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 …
Self-Closing Doors Q&A
Question: Do all the offices and day rooms need to have self-closing doors on inpatient psych units? I was informed that a recently surveyed hospital …
Medical Staff vs. Governing Board Guidelines Q&A
Question: Are there any requirements to have Governing Board Bylaws in addition to having Medical Staff Bylaws? The question centers around the …