Newsletters

ACCREDITATION NEWS is published periodically by Steven Hirsch & Associates, offering important updates on licensing accreditation and certification issues that may impact your organization.

Click on any Accreditation News issue or Supplemental Article to view or download a copy in PDF.

2025

• Accreditation News – Spring 2025 Vol 17 Issue 1
  • Deadline Approaching For Fire Sprinkler Installation In High-Rise Healthcare Facilities
  • The National Practitioner Data Bank Standards For Identifying an Investigation
  • Prevention and Management of Respiratory Virus Outbreaks In Locked Behavioral Health Facilities

2024

• Accreditation News – Winter 2024 Vol 16 Issue 4
  • Food And Nutritional Services
  • CMS Requirement for Reporting of Acute Respiratory Illnesses
  • Need to Demonstrate Sustained Compliance
• Holiday Decoration Compliance – 11.25.24
• Use of CRNAs in Hospitals and Surgical Care Settings (Update) – 09.10.24
• Accreditation News – Fall 2024 Vol 16 Issue 3
  • Use of CRNAs in Hospitals and Surgical Care Settings
  • Background Checks
  • Revised Infection Prevention and Control Chapter for Joint Commission Accreditation
• Revisions to CMS Interpretive Guidelines for Informed Consent – 06.13.24
• Accreditation News – Summer 2024 Vol 16 Issue 2
  • Fire Drills – Timing is Everything
  • The Importance of the Quality Assurance and Performance Improvement Program
  • Enhancing Collaboration Between Infection Preventionists and the Healthcare Team
• Accreditation News – Spring 2024 Vol 16 Issue 1
  • Dialysis Wall Boxes
  • Healthcare Worker Burnout
  • The Risk Assessment

2023

• Accreditation News – Winter 2023 Vol 15 Issue 4
  • Diversity, Equity, and Inclusion
  • Key Points for Hospitals Participating in a Professional Graduate Education Program
• Accreditation News – Fall 2023 Vol 15 Issue 3
  • Update for Compliant Use of Power Strips in Patient Care Areas
  • Lice and Scabies Outbreaks in the Behavioral Health Setting
• Important Notice – CMS Requirement: All Accreditation Visits are to be “Unannounced.”– 06.20.23
• Accreditation News – Summer 2023 Vol 15 Issue 2
  • Is the Patient Considered a Transfer or an Admission?
  • What Makes an Excellent Infection Prevention and Control Program
• Accreditation News –Spring 2023 Vol 15 Issue 1
  • Water Management Programs in Health Care Facilities
  • Be Prepared for Computer System Failures

2022

• Accreditation News – Winter 2022 Vol 14 Issue 4
  • Accreditation and Licensing Requirements for Leased Spaces
  • A Team Approach for Your Infection Control Risk Assessment (ICRA)
• Accreditation News – Fall 2022 Vol 14 Issue 3
  • Pain Management Issues Remain
  • GFCI Electrical Outlets
• Accreditation News – Summer 2022 Vol 14 Issue 2
  • CMS 2567
  • The Importance of Documenting Education
• Accreditation News –Spring 2022 Vol 14 Issue 1
  • Emergency Management Standards Revisions 2022
  • Don’t Forget to Include Dialysis in Your Nursing Care Plan

2021

• Accreditation News – Winter 2021 Vol 13 Issue 4
  • Respiratory Protection Programs–An Area of Unexpected Vulnerability for Many Organizations
  • Spare Fire Sprinklers
• New COVID-19 Vaccination Requirements for Healthcare Workers in Medicare Certified Facilities – 11.10.21
• Quarterly Fire Drills – 11.08.21
• Prepare for Your Triennial Accreditation Survey – 11.04.21
• Spare Fire Sprinklers – 08.30.21
• Respiratory Protection Programs–An Area of Unexpected Vulnerability for Many Organizations – 08.25.21
• Life Safety Survey of “Business Occupancies” – 07.07.21
• Accreditation News – Fall 2021 Vol 13 Issue 3
  • Rodent Traps in Healthcare Settings
  • The Joint Commission 2022 Performance Improvement Standards
  • Need to Maintain Regulatory Compliance
• Accreditation News – Summer 2021 Vol 13 Issue 2
  • The Joint Commission Human Resources Competency Session
  • How to Create Competencies that Truly Test The Competence of the Individual
• Accreditation News –Spring 2021 Vol 13 Issue 1
  • The Joint Commission COVID-19 Recovery Preparation Assessment Checklist
  • Proctoring Reports Received–Now What?
  • Potential Control Measures of SARS-COV-2 Transmission in Healthcare Environment
• CMS Revised COVID-19 Checklist – 03.11.21
• Infection Prevention Connection–Quick Answers to Common Questions About COVID-19 Vaccines – 02.22.21

2020

• Accreditation News – Winter 2020 Vol 12 Issue 4
  • Provision of Care, Treatment and Services Standards for Maternal Safety
  • Common CMS Infection Control-Focused Survey Finding
• Accreditation News – Fall 2020 Vol 12 Issue 3
  • CMS Revises Infection Control “Conditions of Participation”
  • Compliance in the Kitchen
• Governing Body Appointment Required for Infection Prevention and Antibiotic Stewardship Leaders – 06.10.20
• Accreditation News – Summer 2020 Vol 12 Issue 2
  • Guidance on Opioid Utilization
  • Principles of Adult Education for Infection Control Professionals
  • Nurse Practitioner – Orthopedic Specialty
• Emergency Management: Preparedness for Infectious Diseases – 04.15.20
• The Joint Commission and the Covid-19 National Emergency – 04.09.20
• Accreditation News – Spring 2020 Vol 12 Issue 1
  • Elements of the Antimicrobial Stewardship Program
  • Granting Deep Sedation to Non–Anesthesiologist

2019

• Accreditation News – Winter 2019 Vol 11 Issue 4
  • How to Formulate a Risk Assessment Document
  • Boosting Influenza Vaccinations for Healthcare Workers
  • Environmental Cleaning and Disinfection
• Accreditation News – Fall 2019 Vol 11 Issue 3
  • Joint Commission: New Standards Addressing Maternal Safety
  • Fire Sprinklers—Some Pointers
  • Is Your PPE Choice Correct?
• Accreditation News – Summer 2019 Vol 11 Issue 2
  • WHY? – Questions asked by Hospital Staff during a Mock Survey
  • Management of Linen in Healthcare Facilities
  • Best Practice: Reciprocal Proctoring Reports
• Accreditation News – Spring 2019 Vol 11 Issue 1
  • Best Practice: Determining Competency When Granting Privileges
  • Notes from the Field of Regulatory, Accreditation, and Administrative Surveys
  • Paper-Plastic Peel Pouches: Shelf Life

2018

• Accreditation News – Spring 2018 Vol 10 Issue 1
  • Patient Activity Logs: Do You Really Need Them?
  • Hand-Off Communication
  • Emergency Generator Fuel Testing

2017

• Accreditation News – October 2017 Vol 9 Issue 3
  • Outbreaks
  • Credentialing Licensed Clinical Social Workers in the Healthcare Setting
  • The Joint Commission Elements of Performance
• Accreditation News – June 2017 Vol 9 Issue 2
  • Water Management Plan
• Accreditation News – February 2017 Vol 9 Issue 1
  • Temperature and Humidity
  • Health Literacy and Safe Patient Care
  • Don’t Let ASP Bite – Part 2

2016

• Accreditation News – October 2016 Vol 8 Issue 4
  • Don’t Let ASP Bite
  • Behavior Management Committee: A Way to Provide Positive Intervention
  • Titratable Medications… Is Your Organization in Compliance?
• CA ONLY: Hospital Language Assistance Services in California (May-September 2016 Supplement)
• Accreditation News – May-September 2016 Vol 8 Issue 3
  • Educate for C-LEAN-ing
  • ECRI In Case You Missed It
  • “There is Nothing Permanent Except Change.” Heraclitus
• CA ONLY: General Acute Care Relicensing Survey (GACHRLS) (March-April 2016 Supplement)
• Accreditation News – March-April 2016 Vol 8 Issue 2
  • Surgery Without Risk of Infection: Everyone’s Goal
  • General Rules and Regulations: When Were They Reviewed?
  • Our Health is In Our Hands
  • Sterile Processing Department Certification
• Accreditation News – January-February 2016 Vol 8 Issue 1
  • Patient Safety Systems
  • Care Plans
  • Why is Claims History Important in Credentialing?

2015

• Accreditation News – December 2015 Vol 7 Issue 8
  • 2015 Recap–Top Healthcare Issues
  • “Best Practices” In Healthcare and Day-to-Day Life
  • The Importance of Patient Triage in the Emergency Department
• Accreditation News – November 2015 Vol 7 Issue 7
  • Ebola Preparedness—Lessons Learned
  • Clinical Alarm Systems
• Accreditation News – October 2015 Vol 7 Issue 6
  • Standardized Procedures in California
  • It Happens–Surgical Fires Continue to Occur
  • Compliance with the NPSG.07.01.01 (Hand Hygiene)
• Accreditation News – August-September 2015 Vol 7 Issue 5
  • Olympus Duodenoscope Model TJF-Q180V
  • NHSN HAI Surveillance Changes for 2015
  • OPPE: Are the Indicators Chosen Still
• Accreditation News – July 2015 Vol 7 Issue 4
  • Ortho-Phthalaldehyde Testing
  • Herpes Zoster (Shingles)
  • Medical Staff Committee Minutes: Who Has Access?
• Accreditation News – June 2015 Vol 7 Issue 3
  • Patient Safety Initiative Worksheets from CMS: Quality Assessment Performance Improvement
  • What Does It Take To Be a Medical Staff Professional?
  • CMS Issues Guidelines and Categorical Waivers for Use of Power Strips in Patient Care Areas
• Accreditation News – April-May 2015 Vol 7 Issue 2
  • New Technology – New Procedures
  • Food Safety Goal: Provide Safe, Nutritious Food For All Patients
  • Waived Blood Glucose Monitoring Systems
  • Clostridium Difficile Prevention – The Ongoing Challenge
  • Don’t Sweat the Small Stuff?
  • Streamlining Department Rules and Regulations
• Accreditation News – March 2015 Vol 7 Issue 1
  • Continuous Survey Readiness – Are you Ready?
  • Plan of Care Standards
  • Waterless Alcohol for Hand Hygiene—An Overview

2014

• Accreditation News – Winter 2014 Vol 6 Issue 3
  • Locum Tenens Practitioners: How Much Credentialing?
  • Emergency Generator Batteries—Inspection Requirements
  • Immediate Use Sterilization
  • If It’s Damaged or Torn, Throw It Out!
  • Medication Administration: One TIP to Help Achieve Performance Improvement
• Accreditation News – Summer 2014 Vol 6 Issue 2
  • Focus on Discharge Planning
  • Bloodstream Infections – Isolate or Not?
  • Carbapenem Resistant Enterobacteriaceae
  • A Review of Restraint Documentation
  • Sterile Compounding
  • What is the Difference Between Nurse Practitioners and Physician Assistants?
• Accreditation News – Spring 2014 Vol 6 Issue 1
  • 2014 Survey Readiness
  • Understanding Rapid Influenza Diagnostic Tests Part 2 of 2
  • The Value of Peer References
  • The Joint Commission Accreditation Survey… The Competency Review Session

2013

• Accreditation News – Winter 2013 Vol 5 Issue 3
  • TJC Disease Specific Certification 2014
  • Understanding Rapid Influenza Diagnostic Tests – Part 1 of 2
• Accreditation News – Summer 2013 Vol 5 Issue 2
  • Dialysis Service Meets Regulations
  • Why is CRE Getting So Much Attention Lately?
• Accreditation News – Spring 2013 Vol 5 Issue 1
  • Hospitals, Critical Access Hospitals, and Ambulatory Surgical Centers
  • Intracycle Monitoring 2013

2012

• Accreditation News – Winter 2012 Vol 4 Issue 4
  • A New Year’s Resolution to be Survey Ready
  • Multi-Drug Resistant Organism Alerts
  • Patient Flow Standards Updated
• Accreditation News – Fall 2012 Vol 4 Issue 3
  • It’s That Time Again… The Influenza (flu) Season
  • Credentialing: How Much Do You Really Need to Do?
• Accreditation News – Summer 2012 Vol 4 Issue 2
  • Abuse – A Dirty Secret
  • Public Reporting of Healthcare-Associated Infections
  • Proctoring the Allied Health Professional Staff
  • CMS Provides Flexibility for Life Safety Code Compliance in Hospitals… Or Do They?
• Accreditation News – Spring 2012 Vol 4 Issue 1
  • Dissecting the DEA Certificate
  • The Joint Commission Laboratory Accreditation Standards
  • Don’t Forget to Check the Glucose Meter
  • 30 Minutes or Less Per CMS: Administration of Scheduled Medications

2011

• Accreditation News – Summer 2011 Vol 3 Issue 3
  • Celebrating our Silver Anniversary with A Mission
  • Accountability from the Top Down
  • New Telemedicine Regulations
• Accreditation News – Spring 2011 Vol 3 Issue 2
  • Able to Support DNV Accredited Healthcare Facilities
  • Patient Safety Licensing Survey (PSLS)
  • Ortho-Phthalaldehyde (OPA) High-Level Disinfectant
  • CMS Issues Clarification on Occupancy Classification Under the Life Safety Code
• Accreditation News – Winter 2011 Vol 3 Issue 1
  • Important Changes to the Life Safety Survey
  • Ongoing Professional Practice Evaluation for Allied Health Professional Staff
  • Handling Media Inquiries in an Age of Outcomes Security
  • Reporting Central Line-Associated Bloodstream Infections (“CLABSI”)

2010

• Accreditation News – Fall 2010 Vol 2 Issue 3
  • Requirements for Clinical Contracts and Contracted Employees
  • CMS Makes Changes to Anesthesia Services
• Accreditation News – Summer 2010 Vol 2 Issue 2
  • CMS Telemedicine Proposed Changes Delayed
  • Administrative Support of Infection Control
  • Effective July 1, 2010 – Interim Staffing Effectiveness Standards
• California State Registration for Waived Testing (Accreditation News Supplement, Summer 2010 Vol 2 Issue 2)
• Accreditation News – Spring 2010 Vol 2 Issue 1
  • Updating the Medical Staff Bylaws: Requirements for History & Physicals
  • CMS Jeopardy: Disinfection for $50,000
  • SHARP Prepares Hospitals for Accreditation Survey

2009

• Accreditation News – Fall 2009 Vol 1 Issue 3
  • The Right Thing to Do: TJC Accreditation Standard LD.04.04.03
  • Life Safety Issues
• H1N1—The Saga of the Mask (Accreditation News Supplement, Fall 2009 Vol 1 Issue 3)
• Accreditation News – Spring 2009 Vol 1 Issue 2
  • Carbapenem-Resistant Enterobacteriaceae (CRE)
  • Revised 2009 Accreditation Requirements
• Accreditation News – Spring 2009 Vol 1 Issue 1
  • Welcome to Our First Issue!
  • Infection Control and Hospital Epidemiology Planning