The Centers for Medicare & Medicaid Services (CMS) has issued the attached survey and certification letter updating the interpretive guidance in Appendix A of the State Operating Manual for hospital conditions of participation for radiologic and nuclear medicine services. The updates reflect current standards of practice and provide more detailed instructions for compliance assessment. Included in the update is a description of the types of radiologic/nuclear medicine services provided and discussion of safety precautions hospitals are expected to take to decrease radiation exposure risks.
The National Healthcare Safety Network (NHSN) has announced that the annual deadline for ambulatory surgical centers (ASCs) to submit data on influenza vaccinations among health care personnel (ASC-8: Influenza Vaccination Coverage among Healthcare Personnel) has been extended from May 15 to Aug. 15. The extension is intended to assist as many ASCs as possible in meeting the requirement during its initial implementation year. To submit data, ASCs must enroll in NHSN at least eight weeks before the Aug. 15 deadline. For additional information, visit https://images.magnetmail.net/images/clients/AHA_11/attach/NHSN_ASCUpdate.pdf.
Gov. Brown has appointed Karen Smith, MD, MPH, as director of the California Department of Public Health (CDPH). Dr. Smith has been medical staff for infectious disease at Queen of the Valley Medical Center since 2012, has served as public health officer and deputy director at the Napa County Health and Human Services Agency since 2004 and has been a faculty consultant at the Francis J. Curry International Tuberculosis Center since 1997. In addition, Dr. Smith is a liaison to the Centers for Disease Control and Prevention, Office of Public Health Preparedness and Response Board of Scientific Counselors, and is president-elect of the California Conference of Local Health Officers. She served as assistant section chief at the California Department of Health Services Tuberculosis Control Branch from 2000 to 2001.
“CHA congratulates Dr. Smith on her appointment to this important position and looks forward to working with her,” said CHA President/CEO C. Duane Dauner.
The Centers for Medicare & Medicaid Services (CMS) released on Jan. 30 a Survey and Certification Letter providing revised guidance for rule changes to the Conditions of Participation affecting hospitals, ambulatory surgical centers, rural health clinics and federally qualified health centers.
CMS adopted its Medicare and Medicaid Programs; Regulatory Provisions To Promote Program Efficiency, Transparency, and Burden Reduction; Part II final rule on May 12, 2014, and since then has issued several other Survey and Certification Letters with revised guidance. Affected organizations should review their policies and procedures to ensure compliance.
The California Department of Public Health (CDPH) has announced it will host a stakeholder meeting Nov. 13 from 3 p.m. – 5 p.m. to discuss new recommendations for its Licensing and Certification Program. In August 2013, CDPH engaged a consultant to perform an organizational assessment and identify the challenges associated with fulfillment of state licensing and federal survey and certification requirements. The assessment resulted in the attached report and remediation recommendations. The upcoming meeting, to be held at 1500 Capitol Avenue in Sacramento, will focus on prioritizing the remediation recommendations. CDPH plans to distribute an agenda and other meeting materials soon.
To explore the challenges and benefits associated with creating a statewide registry for Physician Orders for Life-Sustaining Treatment (POLST), the California HealthCare Foundation (CHFC) has announced it will host a pilot program to test the registry concept in a single California community. To launch its pilot program, CHCF has issued two requests for information. First, the foundation seeks letters of interest (due Nov. 14) from potential pilot communities with the ability to convene acute care hospitals, medical groups, nursing homes, hospices, health plans and emergency medical services to test a registry platform. In addition, CHCF requests information from vendors (due Oct. 31) around the technology, operational and support services necessary to establish a POLST registry, as well as estimates of corresponding costs.
The California Department of Public Health has issued the attached notice clarifying fluoroscopy permit requirements for users and operators of fluoroscopic equipment. The notice provides details on spatial relationships, movement of equipment when it is not energized, movement during fluoroscopy, and movement of the patient during automatic exposure. Providers that use fluoroscopy should review the notice with their radiology technologists.
The Centers for Medicare & Medicaid Services (CMS) has issued a Survey and Certification Memo updating its guidance for the use of “flash” sterilization. The memo is intended to assist surveyors when they assess a hospital, critical access hospital or ambulatory surgical center for compliance with Medicare’s sterilization standards for surgical settings. The guidance notes a change in terminology — as recommended by nationally recognized organizations with expertise in infection control — from “flash” sterilization to “immediate use steam sterilization” (IUSS). The memo also reiterates and updates information on nationally recognized infection prevention and control guidelines and professionally acceptable standards of practice with respect to IUSS.
The California Department of Public Health’s Center for Health Care Quality will hold a public stakeholders’ forum from 9 a.m. – 11 a.m. Sept. 4 in the East End Complex Auditorium at 1500 Capitol Ave., Sacramento. According to the 2014 requirements established in SB 857, this is to be a semiannual meeting for all stakeholders interested in providing feedback on the Center for Health Care Quality’s Licensing and Certification Program.
The Joint Commission (JC) and Institute for Medical Quality (IMQ) yesterday emailed the attached joint letter to all California JC-accredited hospitals announcing the physician surveyor option for future triennial hospital accreditation surveys. Hospitals may choose to have a JC physician surveyor or an IMQ surveyor as a member of the triennial hospital accreditation survey team. According to the letter, the surveyor choice will not affect the California Department of Public Health’s oversight of hospitals and compliance with Title 22. Hospitals will make their choices when they submit a survey application, which will include a comparison of cost differences between the two options. Hospitals with questions about the new process should contact their JC account executive.
You’ve received a licensing violation. You may have been expecting it from a recent survey, or it may have come as a complete surprise. One thing is for certain, survey activity — and subsequent violations — will be more common now that California Department of Public Health (CDPH) has issued new regulations for hospital penalties, including non-immediate jeopardy violations.
The CHA Joint Committee on Accreditation & Licensing is currently accepting new member applications. The committee, which meets quarterly in Sacramento, addresses hospital accreditation, regulatory and licensing issues and makes policy recommendations to the CHA Board of Trustees. To be eligible to serve on the committee, individuals must be employed with a CHA member hospital and serve as liaison for accreditation and licensing issues at their facility. To apply, send a biography to Lori Woolsey at firstname.lastname@example.org by April 4.