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√TJCsvyrMD_Katz_EDWARD K. KATZ, M.D., M.P.H.
Field Representative



Surveyor Program(s): Accreditation Manual for Hospitals, Long Term and Critical Access Hospitals, Integrated Survey Process for Ambulatory Health, Home Care, Rehabilitation Hospitals, Long Term Care, and Behavioral Health

Surveyor Tenure: x 1998

Lives: Georgia

TJC Bio:

  • Dr. Katz received his Bachelor of Science degree at Cornell University, his Doctor of Medicine degree at Tufts Medical School, and his Masters of Public Health at Harvard University
  • Practiced public and private psychiatry in Thomasville, Ga.
  • Past public administrative positions include:  Chief Clinical Officer, Summit County, OH; Medical Director, Mecklenberg County Mental Health, North Carolina
  • Past academic administrative positions include: Psychiatry Residency Training Director, Director of Consultation-Liaison Services, and Co-Director of the Internal Medicine and Psychiatry Training Program, East Carolina University School of Medicine.
  • Held Faculty positions at Harvard Medical School, the Medical College of Georgia, East Carolina University and the University of Pittsburgh’s School of Medicine and School of Public Health.

Other Background:

Comments & Recommendations

  • Loved that we were upgrading our camera systems.  Loved that we had a bowel protocol. Commented that we do an excellent job using visual things for our patients.   He mentioned that our patients are sicker here than what they were seeing at the other SOFs.  Positives regarding our Peer Specialist Program, WRAP programming.11/19/2013
  • He likes when staff are receptive to talking to him rather than being stand offish.  They liked eating at the facility rather than going out.
  • Dr. Katz has been paying more attention to CMS issues and pursuing some of them rather aggressively.  He may ask for death records back as far as 3 yrs (CMS surveyors typically only ask for the last year).  His teams have been asking for 10 discharge records (this is fairly standard practice for CMS), but requiring the organization to pull by specified diagnoses and/or procedures (e.g., Pts with schizophrenia who were referred out to podiatry).  CMS surveyors typically asked for D/C records by unit or treatment team. During D/C record review, Dr. Katz has reportedly  been making citations for a lack of a psychiatric, physical and functional assessment being documented in the D/C summary. Although this appears to be a misinterpretation of B133 (the interpretive guideline/CMS Survey form calls for “Baseline of psychiatric, physical and social functioning at time of discharge”.) hospitals have so far had little choice but to attempt to comply.  It may be useful to have a copy of the Interpretive Guideline for B133 or the CMS D/C Record Review Form available to show Dr. Katz.
  • He has also asked to see a hospital’s definition of ‘Chemical Restraint’ [Note: this is not specifically required by TJC or CMS nor does either agency use that term.  However, CMS does define the use of medications as restraint.] Consider having the CMS language @ Medications used as restraint in your policy or medication ordering]
  • In a recent survey, Dr. Katz made a rare finding in the Transplant Safety standards for a state psychiatric hospital.  The citation was somewhat unusual in that it went beyond the basic requirements of TS.01.01.01, EP1 for having organ donation/procurement P&P.  This already seems like a stretch, but it is applicable.  Well, so are EPs 4 and 5 that call for particular work (e.g., reviewing death records…, and staff education).  Interestingly, Dr. Katz related this to reducing stigma for the mentally ill in that it should not be presumed that their organs (due to long-term psych meds or other reasons) are less worthy of consideration.
  • Whether intended or not, there is sometimes a craftiness about Dr. Katz.  Survey participants need to be careful of his sometimes casual, low key comments and style of getting you to admit things are not going as well as they could/should. Your equally casual, off hand replies may show up as support for his unsuspected citations. 07/2013


  • Lead Surveyor – he focused on national patient safety goals and credentialing. 06/19/2009
  • Very detail-oriented particularly in the area of Environmental Risks within a Psychiatric facility.  Steadfast in meeting each aspect of all standards. 05/2009
  • Survey Leader – Worked to set a customer service based survey environment/culture.  Took time to explain his reasoning on a subject, and as well, provided time for you too as well. 04/2009 
  • He’s reasonable and you can convince him to see your side of things.  His best advice (and I held him to this) was:  “you only need to show me you meet the standard at a ‘D’ level, not an ‘A+’ level.”  He gave us lots of ideas on how to improve but didn’t hold us to the A+ measure in the end. 02/2009
  • Dr. Katz served as team leader for the Indiana system in 2007.
  • Edward Katz, MD 3/9-3/12/main surveyor/tracers/med managemt-fair, took time to explain his reasoning and accepted our explanations.
  • Stated by Dr. Katz: “you only need to show me you meet the standard at a ‘D’ level, not an ‘A+’ level.”

Relevant Surveying History:

• Eastern Regional State Hospital11/19/13
• Lincoln Regional Center01/7/14, 1/14/11 • Tinley Park MHC02/09/10
• Torrance State Hospital06/19/09 • Danville State Hospital
• Wernersville State Hospital 04/02/09 • Warren State Hospital 03/12/09
• Clarks Summit State Hospital 03/06/09 Arizona State Hospital 02/20/09
• Norristown State Hospital 02/13/09 • Arkansas State Hospital 01/30/09
• Bronx Childrens Psychiatric Center 07/11/08 • South Beach Psychiatric Center 05/09/08
• Creedmoor Psychiatric Center 04/11/08 • Logansport State Hospital 09/14/07
• Madison State Hospital 07/12/07 • Richmond State Hospital 06/29/07


** Sample Survey Citations (Premier Level)**

[private Membership premier]


Sample Citations:


  • MS.05.01.01/EP 9/ Our policy did not have the exact wording they were looking for regarding our physicians being notified of autopsies.11/19/2013
  • MS.06.01.01/EP 2/ Privileges for podiatrist were too vague.11/19/2013
  • RC.01.01.01/EP 19/ 3 H&Ps were found with no time entry by the MD. 11/19/2013
  • RC.02.04.01/EP 3/ 2 discharge summaries did not have the functional status noted.11/19/2013
  • EC.02.06.01/ EP1/ Our teaching kitchen didn’t have a lock off switch.11/19/2013
  • EC.02.01.01/EP 3/ Our quiet room had sound machine and radio which had cords which could not be removed from machine causing ligature points.11/19/2013
  • MM.01.01.03/EP 3/ Observed in Individual Tracer: One of the processes to safely manage high alert insulins is to have a red, octagonal sticker labeled “high alert” attach to the vial of insulin. For a second patient not all of their insulin was so labeled. In one medication refrigerator, the insulin plastic bin had three of five vials of insulin without a warning sticker. /Direct Surveyor#1
  • PC.01.02.03/EP 2/ Observed in Individual Tracer: Psychiatric assessment performed for a patient admitted November 30th. Because there was no authentication, it could not be determined if the evaluation was completed within 60 hours which is the hospital policy and required by CMS. For another tracer patient admitted November 13th, the psychiatric evaluation was signed 11/24 and had “final draft”11/17 printed on it. This was four days (96 hours) later. Therefore, the completion and availability of the information in the clinical record was greater than the sixty hours required by this hospital’s policy and by CMS regulations. /Direct Surveyor#1 
  • PC.01.02.03/EP 4/ Observed in Individual Tracer: For a patient admitted December 29, 20##, the written History and Physical was dated (the following) January 3, 20##. There was not information when the dictated H&P was placed in the chart. On the Building Ten Unit, the paper and dictated History and Physicals lacked information of when they were placed on the chart and therefore available to the Treatment Team. Although the organization stated that once these H&Ps were dictated they were available through the hospital electronic medical record, two of two staff who tried to access this information could not access /Direct Surveyor#1
  • LD.01.03.01/EP 2/ Observed in Building Tour: The hospital failed to ensure that the infection control condition of participation was met. The governing body is accountable for organization management and planning. /Indirect/Surveyor #1
  • LD.04.03.01/EP 1/ Observed in Tracer Activities: Review of the activities scheduled for the patients of Unit # and discussion with leaders provided evidence that the licensed therapists who provide various types of therapies Monday through Friday do not provide these services on weekends. Review of the schedule indicated that activities scheduled would not substitute for clinical services that a licensed therapist would provide. A committee had been formed prior to the survey and continues to work to develop therapy services on weekends. /Indirect/Surveyor #1
  • LD.04.03.09/EP 2/ Observed in Data Session: One of the tracer patients was receiving maintenance dialysis from a community vendor. The organization had not described the services provided, including expectations that services are consistent with the standards of the Joint Commission, in writing. /Indirect/Surveyor #1
  • LD.04.03.09/EP 4/ Observed in Tracer Activities: An outside laboratory provides blood drawing and laboratory testing services. A corner of the medical evaluation clinic is used for phlebotomy supplies and has a centrifuge. The only indication of preventative maintenance on the centrifuge was a 20## sticker. Discussion with the phlebotomist verified that there is no preventative maintenance for this centrifuge. Because this facility had not established expectations for the performance of this service, the lack of preventative maintenance was not recognized until this survey. /Indirect/Surveyor #1
  • LD.04.04.7/EP 3/ Observed in Data Session: The organization implemented a medical staff approved Metabolic Syndrome Monitoring Protocol in July, 20##. A process to monitor implementation of the protocol, to manage and evaluate its use, was not available. Data about implementation of the protocol were not identified, collected or used to evaluate its use. /Indirect/Surveyor #1
  • MS.08.01.03/EP2/ Observed in Medical Management Session: On one Credential file review several privileges were requested but the corresponding boxes were not “checked” to indicate if the privileges were granted or denied. During a second Credential file review, it was observed that several privileges were requested but the corresponding boxes were not “checked” to indicate if the privileges were granted or denied. For several additional Credential files reviewed, multiple privileges areas were left blank. It was not clear for these credentialed practitioners /Indirect/Surveyor #1












You may provide surveyor feedback by clicking on the ‘Comments’ link above (2nd line, top left) and/or via the New Post Survey Questionnaire (PSQ).

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