LASA and HA Medications Poster
Question: We do not have unit specific information on Look-Alike/Sound-Alike medication and high-alert medications. We have the policy we reviewed, …
Medical Executive Council Policies
Question: Do you have a list of policies which need to be reviewed by a Medical Executive Council or Medical Executive leadership? Answer: Listed …
ICU Admission And Discharge Criteria
Question: Is there a requirement for intensive care units to have admission and discharge criteria? Currently, our hospital has a “scope of …
Timing of Pre-Induction Assessments
Question: We were cited by The Joint Commission during our last survey for our documentation process for immediate pre-induction assessment. The …
Sending Notice To Other Providers
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 …
Wire Shelving Shelf Liners
Question: We have heard that TJC is citing not having impermeable liners on all wire storage shelves holding sterile supplies. Have you heard this? …
Sterile Instrument Storage
Question: Does a sterile single use/ disposable instrument that will be used as a critical instrument still require sterile storage requirements (T, …
Nail Polish & USP 797
Question: Current 797 does not prohibit nail polish, but the new 797 draft does prohibit nail polish. What should a surveyor look for when …
Central Sterile Prep & Pack Area
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 …
OPPE/FPPE Reporting
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 …