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Patton Post Newsletter

You are here: Home / Resources / Patton Post Newsletter

Patton Post

The Patton Post is a monthly newsletter that provides healthcare administrators with timely and actionable advice on regulatory and compliance issues from The Joint Commission, CMS, and other leading accreditors and industry decision-makers. It is distributed to over 2,500 healthcare professionals in hospitals, behavioral health facilities, ambulatory clinics, laboratories, pharmacies, and more!

Read the current issue or previous issues of the Patton Post. Scroll down or search by year to access the specific publication of interest. Each one conveniently contains an outline to provide you with an overview on the covered topics.

IssueYearDownloadIssue Highlightshf:tax:newsletter_year

May NEW!

2025

TJC Perspectives
•  Cardiac and Stroke Certification Eligibility Updates
•  Time Outs Prior to Invasive Procedures

TJC EC News
•  Guidance on Opening Protectives
•  Time Limited Waivers and Equivalencies
•  MRI Safety

Accreditation Resources
•  ACHC: Medical Staff Credentialing Webinar
•  DNV: Healthcare University Dates

CMS
•  Updates Likely Coming Soon

Office of Inspector General
•  Opioid Addiction Treatment

2025 view-all

April

2025

TJC Perspectives
•  2024 Sentinel Event Data
•  Opioid Treatment Programs
•  New Hospice Standards
•  State Licensure Change APR
•  Linen and Waste Chutes

TJC EC News
•  Kitchen Environmental Tour
•  Storing Medical Gas Cylinders

TJC EM Leader
•  Responding to Disasters
•  Wildfires
•  Medical Gas Pressure Failure
•  Water Disruptions
•  Chemical Decontamination

Accreditation Resources
•  ACHC:
•  CIHQ: Upcoming Webinars

Becker’s Hospital Review
•  CMS Forecasting

 

2025 view-all

March

2025

TJC Perspectives
•  ALC, BHC, and NCC Adverse Decisions
•  New IC Chapter for Laboratories
•  Hospice Life Safety Code Surveyor
•  Multifactor Authentication
•  Orientation of New Staff

TJC EC News
•  Clinical Fires
•  Preventing Falls in the Physical Environment
•  Emergency Lighting Q&A
•  Protection from Fire

TJC EM Leader
•  Natural Disasters and Evacuations

Accreditation Resources
•  ACHC: Physical Environment Management Plans
•  DNV: Compliance Automation
•  CIHQ: Standards, Policies, and Survey Activity Guide

CDC
•  NIOSH: Hazardous Medications

CMS
•  NCC Restraints & Psychotropic Medications

2025 view-all

February

2025

TJC Perspectives
• IC & Antibiotic Stewardship Resource Center
• Wall and Ceiling Penetrations

TJC EC News
• New Survey Report Format
• Bariatric Mobility and Facility Design
• Security Risk Advice
• Basic Building Information (BBI)
• Environmental Disasters

ACCREDIATION RESOURCES
• ACHC: ACHCU Academy 2025
• ACHC: Becker’s Hospital Review Webinar
• ACHC: Most Frequent Findings
• DNV: Infection Prevention Podcast

CMS
• Laboratory SOM Update
• Nursing Home New/Revised Content Training Materials

2025 view-all

January

2025

Perspectives
• TJC Updates – Survey Process and Report Design
• Revised EM and IC Standards
• Consistent Interpretation

EC News
• Additional Content on Recent Topics
• Workplace Violence
• Life Safety Drawings

Accreditation Resources
• ACHC: 1135 Waiver for Wildfires
• DNV: AI in Healthcare

CMS
• Maternal Safety Requirements

2025 view-all

December

2024

TJC Perspectives
• Data Submission for Hip/Knee Certification
• Water Management Programs

TJC EC News
• Life Safety Code Surveyor Scope of Work
• Fire Drill Requirements
• Reducing Corridor Clutter
• Physical Environment ITHS

Accreditation Resources
• ACHC: Water Management
• AHRQ: Patient Safety Culture

CMS
• Hospice Providers and Fraud
• Nursing Home F-Tags Update
• Critical Access Hospital Space Sharing
• Immediate Jeopardy Process

2024 view-all

November

2024

TJC Perspectives
• New LAB Standards
• USB Storage Devices
• Blood

TJC EC News
• High Rise Hospitals
• Physical Environment Myths
• Building Design and Signage for Vision Impairment
• ILSM Q+A

TJC EM Leader
• Hospital Fires
• Emergency Communications Plan
• After Action Reports and EM Plan Evaluations

Accreditation Resources
• ACHC: Proficiency Testing
• CIHQ: Respiratory Therapy Orders

CMS
• Respiratory Illness Reporting

FDA
• DSCSA Deadline

2024 view-all

October

2024

TJC Perspectives
• Standards & SAG Updates
• Off Site Review Option for DSC
• Continuity of Operations Plan (COOP)

TJC EC News
• USP Chapter 797
• Physical Environment Most Frequently Scored
• Fire Response Plan
• Suicide Prevention

Accreditation Resources
• ACHC: Resources
• DNV: Symposium
• CIHQ: Summit

CMS
• Rural Emergency Hospital Update
• Hospice Special Focus Programs

2024 view-all

September

2024

TJC Perspectives
• Certification Programs
• Get With the Guidelines (GWTG) Upload
• The Consent Process

TJC EC News
• Workplace Violence Standards
• Workplace Violence Prevention
• Training on De-escalation
• ITM of Medical Gas Systems and Shutoff Valves

TJC EM Leader
• Workplace Violence Response Process
• Disaster Supplies
• Wildfire Exercise

Accreditation Resources
• ACHC: Infection Prevention in Surgery Webinar
• CIHQ: Accreditation and Regulatory Summit

CMS
• New EMTALA Sign
• Extension Site Locations
• Pancreata Reporting Requirements
• Initial Accreditation Requirements for Home Health & Hospice

2024 view-all

August

2024

TJC Perspectives
• CMS Consent Memo, Revisited
• Life Safety Drawings
• Texting of Medication Orders

TJC EC News
• Autism Friendly Spaces

Accreditation Resources
• ACHC: Assessing Competencies
• CIHQ: Incident Reporting Software
• DNV: Cybersecurity & AI

CMS
• ESRD Programs: Medical Director Board Certification

2024 view-all

July

2024

TJC Perspectives
• New CAMBHC EPs on Addiction
• CAMBHC Physical Hold of a Child
• New IC EPs for OME, ALC, & NCC
• AHC Standards Changes
• Change to the ESC Process?
• Staffing Standards

TJC EC News
• Rural Health Clinic EC Standards
• CAMBHC Workplace Violence Standards
• Case Study: Workplace Violence
• Safety and Security Risk Assessments

TJC EM Leader
• Top 4 Most Frequently Scored Standards
• Case Study: Coping with Civil Unrest

Accreditors
• ACHC: Free Webinars: AI & Cybersecurity
• CIHQ: Medical Record Reviews
• DNV: Corrective Action Timeline Update

CMS
• Surgical Procedure Consent Continued

2024 view-all

June

2024

TJC Perspectives
• Rural Health Clinic Accreditation
• Hospice Standards Changes
• Sprinkler Pipe Non-Compliance
• Potential Standards Development

TJC EC News
• Sustainability
• Pest Management
• Metal Detectors
• Illuminated Exit Signs

TJC FAQ
• Bronchoscopy Environment

ISMP
• High Alert Medications and Error Prone Abbreviations

Accreditation Resources
• ACHC: Joint Ventures Webinar
• CIHQ: Sterile Processing

CMS
• Surgical Procedure Consent
• Authorized Service Providers

2024 view-all

May

2024

TJC Perspectives
• Most Frequently Cited Certification Standards
• Multiple Tenant Occupancies
• Fall Precautions
• Telehealth Accreditation
• Texting Update

TJC EC News
• Top Scored, High Risk Physical Environment Standards
• EOC Management Plans
• Laser Safety

TJC EM Leader
• Free Courses & Webinars
• Tornado Readiness

ACHC
• 2023 Annual Report

CMS
• Updated SOM Appendix A
• QSO Memos

CDC
• Mandatory Covid Reporting Canceled

2024 view-all

April

2024

TJC Perspectives
• 2023 Most Frequent Higher Risk Standards
• System Tracer Changes
• NHSN Deadline Approaching
• Emergency Power System Noncompliance

TJC EC News
• Fire Door Inspections
• ICRA, PCRA, Life Safety Inspections, and ILSM
• Spring Cleaning

CIHQ
• Discharge Planning

DNV
• Validation Surveys

ACHC
• Dialysis Surveys

CMS
• Home Health Manual Rewrite
• EMTALA and Release of QIO Reports
• Informed Consent Process
• QAPI Revisited

2024 view-all

March

2024

TJC Perspectives
• Language Updates
• History & Physicals

TJC EC News
• Preventative Maintenance Inspections
• ICRA, PCRA, Life Safety Inspections and ILSM

TJC EM Leader
New Publication
• Success After a Flood
• EM Survey Session Preparation
• Cybersecurity

ACHC
• Informed Consent

CIHQ
• Competency Expectations

CMS
• Texting Orders
• Federal Register Proposed Rules

2024 view-all

February

2024

Perspectives
• Fire Extinguishers
• Kitchen Exhaust Hood
• Protecting Kitchen Gas Lines
• Automatic Fire Suppression System
• Protecting Kitchen Gas Lines

EC News
• Environmental Sustainability
• Age Inclusivity
• Sprinkler Escutcheons

CMS
• Approved Accrediting Bodies
• QSO Memo

2024 view-all

January

2024

Perspectives
• New IC Standards
• New BH Workplace Violence Standards
• Revised EM Standards for AHC & OBS
• Pre-Anesthesia Assessments
• Medicare Deficiency Surveys

EC News
• AHC Most Frequently Scored EC/LS
• EC/LS Kitchen Checklist

CMS
• QSO-24-02: EMTALA During Disaster
• QSO-24-03: Laboratories & CLIA

2024 view-all

December

2023

Perspectives
• Sentinel Event Involving Suicide
• Summary of Changes- Revisions and Removals
• Critical Areas and Ventilation Systems
• Quick Safety on Pressure Injuries
• Simplification of MS.06.01.05, EP 6

FAQ
• Opioid Reversal Agents

Extranet
• New Sterile Compounding Evaluation Tool

EC News
• Emergency Management Leader Publication
• Behavioral Health Workplace Violence Standards
• Sharps Containers Requirements

CMS
• Rural Emergency Hospitals

2023 view-all

November

2023

Perspectives
• 2024 ORYX Reporting Requirements
• Certification Document Upload
• Managing Complaints
• Prevention of Surgical Fires

EC News
• Environmental Standards in Critical Access Hospitals
• Winter and Grounds Maintenance
• New USP Chapters

2023 view-all

October

2023

Perspectives
• Sentinel Event Data
• New Decision Rule
• SE Alert on Cyberattack
• Managing Utility System Risks
• Designated Person

EC News
• Potential Utility Failures
• Most Frequently Scored BHC Environmental Standards
• Delayed Egress Doors

CMS
• Nurse Midwives
• Patient Safety Work Products and QAPI Survey Documents
• Validation Surveys Resuming

2023 view-all

September

2023

Perspectives
• Standards Revisions
• Applicability of USP
• New Hospice EM Requirement
• New Resuscitation Standards

EC News
• Environment of Care Data Collection
• Managing Mass Casualties

CMS
• New SOM Appendix A Manual
• Hospice Billing Investigation
• Fentanyl Handling and Exposure

2023 view-all

August

2023

Perspectives
• Certification Programs Most Frequently Scored
• Total Hip and Knee Performance Measure
• New Leaders at Joint Commission
• MRI Safety

EC News
• Medical Devices and Recalls
• Active Shooter Exercises
• Family Assistance Centers
• Preventing Infant Abductions

CMS
• Vaccine Mandate
• Suicide Safety and Workplace Violence

2023 view-all

July

2023

Perspectives
• Deleted, Consolidated, and Revised EPs
• Healthcare Equity Certification Resource Center
• Medication Compounding

EC News
• Ambulatory Care Environmental Standards
• Potential Summer Heat Emergencies
• Environmental Tours

CMS
• Hospital Discharges to Post-Acute Requirements
• Eliminated Practices

2023 view-all

June

2023

Perspectives
• ORYX Data Submission
• Critical Access Hospital Standards
• Integrity of the Egress
• Preventing Light Source Burns
• Single Medical Staff Option Leading to New Burdens

EC News
• BHC Workplace Violence Standards
• Emergency Management Drills and HVA Development
• Risk Assessments
• Infection Prevention Standards Status

USP
• Implementation Deadline Approaching

CMS
• CMS and Accrediting Bodies Compared
• Post Pandemic Laboratory Changes

2023 view-all

May

2023

Perspectives
• Ethical Issues Requirement
• Ventricular Assist Device (VAD) Implant Volume Reinstated
• Use of Validated Tools for Suicide Risk Screening
• Informed Consent Process
• New IC Standards?

EC News
• Environmental Sustainability Standards
• ITM for Diagnostic Imaging Equipment
• Top Cited Physical Environment Standards
• Electrosurgery Safety

CMS
• End of the Public Health Emergency

CDC
• NIOSH Managing Hazardous Medications

2023 view-all

April

2023

Perspectives
• Most Frequently Scored 2022
• Sentinel Event Statistics
• National Practitioner Data Bank Query

EC News
• Reducing Noise
• Sprinkler Pipe RFI and ESC
• Alternative Equipment Maintenance Requirements

Other TJC News:
• New Requirements for Certified Community Behavioral Health Clinics
• Environmental Sustainability

CMS:
• Discontinued Nursing Home Memos
• LSC Memo – Health Care Microgrid Systems
• Hospital Memo – Appendix A QAPI Modification

2023 view-all

March

2023

Perspectives
• Racial and Ethnic Disparities in Pregnant and Postpartum Patients
• Collecting Data on Discrepancies Between Diagnoses
• Titrations
• Medication Compounding for Home Care

FAQs
• Accessing Medications at Night

EC News
• Hyperbaric Chamber Fire Drills
• Behavioral Health Crisis Units
• Hazard Vulnerability Analysis
• EM Chapter for Home Care

2023 view-all

February

2023

2023 Survey Activity Guide
• SAG is Now Program Specific
• Day One Document List Changes
• Safety Briefing and Leadership Session
• Updated EC/LS Document Tool

Perspectives
• ORYX Data Submission Platform Delay
• Portable Fire Extinguishers

EC News
• Deleted Standard Explanations
• Cleaning Kitchen Exhaust Systems

CMS
• End of the Public Health Emergency
• Quality Videos
• Rural Emergency Hospitals
• Hospice Surveyor Training
• Aligning Clinical Quality Measures

Industry News

2023 view-all

January

2023

PERSPECTIVES
• Healthcare Equity Standards
• Deleted Standards
• Revised EM Standards for Home Care
• Food and Nutrition Products

EC NEWS
• Completing an ESC
• Workplace Violence Standards
• Home Care Oxygen Safety

CMS
• Workplace Violence Standards

Pharmacy Practice News:
• Medication Errors 2022

CDC Health Alert Network:
• Dental Water Lines

2023 view-all

December

2022

PERSPECTIVES
• Practitioner Privileging Cycle
• Eye Wash Station Checks
• Health Care Equity
• LIP Terminology Removed
• Health Information Privacy and Security

EC News
• Water Management
• Business Occupancies Requirements
• FGI Guideline

CMS
• LTC Covid-19 Therapeutics

USP Chapter 797
• Sampling and SOPs
• New Acronyms and Terminology Changes
• Next Steps
• FAQs and the One Hour Rule

2022 view-all

November

2022

PERSPECTIVES
• New ORYX Performance Measure Requirements for 2023
• New Safety Briefing for 2023 Surveys
• 2023 Standards Database and Updates
• High-Risk Medical Equipment Preventative Maintenance
• New TJC FAQ on Healthcare Worker Masking

EC News
• Most Problematic EC/LS Standards and EPs
• Managing an Evacuation and Lessons Learned

CMS
• Covid Vaccination Requirements of the Workforce

USP
• Chapter 797 Has Officially Been Published

2022 view-all

October

2022

PERSPECTIVES
• EC and LS Standards: New and Changes
• Definition of Sexual Abuse/Assault
• Proficiency Testing Regulations for Laboratories
• Medical Air vs. Instrument Air

EC NEWS
• Decarbonization
• ED Access and Security

CMS
• Asymptomatic Covid Testing

CDC
• Covid Source Control for Healthcare Workers

2022 view-all

September

2022

PERSPECTIVES
• Sentinel Events
• Climate Pledge
• Health Care Worker Well Being
• History & Physicals
• New Infection Prevention and Control Requirements

EC NEWS
• Extreme Heat and Power Outages
• Decarbonizing the Health Care Sector
• EC Risk Assessments

CMS
• EMTALA and Abortion in Texas
• Public Health Emergency Ending?

2022 view-all

August

2022

PERSPECTIVES
• Diagnostic Overshadowing
• Direct Data Submission Platform

EC News
• Greenhouse Gases
• Top Scored Physical Environment
• GFCI Outlets
• Emergency Operations Plan Requirements

CMS
• Covid Vaccination Requirements for State Surveyors
• Infection Prevention & Antibiotic Stewardship

2022 view-all

July

2022

PERSPECTIVES
• Health Care Disparities
• Antimicrobial Stewardship
• Interior Spaces

EC News
• Workplace Violence
• Anesthesia-Related Greenhouse Gas Emissions
• FAQs on Emergency Management Standards
• Commercially Prepared Sterile Supplies and Devices

CMS

2022 view-all

June

2022

PERSPECTIVES
• Suicide Safety Performance Improvement

EC NEWS
• Fire Safety Testing
• Emergency Power Systems
• Medical Equipment Preventative Maintenance
• Interim Life Safety Code Measures

ASHP
• Contrast Shortage

CMS
• Covid Vaccination Medical Exemptions
• Emergency Management Exemptions
• Reporting Covid Statistics

2022 view-all

May

2022

PERSPECTIVES
• IC.02.04.02 – New Covid Vaccine Standard

CMS
• Workforce Vaccination

EC NEWS
• EM Standards Effective July 2022
• Top Scored EC/LS Standards in Ambulatory

2022 view-all

April

2022

2022 Surveys
• COVID Vaccine Mandate Scorings
• MIFU Noncompliance Findings

Perspectives
• Top 10 Frequently Scored for 2021

EC News
• Causes of Ventilation Failures
• Workplace Violence Standards
• Fire Department Connections

CMS
• Surveying Laboratories Resumes

2022 view-all

March

2022

Survey Activity and Vaccination Data
PERSPECTIVES
•2021 End of Year Analysis
•Hospice Changes
•Suicide Prevention and Screening

EC NEWS
• Prevention of Surgical Fires
• Protecting Patients at Risk for Suicide

CMS
• Surveying for Vaccine Compliance
• Medication Errors

2022 view-all

February 

2022

PERSPECTIVES
• Standard Language Changes
• ESC and Clarifications
•Covid Vaccine Requirements

EC NEWS
• Smoke Barriers vs. Fire Barriers vs. Smoke Partitions
• “New” Emergency Management Chapter

CMS
• Vaccination Requirements

2022 view-all

January

2022

PERSPECTIVES
• New Standards for July 2022
• Patient’s Rights Standards Changes
• Environment of Care Standards Changes
• New Requirements for Inpatient Hospice
• Hand Hygiene Scoring

EC NEWS
• ITHS Findings
• Survey Process for Business Occupancies
• Checklist for Assessing Business Occupancies

CMS
• Validation Survey Process
• Vaccine Mandate

2022 view-all

December

2021

PERSPECTIVES
• 2022 ORYX Requirements
• Cybersecurity
• Water Management Requirements
• Extranet Access and Security
• Standards Interpretation
• Future Standards

EC NEWS
• What’s New for 2022
• ICRA for Construction

CMS
• COVID Vaccine Mandate Update
• Obstetric Emergencies and Maternal Safety

2021 view-all

November
(Supplement)

2021

Covid Vaccine Mandates
• New Regulations for Employees
• Key Dates
• Applicability
• Vaccination Program Tracking
• Exemptions
• Questions

2021 view-all

November NEW!

2021

PERSPECTIVES
• 2022 Manuals and Workplace Violence & Resuscitation Standards
• Influenza Immunization
• Non-Ventilator Hospital Acquired Pneumonia
• Human Resource Scoring Guidance

EC NEWS
• EC/LS Most Frequently Cited
• Snow Mitigation Efforts
• Alternate Care Site Guidance
• USP Chapter 797

CMS
• Hospice QSO Memo

2021 view-all

October

2021

PERSPECTIVES
• Interoperability Requirements
• Psychiatric Patient Boarding in the ED
• Nutritional Assessments

EC NEWS
• EOP vs COOP
• Home Care – Most Frequently Cited EC, LS, and EM
• Preventing Eye and Skin Injuries
• Compressed Gas Policies
• Surveyors in Multi-Tenant Buildings

CMS
• Pregnant Patients in the ED</span

AHRQ
• Maternal Morbidity

FDA
• Sterile Compounding in the Pharmacy

2021 view-all

September

2021

PERSPECTIVES

• Sentinel Event Statistics
• Diverse Populations
• Home Care SAG Error
• Draft Standards Field Review
• Building Fire Protection
• TJC Advisory Group– Vaccines, Backlogs, & Maternal Standards
• TJC & Covid-19
• Covid Vaccine Side Effects

EC NEWS

• Ligature Hazards
• EC/EM System Tracers
• Workplace Violence Standards
• Training Staff for Emergencies

2021 view-all

August

2021

PERSPECTIVES

• Patient Visitation Policies
• Insulin Pumps and Continuous Glucose Monitoring Devices
• HAP or BHC Manual?
• Emergency Power Systems
• Requirements in Development

EC NEWS

• Family Reunification
• New Water Management Standards
• Planning for Construction
• Electrical Hazards in Health Care

CMS

• COVID-19 Data

2021 view-all

July

2021

PERSPECTIVES

• Workplace Violence Standards
• Resuscitation Services Standards
• Performance Improvement Standards
• Spare Sprinkler Heads
• Processing Bloody Surface/External Ultrasound Transducers

EC NEWS

• Emergency Coordinators
• Extreme Temperature Preparation
• Crash Carts

CMS

• COVID-19 Data
• Emergency Management Exercise Waiver

INSPECTOR GENERAL REPORT

• Emerging Infectious Disease Preparedness

2021 view-all

June

2021

PERSPECTIVES

• Inpatient Insulin Pumps and Glucometers
• Insulin Pump/Continuous Glucose Monitor Policy
• TJC FAQ on Vaccinated Staff and Masks
• TJC FAQ on Medication Autoverification

EC NEWS

• Hazardous Chemicals and Waste Hauling
• Keeping Facilities Safe for Seniors
• 2020 Most Frequent EC/LS & Ambulatory Standards

CMS

• COVID-19 Data
• Nursing Home and Covid-19 Vaccinations

IN OTHER NEWS

• PPP: Hazardous Waste Medications

2021 view-all

May

2021

PERSPECTIVES

• Top 10 High & Moderate Risk Findings for 2020
• Interoperability Standard Revision
• New Speak Up Video
• Insulin Pen Sharing, Glucometer Cleaning, Lancet / Lancet Holder Sharing
• Sentinel Event Alert – Infusion Pumps

EC NEWS

• Alternative Equipment Maintenance (AEM) Strategies
• Conventional, Contingency, and Crisis Care Standards
• Medical Gas Room Signage

CMS

• COVID-19 Test Positivity Rates
• Interoperability Requirements

2021 view-all

April

2021

PRIORITY NEWS

• Surveys are Restarting
• CAH Leadership Standards Changes
• Full-Service Acute Hospital IM Standards Changes
• Water Management Requirements
• Emergency Management Standards Guidance
• Visitation Rights

PERSPECTIVES

• Suite Aisle Width
• Medical Assessments for Outpatient Procedures

EC NEWS

• Maintaining Security Systems
• BH Environment Most Frequently Scored
• EC Top 10 Most Frequently Scored
• BH Top 10 Most Frequently Scored
• Portable Fire Extinguishers

TJC RESUMES SURVEYS

• Personal Client Experiences

CMS

• Suitability for Survey

2021 view-all

March

2021

HIGHLIGHTS

• Email from TJC COO

PERSPECTIVES

• Suicide Sentinel Events
• Supporting Health Care Workers
• Eye Wash Station Compliance
• Dental Services Hazardous Chemicals
• Deemed Status Home Care Changes

EC NEWS

• COVID-19 Vaccination Site Tips
• Internal Flooding
• NCC Most Frequently Scored EC/LS

HEADS-UP REPORT

• Reducing the Risk of Suicide

CMS

• Surveys and COVID-19

ISMP PHARMACY PRACTICE NEWS

• Medication Errors

AHRQ

• National Healthcare Quality and Disparities Report

2021 view-all

February

2021

PERSPECTIVES
• Performance Measurement Data
• Flammable Antiseptics
• Medical Staff Updates
• Reduced Volume Requirements
• Remote Surveys
• New Speak Up™ Materials

EC NEWS
• EM Standards for 2022
• After-Action Reports
• Fire Doors
• Hyperbaric Checklist
• Wrong-Site Surgeries

CMS
• QSO 21-12
• Annual Report to Congress
• QSO 21-13
• Suspending Surveys

2021 view-all

January

2021

PERSPECTIVES
• Standards Changes – APR, EC, LS
• EM Changes in Home Care
• Certification Performance Measures
• Pediatric Cardiovascular Programs
• Consistent Interpretation – Thermometers

EC NEWS
• Spare Circuit Breakers
• Elevator Advertising
• Fire Drill Matrix
• Spare Sprinkler Heads
• Reducing Corridor Clutter
• Surgical Smoke

CMS
• Ambulatory Facilities as Hospitals?

2021 view-all

December

2020

PERSPECTIVES
• ORYX Requirement Changes
• Mandatory COVID Reporting
• Sentinel Event Definitions
• Medical Staff Tracer Tools
• Changes to Standards for 2021
• Medication Storage

EC NEWS
• Air Handling Requirements
• EC/LS Top 10
• Water Management
• Non-Waivable ITM Requirements
• Issues in the Kitchen

CMS
• Hospitals Without Walls
• Lab Remote Surveys

TJC Advisory Group

2020 view-all

November

2020

PERSPECTIVES
• Flu Vaccine for Staff and LIPs
• Advanced Stroke Requirement Changes
• EC Survey Change
• Covid and Surveys
• Access to Perspectives
• New MS Tracer Tools
• USP Chapter 825
• Upcoming Changes?

EC NEWS
• EM Planning and Prep
• FEMA & Flooding
• Fire Drills
• ABHR Fire Safety

CMS
• Vaccine Resources

2020 view-all

October

2020

PERSPECTIVES
• Fluoroscopy Services
• Consistent Interpretation – Maternal Safety Standards

FAQs
• Multimodal Therapy
• Expired Credentials

EC NEWS
• Cybersecurity
• Documentation
• Medical Gas Checklist

CMS
• Emergency Preparedness Drills
• Covid-19 COPs

2020 view-all

September

2020

PERSPECTIVES
• Family Visitations
• Clinical Respiratory Services
• Consistent Interpretation
• Update on USP
• Survey Process Modifications

EC NEWS
• Minneapolis EM Response
• Reopening Closed Sites
• Rated Walls

CMS
• Resuming Surveys
• New COP

2020 view-all

August

2020

PERSPECTIVES
• LSC Surveyors, Scope Expansion
• Resuscitation Changes

EC NEWS
• Survey Requirements Post National Emergency
• LSC: Condition Level Findings
• Kitchen Tracers
• Waiver Tracking Tool & COVID Recovery Prep Checklist

CMS
• Redeeming Application
• CMS & TJC

2020 view-all

July

2020

PERSPECTIVES
• Surveys Resuming – More Details
• Remote Surveys
• New Laboratory Standards
• Fire Drills
• Promoting Psychological Well-Being
• TJC Pandemic Q+A Webinars
• Authorizing Less Potent Analgesics
• Do You Have a Policy?

EC NEWS
• Medical Gas Flow
• Emergency Room Design and COVID-19
• Fire Sprinklers in Elevator Machine Rooms

CMS
• Public Health Emergency Being Extended?

2020 view-all

June

2020

LIMITED SURVEYS RESUME

PERSPECTIVES
• Federal Burden Reduction Updates
• Changes in Titrations
• Behavioral Health Care Name Change
• Falls, New Sentinel Event Definition
• Consistent Interpretation – Victims of Abuse

EC NEWS
• Alternate Care Sites
• Most Frequently Scored EM Standards
• EM Top 10 Frequently Scored
• Elevator Doors – Warning

CMS
• Nursing Home Industry Memos

2020 view-all

May

2020

PERSPECTIVES
• ORYX Temporary Modifications
• Direct Data Submission Program
• Perinatal Care Delay
• Consistent Interpretation
• Face Masks
• Emergency Management Note

EC NEWS
• Special Pathogens, Emerging Infectious
• Disease Program
• COVID-19, Patient Separation and Preparedness

CMS
• Freestanding EDs
• EM Critique Form

2020 view-all

April

2020

• Keeping Up with Essential Information
• Perspectives & EC News
• More: CMS & State Waivers
• CDC
• Emergency Management & Infection Control Plans

2020 view-all

March

2020

CMS
• Coronavirus Memos

CDC
• Coronavirus Update

PERSPECTIVES
• CMS Rules
• Sentinel Event Data
• Psychiatric Advance Directives

EC NEWS
• FGI Guidelines 2018
• Slips, Trips, and Falls by Staff

2020 view-all

February

2020

PERSPECTIVES
• Changes to Survey Agendas
• Home Infusion Deeming
• Closed Loop Communication of Test Results
• Consistent Interpretation
• Sterile Compounding

EC NEWS
• Mold
• Waste Anesthesia Gas

CMS
• Coronavirus Memos
• Correction – Medical Records

2020 view-all

January

2020

PERSPECTIVES
• New Dissemination Policy
• Safety Goal Changes
• Public Reporting
• New BHC Standards
• Medication Order Changes
• Consistent Interpretation

EC NEWS
• EM Exercise
• Fire Drill Requirements

CMS
• Burden Reduction – A Tags

2020 view-all

December

2019

PERSPECTIVES
• Emergency Management
• FSA Tool Temporarily Offline
• Consistent Interpretation

FAQS
• Suicide Risk Monitoring
• Essential Oils – A Medication?
• IFU
• Attire in the OR

EC NEWS
• New Requirements
• Fire Risk in Hospital Kitchens
• PCRA & ICRA

CMS
• Restraint Death Reporting
• Omnibus Burden Reduction Final Rule 3346-F

2019 view-all

November

2019

PERSPECTIVES
• ORYX: Sometimes Forgotten, but Not Gone
• Sentinel Event Definitions
• The Role of the Consultant
• New Payment Address for TJC
• BoosterPaks and Leading Practice Library are Retiring
• Consistent Interpretation
• PDF Manuals are Back!
• Quick Safety

EC NEWS
• Fire Extinguishers
• EC & LS Most Frequently Scored
• Minimizing Construction Risks

IN OTHER NEWS
• Vending Machines, Ice Machines, & Water Fountains
• CMS A-Tag Review

2019 view-all

October

2019

PERSPECTIVES
• ORYX 20-Year Anniversary
• Eliminating Redundancy
• Heads Up – Nursing & Home Care
• ASC Dashboard

EC NEWS
• Relocatable Power Taps
• USP 797 Delay
• Medication Compounding Certification Program
• USP 797 Track Record
• Environmental Surface Sampling

EXECUTIVE BRIEFINGS

FDA
• Disposable Duodenoscope Components

CMS
• Rural Health Clinics & Emergency Medications

2019 view-all

September

2019

PERSPECTIVES
• FPPE/OPPE Requirement Update
• Sentinel Event Statistics
• HR Requirement for Fluoroscopy Deleted
• Frequently Scored Standards
• New Standards for Perinatal Safety
• Sentinel Event #61 – Direct Oral Anticoagulants
• Consistent Interpretation

CONSULTANT FORUM
• Scoring Patterns

EC NEWS
• Time Limited Waiver
• Mold is on the Radar
• Construction Compliance
• Active Shooter Drills
• ASHE Conference – 6 Commonly Scored

CMS
• EMTALA Memos

IN OTHER NEWS
• FDA Dispute

2019 view-all

July

2019

PERSPECTIVES
• Square Footage
• Patient Feedback – Qualitative Data Collection
• E-Prescribing
• Patient Self-Management
• Anticoagulant Therapy

FAQS
• Tamper Resistant Electrical Outlets

EC NEWS
• Interim Life Safety Measures
• Heliports?
• Laser Safety

NEW USP MANUALS
• New Requirements Effective December 1, 2019

CMS
• Emergency Medical Treatment & Restraints
• Opening Conference Documents

2019 view-all

June

2019

PERSPECTIVES
• Ophthalmology Disinfection
• Preventing Drug Diversion
• Consistent Interpretation – Power Strips
• Intracycle Monitoring Suspension

FAQs
• Ligature Risks
• Pre-Spiking IV Bags

E-EDITION
• New Standards to Take Effect July 1

EC NEWS
• Emergency Generator – Remote Stop Stations
• COOP Requirements
• HCID Preparation

CMS
• Draft QSO Memo – Co-Located Hospitals

2019 view-all

May

2019

PERSPECTIVES
• Two New Suicide Safety FAQs
• Consistent Interpretation – Range Orders

EC NEWS
• Danger Zones
• Medical Gas Safety

CMS
• Ligature Hazard QSO Memo
• Violence Hazards

ELECTRONIC HEALTH RECORDS
• Death by 1,000 Clicks

2019 view-all

April

2019

PERSPECTIVES
• 2018 Scoring Patterns
• Infection Control Requirements

EC NEWS
• Fire Doors
• Fire Sprinkler Systems
• Risk Assessment
• Preventing Patient Suicide

CMS
• QSO Memo 19-09

2019 view-all

March

2019

PERSPECTIVES
• Sentinel Event Statistics
• Quick Safety Issue 47
• Food and Drink Safety
• Environmental Risk Assessments
• Consistent Interpretation

EC NEWS
• Eyewash Stations
• Equipment Maintenance
•Fire Drills

TJC FAQs

Frequently Scored Standards:
• Day-One Documents

CMS
• QSO Memo
• Wall Street Journal

2019 view-all

February

2019

PERSPECTIVES
• Disease Specific Care Updates
• Hospital Accreditation Standards
• Consistent Interpretation Column

STERILE COMPOUNDING
• USP Chapter 797
• What Can Go Wrong During the Evaluation of Sterile • Compounding?
• What Can Be Done About It? Remediation

TJC SURVEY PROCESS CHANGES
• A-Tag Review
• Validation Pilot Survey Update
• FSA Requirements Suspended for Some
• Pain Standards
• Survey Statistics from 2018

EC NEWS
• Emergency Management and Preparing 1135 Waivers in Advance
• Legionella in a New CMS QSO Memo
• Suicide Risk Assessment Tools

FREQUENTLY SCORED STANARDS
• Testing and Maintenance of Fire Safety Systems

CMS
• All Hazards Approach

2019 view-all

January

2019

SENTINEL EVENT ALERT
• #60 – Developing a Reporting Culture

PERSPECTIVES
• New CDC Infection Control Resource
• Pain Management Standards Changes – Home Care, Behavioral Health, & NCC
• Fluoroscopy Standards Modification
• Two New FAQs on Suicide Safety – Note Changes
• Consistent Interpretation

WALL STREET JOURNAL
• Continuing Focus on TJC

EC NEWS
• Top Cited EM Standards
• Workplace Violence

FREQUENTLY SCORED
• Infection Prevention
• Dialysis Machine & Water Findings

CMS:
• Federal Register Announcement

EPA
• Federal Announcement – Hazardous Drug Waste

2019 view-all

December

2018

PERSPECTIVES
• Changes to Safety Goals for July 2019 – Suicide
• Changes to Safety Goals for July 2019 – Anticoagulation
• Consistent Interpretation Column

EC NEWS
• Frequently Scored EC/LS Findings
• Active Shooter Drill Considerations
• Emergency Event Announcements

PATTON NEWS
• Problematic Standards in our Database

CMS UPDATE

2018 view-all

November

2018

PERSPECTIVES
• A Quiet Month for Change
• 9 New EPs for 2019
• E-Edition
• Consistent Interpretation

JOINT COMMISSION ONLINE

EC NEWS
• Reopening After Disaster
• Vaccine Storage
• Frequently Scored, Higher Risk, Frequent Pattern, Red and Orang•

CMS UPDATE

2018 view-all

October

2018

PERSPECTIVES
• The Pendulum Swings: More Changes for High Level  Disinfection & Sterilization
• When to Document the Biologic Indicator & Re-usable Brushes
• Cleaning Ultrasound Transducers
• Keeping Instruments Moist – Simplified
• TJC Webinar on Sterilization/HLD
• Correction: No Need to Update the Address to TJC Office of  Quality on your Posters
• Incidence and Method of Suicide in Hospitals
• New CMS Requirements in Standards
• Change Needed to Fire Response Plan
• Periodic Conversation Between Board and Lead of Organized  Medical Staff Needed
• An RN Needs to Supervise Perioperative Services

EC NEWS
• Frequently Scored EC/LS Standards Graphically Displayed
• TJC Defines Timeframes in Standards

CMS UPDATE
• Important New Memo from CMS – Compliant Surveys Published & New Validation Survey Pilot

2018 view-all

September

2018

PERSPECTIVES
• A Change in Quality and Patient Safety Reporting
• New Perinatal Care Measure
• New Guidance on Using Scribes
• Mandated Equipment in Operating Room Suites
• Top 10 Most Frequently Scored Standards Updated
• Sentinel Events
• Consistent Interpretation – More Guidance on Sterile Compounding
• Air Pressure Monitoring and Documentation
• Chemotherapy Compounding
• 411 Initiative

TJC CONSULTANT FORUM NEWS
• The Pendulum Swings, We Think
• Adverse Decisions

EC NEWS
• Hazardous Chemical and Medication Compliance
• BAS Compliance
• Fire Safety Requirements

CMS UPDATE
• CMS Not Developing Ligature Risk Task Force!
• Outpatient Dialysis Center Compliance Expected

2018 view-all

July

2018

PERSPECTIVES
• New FAQs on Ligature Safety
• Consistent Interpretation – More Guidance on Sterile Compounding

NEW STANDARDS FOR 2019
• Naming Newborns – A Standardized Process
• New Requirement for Fluoroscopy
• EP Review Project, Phase IV – More Considerations

EC NEWS
• Means of Egress in Ambulatory Healthcare
• Changes to the LS/EC Document and Review Tool

CMS UPDATE
• Legionella – Revised Recommendations from CMS

2018 view-all

June

2018

PERSPECTIVES
• Leadership Session – Be Prepared for Changes
• SAFER™ Matrix Placement Under Review – # RFIs Still Important
• Not to Miss – New APR Requires You to Notify TJC if You Lose Deeming
• Action Item: Exacting Competency Requirements for USP797 Listed
• Changes to Ligature Scoring and an OSHA Reporting Requirement
• Pediatric Hospitals to Get Experienced Specialized TJC Teams
• Intracycle Monitoring (ICM) Calls Suspended by TJC

EC NEWS
• Active Shooter
• Suggestions for Sprinkler Pipe – Avoid Common Findings

QUICK SAFETY
• Action Item – Ensure you have a Continuity of Operations Plan

CMS Update

2018 view-all

May

2018

PERSPECTIVES
• Staying Safe – New SEA on Workplace Violence
• E-Edition Update – Finding what Changed
• Welcome Changes for Telehealth Applicability Grid
• Sterile IV Compounding Compliance Details

EC NEWS
• Scorecard and Strategy for Creating and Managing the Physical Environment Steering Committee
• Managing Utility Risks Related to General Anesthesia
• Sample Design and Construction Partner Checklist

CMS Update

AHRQ ACTION PLANNING TOOLKIT
• 3 Useful Resources for Culture of Safety Survey

2018 view-all

April

2018

PERSPECTIVES
• Top Scored Standards
• Self-Assess Your Compliance with HLD & Sterilization
• Challenges Posed by EC & LS
• Sentinel Event Statistics

JOINT COMMISSION ONLINE
• Proposed Changes to Suicide Goal NPSG.15.01.01 – Out for Field Review

EC NEWS
• Keep Your Life Safety Drawings Current
• Details on Fire and Smoke Prevention

CMS QUALITY AND SAFETY MOMOS

2018 view-all

March

2018

PERSPECTIVES
• Suicide Prevention
• Field Review for New Standards
• Clinical Contract for Pharmacies is Focus of Increased Attention
• Deletion of Old EP Regarding the Patient’s Right to Pain Management
• Additional Detail on New EC Requirements

EC NEWS
• Documentation Checklist Required by the Life Safety Code Surveyors

CMS UPDATES
• Additional Resources

2018 view-all

February

2018

PERSPECTIVES
• New Focus on Fluoroscopy Service
• Update on Door Requirements
• Oxygen Cylinder Storage – Change
• Effective Now
• New FAQs on Sterile Medication Compounding and USP 797

CONSULTANTS FORUM

EC NEWS

CMS UPADATES
• Important Changes – After CMS
• Removes Deemed Status

2018 view-all

January

2018

PERSPECTIVES
• New Suicide Risk Recommendations for Partial, Day Treatment, and IOP Services
• Change to the Credentialing and Privileging for Pathologists at Contracted Labs
• New PC Requirements for Maternal and Newborn Care
• Things to Share with Facilities Leadership: Consistent Interpretation

EC NEWS
• Revisions and Issues with LS.02.01.35 – Review and Self-Assess
• Lessons Learned from Hurricane Harvey – EOP Committee Take Note

2018 CUSTOMER SURVEY ACTIVITY GUIDE
• Changes to the Day One Document List: Action Required Now
• Revisions to System Tracers and Patient Tracers Focus on Pain and Emergency Management

CMS UPDATES
• CMS Memo Summarizes Ligature Risks in Hospitals
• CMS Offers a Modification to the Texting Prohibition

2018 view-all

December

2017

PERSPECTIVES
• Survey Report Enhancements
• 2018 Prepublication Standards
• Scoring for Hand Hygiene Lapses
• Looking for Hospitals to Meet CMS Definition of a Hospital
• New Decision Rule for PDA

EC NEWS
• Managing Sprinkler Systems
• Changes for the Behavioral Health Organizations
• Another Vincristine Alert
• Suicide Risk Algorithm

CMS UPDATES

READY FOR 2018?
• Medication Relation Standards
• Pain Management Standards

2017 view-all

November

2017

PERSPECTIVES
• Recommendations for Reducing Suicide Risk
• Inpatient Psychiatric Units
• General Acute Inpatient Setting
• Emergency Department

FAQS
• 10 new pain management standard FAQ’s taking effect January 2018

CMS UPDATES

TRENDS ON SURVEY FINDINGS
• Dialysis Focus
• Open Electrode Packages
• Protocols
• Clarity on Clarifications

2017 view-all

October

2017

PERSPECTIVES
• Changes to Emergency Management Standards
• Succession Planning – Delegation of Authority – Transplant Centers
• Maintaining Contact Information
• Training
• System-Wide Preparation
• 7 Recommended Steps for Handoff Communication
• Increased Scrutiny of Sterile Compounding During Next Survey
• To Do: Self-Assess Handling of Hazardous Medications
• Trial Version Available on TJC Website

EC NEWS
• Infection Prevention During Construction

CMS UPDATES
• Defining “Hospital”
• CDC on Flexible Endoscopes
• Ligature Hazards Once Again

2017 view-all

September

2017

PERSPECTIVES
• New Medication Management Standards
• Essential Medication Refrigerators Need Emergency Electrical Backup
• Approved Method for Wasting Medications
• “Signed and Held” Medication Orders
• Medication Overrides to Review
• Top 5 Scored Standards—Scoring Frequently Accelerates
• New to the Top 10
• More Focus on LSC & EC
• Sentinel Event Statistics: First Half 2017

EC NEWS
• Joint Commission Online—Monitoring BH Patients Progress Requirement and Database of Tools

CMS UPDATES
• Another Look at Legionnaires Disease

LINKS

2017 view-all

July

2017

PERSPECTIVES
• New Pain Management Standards
• 4 Tricky Life Safety Clarifications:
–Door Inspections
–ED Occupancy Type
–Door Ratings
–Fire Drill Timing Patterns
• New Behavioral Health Standards
• Sterile Product Preparation
• Ligature Risks, Again

EC NEWS:
• Active Shooter Recommendations and Resources

CMS UPDATE
• Filling Your Own Saline Syringes
• Cleaning Dialysis Equipment After a Patient Leaves the Space
• Screening for Hepatitis C
• Revisions to the 2567 Completion Process

2017 view-all

June

2017

PERSPECTIVES
• Modifications to the National Patient Safety Goals
• Egress, Clutter, and Exiting Focus
• Improving HLD & Sterilization
• FAQ on Syringe and Needle Safety

EC NEWS
• Helpful tip on Medical Equipment Tracking and PM

CMS UPDATE
• Emergency Management Interpretative Guidelines
• New K-Tag requiring a Time out for OR Fire Safety

2017 view-all

May

2017

PERSPECTIVES
• Deletion of EPs for Nonhospital Programs
• Blood Glucose Meter Advice
• Medication Titration Requirements
• Details about Doors
• New Signage Requirement
• Consistent Interpretation-Informed Consent
• SAFER™ Matrix: A Look Back at Psychiatric Hospitals
• New ESC Format for Ambulatory Care
• EC News: A Document Prepared by the FBI on Active Shooter Situations

CMS UPDATE
• Emergency Management Planning
• Still More on Ligature Risks and Resources

2017 view-all

April

2017

PERSPECTIVES
• Top Scored Standards for all 2016
• Revised Decision Rules
• Insights into the 2012 LSC Changes

NEWS FAQ’s
• History and Physical
• Titration Orders
• Linen Managements
• Storage of Sterile Supplies Outside of Central Sterile

FEEDBACK ON THE SAFER™ MATRIX

MORE ON LIGATURE RISKS

EC NEWS

CMS UPDATE

SGNA MULTI SOCIETY GUIDELINE

2017 view-all

March

2017

PERSPECTIVES
• TJC New Survey Notification Email
• Recall on Powdered Glove Reminder
• EC News on Infection Control and Hazardous Medications
• Sentinel Event Alert #57 on the Role of Leadership in Safety Culture

INSIGHTS FROM SURVEY FINDINGS SEEN IN 2017
• Longer Reports, More LS/EC Findings, Scoring on the SAFER™ Matrix
• New Requirements: Inspection of Exit Signs & Testing Battery Specific Gravity
• Installing Manual Stop Station on Generator
• Continued Focus on Air Pressure, Temperature, Humidity
• More Sophistication Mandated in High-level Disinfection & Sterilization
• Emphasis on Ligature Risks in Behavioral Health Areas
• New Focus on Waste Medication Security

2017 view-all

February

2017

• TJC Survey Activity Guide
• SAFER™ Matrix Guide
• LSC Updates
• Lab Accreditation Changes
• Alarm Reduction Highlighted
• Malignant Hyperthermia
• Concurrent Surgeries
• Summary of EC News
CMS K-Tags Published
• CMS Memo on Cyber Security and End Stage Renal Disease
• AHRQ Informed Consent Training

2017 view-all

January

2017

• The new 2017 Survey Activity Guide (SAG) has six new mandatory Day 1 documents
• Survey focus on your Antimicrobial Stewardship Program
• SAFER Matrix explained
• ILSM Requirements highlighted
• Changes to the Behavioral Health Manual – standards changes for July 2017
• Bigger changes to the Behavioral Health Manual coming Jan. 2018 – start now!
• Immediate Post Op Note – two thorny issues clarified
• Refresher on portable fire extinguishers
• CMS UPDATE: Small change for small critical access hospitals

2017 view-all

December

2016

• Revised ILSM expectations for life safety violations
• New Governing Body EP for COP level noncompliance
• Revised life safety expectations – details for LS.01.01.01
• Changes to the clarification process for 2017
• Final word on text messaging physician orders
• Helpful links on falls prevention & sterile compounding
• Catheter Associated UTI National Patient Safety Goal changes
• New CDC Guideline on vaccine storage
• CMS still testing the Infection Control Worksheets

2016 view-all

November

2016

• The new EC and LS chapters have been published.
• Project Refresh Update – 51 EPs to be deleted
• Revised disease certification requirements
• Focus on air pressure differentials
• Cyber security addressed
• Suggestions for managing medical waste
• New emergency management requirements
• Surveyor focus areas

2016 view-all

October

2016

• The TJC SAFER Matrix and changes to the ESCs
• Changes to the clarification process in 2017
• The Measure Of Success (MOS) gone in 2017
• ORYX Requirements Updated
• Changes your facilities leadership team
• Equipment management recommendations
• CMS new Emergency Management Regulations
• Summary of the TJC Executive Briefings
• Changes to the Day One Document list for 2017

2016 view-all

September

2016

• Changes to the Statement of Condition and PFIs.
• New processes for waivers and equivalencies
• Sentinel Event Statistics for 2016
• Top hot spots for 2016
• Helpful Tool for tracking fire drills published in EC News
• New CMS S&C memo on Emergency Preparedness

2016 view-all

July

2016

• Antimicrobial Stewardship Standard
• Capturing medical device identifiers
• Diagnostic imaging standards,
• Implementation date of the 2012 LSC
• EC tracer to the laboratory by your life safety code surveyor
• “Physician Favorite” order sets

2016 view-all

June

2016

• Adoption of the 2012 LSC
• Fire hoses, dampers and more
• Response to violence in in healthcare
• Orders sets, protocols and standing orders
• Air pressure relationships and high level disinfection

2016 view-all

May

2016

• Scoring Logic for 2017
• ESC Deadlines Change in 2017
• PDA Process
• Deleted 225 EPs
• Texting Orders
• Prison Units – CMS Rules
• CMS Adopts 2012 LSC

2016 view-all

April

2016

• Numerous Elements of Performance deleted
• The FAQ page on the TJC website
• Top scored standards for 2015

2016 view-all

March

2016

• Diagnostic imaging standards
• Pain assessment standards
• Fire Drill observations tool
• Infant Security
• Sentinel Event Alert is available on suicide
• Eligibility criteria for critical access hospitals (CAH) CMS

2016 view-all

February

2016

• Interim Life Safety compliance
• High level disinfection booster pack
• Simulation for donning and doffing PPE
• Tips for Succeeding in a Life Safety Code survey”
• CMS memo on infection prevention
• CMS memo for the long term care industry
• OR temperature, humidity, air exchange & pressure
• SGNA clinical practice guidelines

2016 view-all

January

2016

• Patton Healthcare Changes
• Risk icon elements of performance
• Additional team leader identified on some tailored surveys
• Behavioral Health standards effective July 1, 2016
• EC.02.02.01
• OSHA hazards enforcement policy
• Getting your plans set for 2016

2016 view-all

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