Q&A

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 …

Question: We have heard that TJC is citing not having impermeable liners on all wire storage shelves holding sterile supplies. Have you heard this? …

Question: Does a sterile single use/ disposable instrument that will be used as a critical instrument still require sterile storage requirements (T, …