Accreditation & Survey Preparation | .accreditationqualitycenter

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CMS, accreditors update part of process for ligature risk deficiencies

December 19, 2023

Accreditation & Survey Preparation, Patient Safety

Hospitals no longer must worry about new—or in some cases even old—ligature risk extension requests (LRER) for deficiencies that cannot be corrected within 60 days. However, hospitals still need to pe...

Accreditation & Quality Compliance Advisor

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Scheduled maintenance notification

December 13, 2023

Accreditation & Survey Preparation

We will be conducting planned service maintenance for the Accreditation & Quality Compliance Center on Saturday, December 16, 2023, beginning at 7:00 a.m. ET. The maintenance should not exceed 3 h...

Mac's Safety Space

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Mac's Safety Space: Is there anything left to say about eyewash stations?

December 14, 2025

Accreditation & Survey Preparation

Apparently, there is. (Who knew?) Going back once again to devil in the details of Joint Commission surveys during the first six months of 2023, it was noted that among the highest risk findings w...

Healthcare Safety Leader

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Issue

CMS lowers initial training requirement to get surveyors in the field more quickly

December 14, 2025

Accreditation & Survey Preparation, Fire & Life Safety

Facilities might start seeing more CMS surveys soon as the agency lowers the initial level of certification for its own Life Safety Code® (LSC) surveyor candidates. ...

Inside Accreditation & Quality

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TJC: Place focus on clinical care as much as mitigating physical self-harm risks

December 11, 2023

Accreditation & Survey Preparation

Reducing physical risks for self-harm remains a key part of meeting CMS requirements to provide patient care in a safe setting, but don’t focus everything on ligature risk. ...

Inside Accreditation & Quality

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Comment now on CMS revisions to patient harm requirements

December 14, 2025

Accreditation & Survey Preparation, Behavioral & Mental Health

If you are among those frustrated by having to implement costly, time-consuming, and seemingly ever-changing requirements on ligature risk and suicide prevention, now is your chance to speak up. ...

Inside Accreditation & Quality

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Decoding the language of care: How accreditation leaders uphold healthcare excellence

December 05, 2023

Accreditation & Survey Preparation

The pivotal role of accreditation leaders is undeniable in ensuring patient outcomes and institutional integrity. Tasked with navigating the maze of regulations and standards, these leaders are fundam...

Mac's Safety Space

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Mac’s Safety Space: Compliance versus convenience—what’s the winning combination?

December 14, 2025

Accreditation & Survey Preparation, Physical environment, Quality & Errors

When you look at a lot of the “traditional” conditions that end up presenting during survey—propped doors, unsecured or improperly segregated gas cylinders, obstructed access to emergency equipment, s...

Healthcare Safety Leader

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The burning issue: TJC's new Sentinel Event Alert on surgical fire safety

December 14, 2025

Accreditation & Survey Preparation

Best estimates from The Joint Commission (TJC) suggest that 90-100 surgical fires occur annually in the United States, creating safety hazards for patients, surgical teams, and the operating room (OR)...

Inside Accreditation & Quality

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Get hospital lawyer to help set parameters of QAPI program disclosures

November 20, 2023

Accreditation & Survey Preparation, Quality & Errors

Determining how your facility addresses requests for information about how it complies with CMS’ Quality Assessment and Performance Improvement (QAPI) Conditions of Participation (CoP) while protectin...

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CMS, accreditors update part of process for ligature risk deficiencies

Scheduled maintenance notification

Mac's Safety Space: Is there anything left to say about eyewash stations?

CMS lowers initial training requirement to get surveyors in the field more quickly

TJC: Place focus on clinical care as much as mitigating physical self-harm risks

Comment now on CMS revisions to patient harm requirements

Decoding the language of care: How accreditation leaders uphold healthcare excellence

Mac’s Safety Space: Compliance versus convenience—what’s the winning combination?

The burning issue: TJC's new Sentinel Event Alert on surgical fire safety

Get hospital lawyer to help set parameters of QAPI program disclosures

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