Posted October 29th, 2016 | Comments (0)

State & Psychiatric Hospital Compliance Collaborative’s Reading Tips Newsletter (RTN) October 2016, Volume 11, Issue 10
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Article of the Month

  • Clarifications and Expectations: Clarifying Changes in the Life Safety Survey Process by George Mills  EC News, October 2016, Vol 19, #10, Pg 5 – In light of Project Refresh, a number of changes in the Life Safety Survey Process will also be occurring particular with regard to the clarification process, the Statement of Conditions, Interim LIfe Safety Measures, Time-Limited Waivers and Equivalencies. See why having your documentation in order and readily available during survey will be all the more important.
  • Click here for our REVIEW(Mbr/Guest); the FULL TJC ARTICLE(Mbr); to share a COMMENT(Mbr/Guest).


  1. PR: The SAFER Matrix and Changes to the Post-Survey Process(PDF)[REF: SC]
  2. TS: Infection Prevention and Control Standards Update for 2017 (PDF)[REF: IC, SC]
  3. EC: C&E: Clarifying Changes in the Life Safety Survey Process (PDF)[REF: AOM, EC]
  4. EC: Performance Improvement and the Environment of Care (PDF)[REF: EC, Tool]


  • TJC: As of January 1, 2017, the only RFIs eligible for the 10-Day Clarification Process are those RFIs that the customer believes were cited in error, because the organization believes it was in compliance at the time of the survey.
  • TJC: The Customer Value Assessment (CVA) has been replaced by a new, 5 minute or less Surveyor and Reviewer Evaluation to be sent to the organization via link at the end of survey. [Perspectives V36#10pg5]
  • TJC: CMS has made changes in its Hospital IQR program for 2017 , but TJC’s list of eCQMs only includes 13 of CMS’s15 and freestanding psychiatric hospitals will continue to report on the 4 required HBIPS (HBIPS-1, HBIPS-2, HBIPS-3, HBIPS-5) – [Perspectives V36#10pg7]
  • TJC: Key Def – “The Joint Commission defines high-alert medications as those medications involved in a high percentage of errors and/or sentinel events, as well as medications that carry a higher risk for abuse or other adverse outcomes. Examples of high-alert medications include investigational medications, controlled medications, medications not on the approved US Food and Drug Administration (FDA) list, medications with a narrow therapeutic range, psychotherapeutic medications, and look-alike/sound-alike medications. Hazardous medications are those in which studies in animals or humans indicate that exposures to them have a potential for causing cancer, developmental or reproductive toxicity, or harm to organs.”  [Source, v14#10pg2]
  • CMS: [CMS–3178–F] Medicare and Medicaid Programs; Emergency Preparedness Requirements for Medicare and Medicaid Participating Providers and Suppliers
  • Latest TJC Blogs: Physician Leader MonthlyLeadership Blog


** Key: Ftxt=Full Text Link PR=Perspectives (JcE), TS=The Source (JcS), EC=EC News (JcE), CM=CMS, JO=JC Online, TP=JC Topics **[More Abbreviations] **
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