Q&A

Question: Can a physician in our community prescribe infusion services from our hospital? Answer: The answer is yes, they may prescribe infusion …

Question: Is it considered therapeutic duplication if our EMR Power Plans included oral tablet, oral suspension, injectable, and suppository versions …

Question: Are hospital owned ambulance services surveyable by TJC? Answer: If the hospital owns it, yes, it is surveyable, although we have not seen …

Question: Does The Joint Commission require EAPs after a sentinel event in order to be able to provide counseling services to employees involved? …

Question: Should we perform eyewash station risk assessments to determine if a plumbed eyewash is needed for irritating, noncorrosive chemicals? …

Question: We do not have unit specific information on Look-Alike/Sound-Alike medication and high-alert medications. We have the policy we reviewed, …

Question: Do you have a list of policies which need to be reviewed by a Medical Executive Council or Medical Executive leadership? Answer: Listed …

Question: Is there a requirement for intensive care units to have admission and discharge criteria? Currently, our hospital has a “scope of …

Question: We were cited by The Joint Commission during our last survey for our documentation process for immediate pre-induction assessment.  The …

Question: We originally attempted to comply system-wide with CMS regulation CMS 432.13(b)(4) Right of Notice of Admission by building the question …