Q&A: Ongoing compliance success: Tracking compliance issues

February 13, 2026
Accreditation & Quality Compliance Advisor
- Volume
0
Issue
0

Q: What tools should I use to track compliance issues and stay organized for survey readiness?

A: You can use paper tools, such as hard copies of the standards chapters, as your ongoing compliance guide. But it is likely more efficient to use some sort of electronic database. The Joint Commission has the Focused Standards Assessment (FSA) and a new intracycle monitoring (ICM) process. The full PPR tool or FSA tool as it is now called remains accessible and calculates the scoring for you as you move through the standards. The software also stores the elements of performance (EP) and standards scoring.

In addition, the FSA tool provides free text fields for documenting an action plan, MOS, and miscellaneous information. A free text area labeled Miscellaneous Information is designed for your exclusive use. Data within this area are not submitted to The Joint Commission, even when you click the Transmit button. You can track your data or documents in the field to remind you of this information.

No ebook available.

Found in Categories: 
Accreditation & Survey Preparation

More Like This

Inside Accreditation & Quality
- Volume
2
Issue
4
March 24, 2020
What deficiencies would you cite and why? And how would you correct them? You be the surveyor. The following information was taken from a CMS Form-2567 “Statement of Deficiencies” posted online ...