Patton Post Newsletter / Patton Healthcare Consulting

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.

Issue	Year	Issue Highlights	hf:tax:newsletter_year
April NEW!	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