Patton Post – August 2026

August 2026

Inside This Issue

The Post-Survey Process:
The August EC News continues the Physical Environment survey series started last month with a detailed review of what happens after a triennial survey. Although written for Facilities and Physical Environment leaders, the article is also a useful refresher for Accreditation staff and a good primer for leaders or regulatory staff who are new to the post-survey process.

The clarification process was described in detail however; Joint Commission describes the limited circumstances in which a finding may be clarified and notes that findings have already been reviewed multiple times before the final report is issued. The article also reviews the various follow-up activities such as Medicare-deficiency follow-up surveys, Preliminary Denial of Accreditation, abatement surveys, and Denial of Accreditation.

Field Impact
On our consults, we are seeing fewer successful clarification opportunities than in prior years. We recommend using the onsite survey period to discuss questionable findings and provide available evidence to the survey team rather than relying on the post-survey clarification window. This article is also a good primer for new Accreditation staff on clarification, ESC, and follow-up survey requirements.

Workplace Violence Prevention:
The August EC News reviews workplace violence requirements and suggested practices. For hospitals and critical access hospitals, the requirements are now consolidated in NPG.02.04.01. We think the most useful takeaway is the preventive side of the program: monitoring and reporting lower-level aggression before events escalate and completing the required annual worksite analysis.

The article also points to practical approaches used by healthcare organizations. Vanderbilt University Medical Center, for example, provides verbal de-escalation guidance that includes managing your own response, respecting personal space, establishing verbal contact, active listening, setting limits, knowing when to call for help, and debriefing after an event. The article also notes the increasing use of staff escorts and parking lot patrols during shift changes. As we noted in last month’s Patton Post, weapon detection systems are also increasingly being used and should be evaluated carefully for life safety and operational impact.

Field Impact
We recommend taking this article to your Workplace Violence Prevention Committee. Review whether your program is identifying and acting on early warning behaviors, not just responding to serious incidents. Readers should also consider Vanderbilt’s de-escalation resources and discuss whether staff escort practices, parking lot surveillance, and other preventive measures should be strengthened.

Vanderbilt resource: Workplace Violence Prevention Education – 11 Steps of Verbal De-Escalation

MRI Safety: New Serious Reportable Event:
The August EC News provides an MRI safety reminder in advance of the January 1, 2027 alignment of Joint Commission Sentinel Events with the updated National Quality Forum Serious Reportable Events list. Two SREs specifically address MRI. SRE 5 addresses introduction of an unapproved, unscreened, or inappropriately approved device, implant, or object into MRI Zone IV regardless of outcome. New SRE 6 addresses patient harm associated with an MRI-related thermal injury.

The article is worth sharing with the MRI safety team. It reviews real MRI injuries that continue to occur and provides reminders on screening, access control, signage, ferromagnetic detection, and fire response.

Field Impact
We recommend sharing this article with your MRI Safety Team and using it as a gap analysis. Pay particular attention to prevention of Zone IV access events and thermal injuries, including near misses. Confirm that screening, access controls, incident reporting, and MRI fire response plans reflect current requirements and evidence-based guidance.

High-Rise Sprinkler Deadline:
The August EC News also highlights the July 5, 2028 deadline for existing high-rise healthcare occupancies to be fully protected by an automatic sprinkler system. Joint Commission also called attention to this deadline in its August materials. The requirement applies to existing high-rise hospitals and critical access hospitals, inpatient hospice settings, certain behavioral health residential facilities that lock doors to restrict movement, and other healthcare occupancies covered by the Life Safety Code.

CMS has advised organizations that sprinkler retrofit projects may require significant time for budgeting, design, permitting, materials, phased installation, and integration with other building systems. CMS has also encouraged organizations with difficult circumstances to communicate with the agency early, before the deadline.

Field Impact
If your organization has an affected high-rise occupancy that is not fully sprinklered, we recommend confirming now that the project is funded and underway. Do not wait for the deadline to approach. CMS specifically encourages facilities with unusual barriers or concerns about timely completion to contact the agency early at EP-LSC@cms.hhs.gov to discuss their circumstances.

Sprinklered Elevator Machine Rooms:
The EC News provided a link to a new checklist for reader’s Toolbox. This tool includes a Sprinklered Elevator Machine Room Assessment Checklist and a detailed review of the safety requirements that apply when elevator machine rooms are sprinklered. The article discusses shunt trip protection, heat detectors, and other safeguards intended to prevent electrical hazards when sprinkler water is discharged.

Joint Commission notes that surveyors continue to identify issues such as missing shunt trip breakers, no means to activate the shunt trip, and heat detectors that are not properly located in relation to sprinkler heads.

Field Impact
We recommend sending this article and checklist to Facilities and using the tool to self-assess sprinklered elevator machine rooms. Verify that required electrical and fire protection safeguards are present, properly located, and maintained.

ACHC: Common ASC Credentialing Deficiencies:
ACHC recently published a survey-readiness article on ambulatory surgery center credentialing. Common problems include completing credentialing steps in the wrong sequence, missing primary-source verification, inadequate evidence of current competence, gaps in privilege renewal, incomplete governing-body documentation, and approval letters signed by individuals without appropriate authority.

ACHC also reminds organizations that privileging decisions are not simply an administrative function. Medical staff review and recommendation are followed by governing-body approval.

Field Impact
For ASCs, we recommend going beyond a simple file-completeness audit. Select several newly appointed and recently reappointed practitioners and reconstruct the credentialing chronology. Verify that required checks occurred before approval, current competence is documented, governing-body action is evident, and there are no gaps in privileges. Source: ACHC: ASC Credentialing Builds Trust, Protects Patients

Inpatient and Long-Term Care Hospital Final Rule:
CMS issued the FY 2027 Hospital Inpatient and Long-Term Care Hospital (IPPS/LTCH PPS) Final Rule on July 31. The rule finalizes three new Hospital Inpatient Quality Reporting measures and will also remove three existing. These are all part of the Hospital Readmissions Reduction Program, a value-based purchasing program that reduces payments to hospitals with excess readmissions.

Field Impact
We recommend that hospital and LTCH Quality, Regulatory, Informatics, Clinical Documentation, and Medical Staff leaders review the finalized measures and implementation dates now. While they are not mandated for a few years confidential early-look reports will be available in FY 2028 and FY 2029, before the measure affects payment reductions beginning in FY 2030. Source: CMS: FY 2027 IPPS/LTCH PPS Final Rule Fact Sheet

Comprehensive Care for Joint Replacement Expanded Model:
CMS finalized the Comprehensive Care for Joint Replacement Expanded (CJR-X) Model and noted in the Q&A that most hospitals paid under the Inpatient Prospective Payment System (IPPS) will be required to participate in CJR-X. The model includes hip, knee, and ankle replacement episodes performed in inpatient and hospital outpatient settings and holds hospitals accountable for cost and quality across the episode of care.

Field Impact
Affected hospitals should consider identifying now who will own CJR-X readiness. Review joint replacement pathways, post-acute relationships, preventable readmissions, emergency department utilization, discharge planning, and the ability to track costs and outcomes across the episode. Source: CMS: CJR-X Model

Inpatient Rehabilitation Facilities Final Rule:
CMS finalized several FY 2027 operational changes for inpatient rehabilitation facilities (IRF). All required therapies must begin within 36 hours of admission. The initial interdisciplinary team meeting must occur on or before the fourth day following admission, and subsequent meetings must occur every seven days.

Field Impact
We recommend that IRFs audit recent admissions against the finalized requirements. Source: CMS: FY 2027 IRF PPS Final Rule Fact Sheet

Hospice Final Rule Changes:
CMS finalized another FY 2027 change requiring the hospice election-statement addendum for all beneficiaries electing hospice, rather than only when requested. The addendum identifies conditions, items, services, and drugs the hospice considers unrelated to the terminal illness and therefore not covered under the Medicare hospice benefit.

Field Impact
Hospices should consider reviewing election workflows and forms now, educating staff responsible for admissions and beneficiary communication, and confirming how determinations about unrelated services are made and documented. Source: CMS: FY 2027 Hospice Final Rule Fact Sheet