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CMS renews HFAP deeming authority

The Healthcare Facilities Accreditation Program (HFAP) has received its continued status as an accrediting organization for hospitals through CMS. The notification was posted in the August 28 Federal Register and goes into effect September 25, 2013.

Accrediting organizations must reapply for deeming authority at least every six years. This decision provides HFAP with deeming authority through September 25, 2019.

The decision can be seen here. 

Ten California hospitals fined for patient safety issues

The California Department of Public Health (CDPH) issued ten penalties this week to California hospitals–and fines totaling $675,000–after investigations found the facilities’ noncompliance with licensing requirements caused, or was likely to cause, serious injury or death to patients.

The penalties range for lack of compliance for everything from telemetry monitoring to cardiac catheterization processes, respiratory care and general patient safety.

Find more on the CDPH site here. 

Patient dumping scandal may cost accreditation

The Joint Commission has issued preliminary denial of accreditation for Rawson-Neal Psychiatric Hospital, a mental health facility in downtown Las Vegas, over a patient dumping scandal.

State officials with the Nevada Department of Health and Human Services have expressed disappointment in The Joint Commission’s decision, stating: “We are disappointed by the Joint Commission’s decision to move for a Preliminary Denial of Accreditation, which appears to be based on outdated survey information and is not an accurate reflection of the hospital’s current practices and policies.”

For more on this story, click here.

CIHQ receives deemed status for acute care hospitals

The Center for Improvement in Healthcare Quality has announced that it is the latest organization to receive deemed status for acute care hospitals from CMS. This allows CIHQ’s hospital accreditation program to deem hospitals to be in compliance with CMS Conditions of Participation.

For more information on this announcement, visit CIHQ’s accreditation home page here.


Emergency Management standards revised

The Joint Commission has announced revisions to its Emergency Management standards intended to take into account leadership accountability for hospitals and critical access hospitals.

Based upon a field review conducted in 2012, these changes will go into effect as of January 1, 2014 and target leadership involvement and oversight as well as staff input.

For more on the revised standards, which will appear in the e-dition of the standards for both programs in November, visit The Joint Commission’s website.

Joint Commission announces alarm safety NPSG

The Joint Commission has announced the creation of a National Patient Safety Goal (NPSG.06.01.01) addressing growing concerns surrounding alarm safety.

The multi-phase implementation process for this new goal will begin January 1, 2014 with a second phase beginning Junuary 1, 2016.  

For specifics on the goal, including requirements and implementation expectations, visit The Joint Commission website. Our sister newsletter, Briefings on The Joint Commission, will have ongoing coverage of this new NPSG leading up to the implementation deadline as well.

AHAP Networking Call, June 19th

Hello, AHAP members. I wanted to let you know that we have set up a time for our next AHAP networking call and we’d love to invite everyone to attend. The call will take place June 19th at 3 PM EST (2 PM Central, 12 PM PST).

We have a great topic to discuss this quarter. Recently, Briefings on The Joint Commission interviewed Rachel Zastrow, MSN, RN, CCRN, and Six Sigma Black Belt about the work her organization has been doing to prevent drift. Her story is really intriguing and we’re very much looking forward to having her share it with you, as well as hearing about what your own organizations are working on in this area.

The dial-in information for all participants is below—feel free, as always, to invite any of your colleagues to listen in as well! I’d like to ask a favor of you—if you plan to attend, please email me at to let me know. This is simply so I can get a rough estimated headcount to ensure we are properly staffed as members dial in to the call. Anyone who emails ahead of time to confirm will receive an electronic copy of the BOJ article on drift in response.

Here is the dial-in information:

Participant Dial-In (Toll Free): 877-869-3841

Password: 370331

Looking forward to having you join us on the call!

A view from the podium

Our afternoon session at the 7th annual AHAP conference included a series of round table discussions, giving attendees a chance to speak in a smaller group with all of this year’s conference. Here’s a view from above:

AHAP kicks off annual conference

Today’s first few sessions have been a huge success. Our 7th annual conference kicked off with a great keynote address by Kurt A. Patton, MS, RPh, on “Joint Commission and CMS standards requirements: Keeping up with the pace of change,” pictured below, and we are currently listening to AHAP advisor Jean Clark, RHIA, CSHA present on “Solving compliance issues: Regulatory changes in 2013 and top RFIs.”

Later on today we’ll be hearing from Brad Keyes, CHSP, on “The Environment of Care documentation that the accreditation professionals never get to see,” followed by a round table discussion with all of our conference speakers and a tracers-related presentation by Jean as well. 

Joint Commission launches adult depression campaign

The Joint Commission has released the latest of its ongoing “Speak Up ™” campaign, this time intended to provide advice on identifying the warning signs of depression and getting the most out of care and treatment for depression.

The campaign was developed with the collaboration of nearly a dozen nationally recognized mental health organizations.

The Speak Up brochure, as well as supporting materials, can be found on The Joint Commission’s web site here or by clicking the link below: