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.
The California Connects Interoperability Exhibition at this year’s Connecting California for Patient Care Conference will feature 12 different health information exchange (HIE) demonstrations. Co-sponsored by the California Association of Health Information Exchanges (CAHIE), the demonstrations focus on HIE standards that enable information flow among unaffiliated organizations.
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 Joint Commission has announced that changes in its accreditation and certification decision reports will be effective July 1. The changes affect the survey decision report by adding sections on opportunities for improvement and addressing plans for improvement, and by changing the process for equivalencies approval. Implemented to align with requirements of the Centers for Medicare & Medicaid Services, the changes are part of The Joint Commission’s application to renew its hospital deeming authority. For additional information, visit The Joint Commission’s Accreditation and Certification web page or contact the Joint Commission.
The Centers for Medicare & Medicaid Services (CMS) has issued the attached Survey and Certification memo addressing the issue of Electronic Health Record (EHR) navigators during the survey process for hospitals and critical access hospitals (CAHs).
The Joint Commission has announced that it will implement a new policy requiring that it clear Plans for Improvement (PFIs) in a more timely manner. The policy is consistent with the expectations of the Centers for Medicare & Medicaid Services.
The Centers for Medicare & Medicaid Services (CMS) this month issued the attached survey and certification letter to clarify the reporting and documentation of deaths associated with restraints and/or seclusion. The requirement applies to all hospitals, including rehabilitation and psychiatric distinct-part units in critical access hospitals. Hospitals must use Form CMS-10455 to report deaths associated with restraint and/or seclusion directly to their CMS Regional Office.
California Business and Professions Code Section 2510 requires hospitals to report each transfer by a licensed midwife of a planned out-of-hospital birth to the Medical Board of California and the California Maternal Quality Care Collaborative. The Medical Board of California has issued a new form for hospitals to use to report the transfer. Hospitals should also note that the licensed midwife is required to provide records and speak with the receiving physician.
In a recent survey and certification memo, the Centers for Medicare & Medicaid Services (CMS) updates its guidance for hospital medication administration requirements and for the surgical services Conditions of Participation (CoP). Both the memo and interpretive guidelines are attached and should be immediately reviewed to validate compliance.
The Joint Commission and the Institute for Medical Quality continue to negotiate a new agreement for collaborating on joint surveys through the Consolidated Accreditation and Licensure Survey (CALS) process. In the meantime, the organizations have agreed to move forward in establishing a voluntary option for hospital participation in the CALS process. Because they don’t expect a new agreement to be signed before the May 26 expiration of the current agreement, the expiration date has been extended to Sept. 30. The attached letter with additional details was sent to all California hospitals that are accredited by The Joint Commission and includes contact information for hospitals that have additional questions about the accreditation process.
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.