In a report to Congress released late Wednesday, CMS said it will continue putting pressure on AOs to do a better job of enforcing Medicare’s Conditions of Participation but is also fine-tuning the process of how it validates their performance. Concerns remained concentrated on AOs failures to find problems within the physical environment that were spotted by CMS’s state survey agencies during surveys to validate the AOs findings. Validation surveys are supposed to be conducted within 60 days of an AO’s triennial visit.

While the memo has many of the same sections on contracted staff, emergency services and identification of shared spaces, much of the more prescriptive sections are either shortened or deleted. That includes guidance for surveyors to ask for floor plans to evaluate how patients are transported from one space to another and examples of when the use of floating nurses are in violation of CoP requirements.

Joint Commission surveyors can cite decorations under five—that’s right, five—different Life Safety standards, including two standards related to hospital areas designated ambulatory healthcare occupancies, outpatient clinics, or areas within a leased building where the hospital offers accredited services.

Perlin currently is the president and clinical operations and chief medical officer at HCA Healthcare, which is based in Nashville. He replaces Mark R. Chassin, MD, FACP, MPP, MPH, who has led the commission for 14 years. Chassin has said he wants to pursue other opportunities in the quality improvement field.

CMS issued a Quality, Safety & Oversight Group (QSO) memo Friday September 17 on “Reinforcement of EMTALA Obligations specific to Patients who are Pregnant or are Experiencing Pregnancy Loss.” The memo, QSO-21-22-Hospitals, not only reminded hospitals to “ensure all staff who may come into contact with a patient seeking emergency care are aware of the hospital’s obligation under EMTALA,” but had an express message for clinicians.

Check your emergency rooms, outpatient clinics, wound care clinics, ambulatory care sites and anywhere else where pandemic-related equipment shortages have forced your facility to go outside normal supply lines for replacement medical devices.

You now have a chance to weigh in on proposed revisions to emergency management standards by The Joint Commission (TJC) as well as the long-delayed revisions to the U.S. Pharmacopeia (USP) chapters on <795> Pharmaceutical Compounding – Nonsterile Preparations and <797> Pharmaceutical Compounding – Sterile Preparations.

The second-largest accreditation organization (AO) in the country will continue to do triennial hospital surveys as required by CMS, but will now conduct NIAHO® annual surveys only remotely.

Among other things, the changes include requiring a hospital to have a stewardship program as an organizational priority, that it allocates staffing, financial and technology resources to support the program, and that quality data is reported to hospital leadership.

The rule is scheduled to be published in the Federal Register August 13, with most elements will be effective October 1. CMS also published a 14-page fact sheet summary. In a press release highlighting the rule’s efforts to improve health equity and hospital readiness related to COVID-19 and future emergencies, CMS says it is trying to reduce disparities in maternal morbidity.