Q&A

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, …

Question: Current 797 does not prohibit nail polish, but the new 797 draft does prohibit nail polish.  What should a surveyor look for when …

Question: I was told by a surveyor that you cannot have brushes in the prep and pack area of central sterile.  We use brushes to inspect lumened …

Question: Does OPPE/FPPE need to be reported to the board? Answer: There is no requirement to report any physician specific OPPE or FPPE data to the …