Accreditation & Survey Preparation | .accreditationqualitycenter

Accreditation & Quality Compliance Advisor

- Volume

Issue

ACHC reapproved as accrediting organization for another 4 years

September 05, 2023

Accreditation & Survey Preparation

Expect ACHC surveyors to pay more attention to the Life Safety Code® and to consider possibly more severe deficiencies after a review by CMS. ...

Healthcare Safety Leader

- Volume

Issue

Add ransomware attacks to emergency risk management and planning

September 05, 2023

Accreditation & Survey Preparation

Which would you rather do? Tell someone in the C-suite the hospital is facing a CMS immediate jeopardy ruling because the staff was so overwhelmed by paper drug prescriptions after a ransomware attack...

Inside Accreditation & Quality

- Volume

Issue

Ask your pharmacy team about USP compliance ahead of November 1 deadline

September 05, 2023

Accreditation & Survey Preparation

Sit down with pharmacy leadership and review section-by-section compliance with the revised U.S. Pharmacopeia (USP) standards on medication compounding because The Joint Commission (TJC), the Accredit...

Accreditation & Quality Compliance Advisor

- Volume

Issue

CDC launches Hospital Sepsis Program Core Elements to help sepsis patients

December 16, 2025

Accreditation & Survey Preparation, Infection Control, Patient Safety, Policies and Procedures, Quality & Errors

On August 24, the CDC launched the Hospital Sepsis Program Core Elements, with seven core elements aimed at strengthening survival and recovery rates for all sepsis patients. Hospitalized patients wit...

Mac's Safety Space

- Volume

Issue

Mac’s Safety Space: Healthcare access and safe inclusive care environments

August 28, 2023

Accreditation & Survey Preparation

As the healthcare industry turns fuller attentions towards the challenges of access, equity, and managing social determinants of health and the disparities arising from those determinants, I wanted to...

Accreditation & Quality Compliance Advisor

- Volume

Issue

Joint Commission issues guidelines for dealing with a cyberattack

December 16, 2025

Accreditation & Survey Preparation, Cybersecurity & Technology, Natural & Manmade Disasters

With healthcare cyberattacks on the rise, the Joint Commission has issued guidance for health system executives on how to react once a data breach has been detected. ...

Inside Accreditation & Quality

- Volume

Issue

MRSA numbers growing: Review updated SHEA recommendations with leadership to control infections

August 22, 2023

Accreditation & Survey Preparation

Review the latest recommendations for controlling methicillin-resistant Staphylococcus aureus, more commonly known as MRSA, with your infection prevention and control team as well as your medical staf...

Mac's Safety Space

- Volume

Issue

Mac’s Safety Space: If you knew there was a problem in the physical environment, you would correct it

August 21, 2023

Accreditation & Survey Preparation

If you knew there was a problem in the physical environment, you would correct it. Wouldn’t you? ...

Accreditation & Quality Compliance Advisor

- Volume

Issue

The CMS’ State Operations Manual appears updated—but not by much

August 09, 2023

Accreditation & Survey Preparation

After years of changing and adding new Conditions of Participation (CoP), CMS has finally updated its only guidance for surveyors, State Operations Manual, Appendix A (SOM). But not entirely. ...

Inside Accreditation & Quality

- Volume

Issue

Surveyors told to look beyond the ligature point to evaluate patient risk for self-harm

August 15, 2023

Accreditation & Survey Preparation

A new CMS Quality, Safety & Oversight group memo on suicide prevention urges hospitals to go above and beyond to help protect patients from themselves. Accrediting organizations like ACHC and TJC ...

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ACHC reapproved as accrediting organization for another 4 years

Add ransomware attacks to emergency risk management and planning

Ask your pharmacy team about USP compliance ahead of November 1 deadline

CDC launches Hospital Sepsis Program Core Elements to help sepsis patients

Mac’s Safety Space: Healthcare access and safe inclusive care environments

Joint Commission issues guidelines for dealing with a cyberattack

MRSA numbers growing: Review updated SHEA recommendations with leadership to control infections

Mac’s Safety Space: If you knew there was a problem in the physical environment, you would correct it

The CMS’ State Operations Manual appears updated—but not by much

Surveyors told to look beyond the ligature point to evaluate patient risk for self-harm

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STET CMS & tools

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Tab 2, Medical Facilities OSHA Manual- August 2023

Tab 2, Dental Facility OSHA Manual- August 2023

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