August 23, 2021 | | Comments 0
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Time has come today: There’s late and there’s LATE

Depending on where you are, you may be bumping up against process elements that are causing certain activities to be “late,” even beyond the grace periods you’ve woven into your management plans, etc. And with the Delta variant becoming more and more of a factor, there is a fair likelihood that the challenges of scheduling activities, particularly those provided by resources external to your organization. I wish that I had a “magic bullet” for this, beyond invocation of the ongoing Public Health Emergency and making use of the 1135 Waiver process (remember when it was really unclear as to what that all meant?). But I think those items should be enough, with a little judicious planning and discussion, to get you over the compliance hump. If you need a primer on that process, be sure to visit the CMS website dealing with such things.

As a somewhat related aside, it does appear more than likely that our friends from Chicago (and, likely, others of the regulatory persuasion) will be moving towards a full embrace of the remote review of documentation. And while that may end up reducing a surveyor day or two from future surveys (they do have a lot of documents to review, so that time would shift from the onsite schedule), it also increased the importance of making sure that your committee minutes, annual evaluations, and other foundation documents provide as much compliance information as possible. Clearly document what waivers have been adopted and for how long; clearly document any risk assessments/mitigation strategies for compliance gaps or shortfalls. While I won’t ask you to “air out your dirty laundry,” you absolutely want to be forthcoming on the impact COVID response has had on normal operations. And if something is late, document the issue resulting in the tardiness of the activity and, again, use the risk assessment process to clearly document that you’re not putting folks at risk while things are sorting themselves out.

As a final note, the Chicagoans are working very diligently to try and get things back on track from a survey perspective, so if you’re expecting them any time soon (or they haven’t shown up yet), I think you need to plan on seeing them before the end of the first quarter of next year. That’s not to say there might not be outliers, but they’re definitely going to be knocking on your door before you know it.

Thanks for all you’ve done and continue to do. It’s made all the difference!

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Filed Under: Hospital safety


Steve MacArthur About the Author: Steve MacArthur is a safety consultant with The Greeley Company in Danvers, Mass. He brings more than 30 years of healthcare management and consulting experience to his work with hospitals, physician offices, and ambulatory care facilities across the country. He is the author of HCPro's Hospital Safety Director's Handbook and is contributing editor for Briefings on Hospital Safety. Contact Steve at

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