Healthcare Accreditation Certification Program Newsletter
March 2020

ARS Regulatory Alerts

CIHQ-ARS notifies member organizations of any new or modified accreditation standard, or CMS COP for acute care hospitals. Each alert summarizes the standard / regulation, likely impact to members, and recommends compliance strategies. Whenever possible, alerts are limited to one-page in length so that they can be quickly read and disseminated.

New Regulatory Alert

Alert Date
February 26, 2020
Alert Subject
Joint Commission Makes Slight Modifications to Survey Procedures
Alert Applicability
Acute Care Ambulatory Care Behavioral Health
Critical Access Home Health / Hospice Laboratory
Long Term Care Other: __________  
Alert Background
In an on-line posting dated 2/26/20, the Joint Commission announced minor modifications to their on-site survey agenda. These changes will go into effect on 3/1/20. According to the Joint Commission, the changes are intended to better accommodate critical survey activities for the following programs:
  • Ambulatory health care
  • Behavioral health care
  • Critical access hospitals
  • Home care
  • Hospitals
  • Nursing care centers
  • Office-based surgery practices
These modifications are not applicable to the laboratory or certification programs.
The changes are as follows:
  • Opening conference/orientation to the organization have been combined and limited to one hour or less.
  • The surveyor planning session (which followed the opening conference/orientation to the organization) has been removed, allowing the surveyor(s) to begin tracer activities immediately.
  • The special issue resolution/surveyor planning session have been combined at the end of each day.
Discussion & Recommendations
HACP Professionals can download this alert in its entirety when logged-in to their HACP account. Alerts are also archived for future access and reference.
Not HACP Certified?
» Find out How to Apply and Why HACP is the Right Choice for YOU!

New Regulatory Alert

Alert Date
February 10, 2020
Alert Subject
CMS Issues Information Concerning Coronavirus
Alert Applicability
Acute Care Ambulatory Care Behavioral Health
Critical Access Home Health / Hospice Laboratory
Long Term Care Other: __________  
Alert Background
In a letter to State Agencies (SA) dated 2/6/20, CMS provided guidance and resources to assist healthcare facilities in meeting the looming challenge of the 2019 Novel Coronavirus (2019-nCoV).
CMS encouraged all healthcare facilities to carefully review the information the U.S. Centers for Disease Control and Prevention (CDC). CDC has issued an updated interim Health Alert Network (HAN) Advisory, information about CDC’s response to 2019-nCoV as well as recommendations for healthcare facilities. Because coronavirus infections can rapidly appear and spread, facilities must take steps to prepare, including reviewing their infection control policies and practices to prevent the spread of infection. The CDC advisory can be located at: https://www.cdc.gov/coronavirus/2019-ncov/summary.html
To ensure health and safety, CMS also expects healthcare staff and surveyors (contractors, Federal, State, and Local) to comply with basic infection control practices. For 2019 novel coronavirus, CDC is currently advising adherence to Standard, Contact, and Airborne Precautions, including the use of eye protection (for more information, see CDC’s Interim Infection Control Recommendations for 2019-nCoV).
Healthcare staff should also adhere to CDC recommendations on standard hand hygiene practices, using alcohol-based hand rub/hand sanitizer (ABHR/ABHS) as the preferred method of hand hygiene in most clinical situations. If hands are visibly soiled, wash with soap and water for at least 20 seconds. Healthcare facilities should ensure that hand hygiene supplies are readily available see CDC Hand Hygiene in Healthcare Settings for more detailed information.
In light of the 2019-nCoV outbreak, the Office for Civil Rights (OCR) at the U.S. Department of Health and Human Services has issued guidance to serve as a reminder of the ways that patient information may be shared so that the protections of the HIPAA Privacy Rule are not set aside during an emergency: https://www.hhs.gov/sites/default/files/february-2020-hipaa-and-novel-coronavirus.pdf
Discussion & Recommendations
HACP Professionals can download this alert in its entirety when logged-in to their HACP account. Alerts are also archived for future access and reference.
Not HACP Certified?
» Find out How to Apply and Why HACP is the Right Choice for YOU!

New Regulatory Alert

Alert Date
February 5, 2020
Alert Subject
The Joint Commission Launches Accelerate PI ™ Performance Improvement Program Dashboard Report
Alert Applicability
Acute Care Ambulatory Care Behavioral Health
Critical Access Home Health / Hospice Laboratory
Long Term Care Office-Based Surgery  
Alert Background
In an online newsletter published February 5, 2020, The Joint Commission announced that its Accelerate PI™ dashboard has launched for the hospital accreditation program.
Discussion & Recommendations
HACP Professionals can download this alert in its entirety when logged-in to their HACP account. Alerts are also archived for future access and reference.
Not HACP Certified?
» Find out How to Apply and Why HACP is the Right Choice for YOU!