Joint Commission’s top 5 compliance challenges

The Joint Commission has listed the five most challenging requirements among health care facilities for the first half of 2016. The data breaks down requirements most frequently listed as noncompliant during surveys and reviews for 11 different certification categories, such as hospitals, critical access hospitals and nursing care centers.

For hospitals, the No. 1 standard cited as noncompliant was EC.02.06.01, establishing and maintaining a safe, functional environment, followed by IC.02.02.92, which lays out requirements for reducing risk of infection associated with medical equipment, devices and supplies. Other compliance challenges among hospitals include risks associated with utility systems, means of egress and fire safety.

Common challenges among critical access hospitals also include infection control risks, fire safety and utility systems, according to the Joint Commission

AHA urges CMS to delay implementing site-neutral proposal

The American Hospital Association (AHA) is urging the Centers for Medicare & Medicaid Services(CMS) to delay implementing the site-neutral provisions of the Bipartisan Budget Act on Jan. 1, as the organization says it would raise significant compliance risks under the Stark law and the Anti-kickback statute.

“Because CMS cannot finalize its proposal without forcing impacted hospitals to accept significant compliance risk, it must delay the implementation of the site-neutral policies in the proposed rule by at least one year,” wrote AHA Executive Vice President Tom Nickels. “This delay would provide the time necessary for CMS to develop a fair and flexible payment policy under which hospitals would be able to receive direct payment for their non-excepted [hospital outpatient departments] and for non-excepted items and services that they furnish in excepted HOPDs.”

The site-neutral proposal was included in the outpatient prospective payment system proposed rule for calendar year 2017. AHA plans to submit detailed comments on the rule’s site-neutral and other proposals in a separate letter to the agency.

New fire drill matrix can help to prevent Joint Commission findings

The Joint Commission is asking hospitals to use a new fire drill matrix to track when fire drills were conducted in an effort to ensure they comply with Joint Commission and Centers for Medicare & Medicaid Services requirements to hold drills under various conditions (times and days), according to the American Society for Healthcare Engineering (ASHE).

Joint Commission surveyors are giving the matrix to facility managers when first arriving for a survey, asking that it is completed by the first or second day of the survey. The matrix is available on the ASHE website so that hospitals can proactively complete the matrix, track their fire drills, and work to vary times and dates of drills.

Jim Kendig, the Joint Commission’s field director for surveyor management and development, said the matrix was created after surveyors noticed that hospitals often conducted drills at the same time but didn’t realize the patterns.

“It becomes apparent,” Kendig says. “Hospitals can use this ahead of time, see patterns and self-correct.”

CDC, Joint Commission partner with 11 ambulatory facilities on infection control

The Centers for Disease Control and Prevention (CDC) and the Joint Commission are entering the next phase of their ADOPT Guidance initiative to adapt, enhance, and disseminate current CDC guidance related to infection prevention and control in ambulatory care settings, such as oncology settings and urgent care facilities.

The organizations have recruited 11 ambulatory focused health care providers and 12 professional associations to help with the project.

FDA issues safety alert for Sciex mass spectrometers

The Food and Drug Administration (FDA) is alerting laboratory staff and health care professionals about a software defect in Sciex mass spectrometers, which may cause the devices to incorrectly assign results to samples analyzed.

Sciex notified the FDA that, under certain conditions, the defect in the software versions Analyst Software Versions 1.6.1 and 1.6.2, and MultiQuant Software Versions 3.0, 3.0.1, and 3.0.2, may lead some of its devices to display results that do not match the specimens tested. The company also has sent Urgent Medical Device Correction Letters and issued two voluntary recalls for the mass spectrometers for clinical use. The FDA recommends that users of the software contact Sciex for necessary corrections.