreditation & Survey Preparation, Policies and Procedures

Do you need to update your hospital’s sign detailing its responsibilities under the federal Emergency Medical Treatment & Labor Act (EMTALA)? What do you do when law enforcement asks for medical r...

Follow these tips for storing holiday decorations to avoid problems later

Keyes offers workshops on emergency preparedness, fire safety compliance

Check splash guards, update to latest infection control practices

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

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

Ask the expert: Answers to recurring EMTALA and HIPAA questions

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