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.
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.
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.