How Plans of Correction Work

When it comes to state agency or accreditation organization surveys, preparation is key and preparing and implementing a plan of correction (PoC) can help ensure ongoing compliance and quality improvement (QI).

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Remove the Stigma of Sentinel Event Reporting

The Joint Commission defines a sentinel event as “a patient safety event that reaches a patient and results in any of the following: death, permanent harm, [or] severe temporary harm and intervention required to sustain life.”

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Establish a Respiratory Protection Program

Surgery centers never had to have a full respiratory protection program before now, but due to the COVID-19 pandemic and the consequent use of respirators, they might soon have to write and implement one.

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Managing Medical Equipment

When a medical device arrives at an ASC it becomes subject to management under at least 14 different Elements of Performance (EP) within The Joint Commission (TJC) Environment of Care (EC) Standards, 2019 Environment of Care, Essentials for Health Care. However, it is important to understand that the requirements for all accrediting bodies stem from Centers for Medicare & Medicaid Services (CMS) guidelines and are essentially the same from a medical equipment management perspective.

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OSHA Updates its Regulations

In 2013, the Occupational Safety and Health Administration (OSHA) issued a proposed rule to improve the tracking of workplace injuries and illnesses through the electronic collection of establishment-specific injury and illness data. After receiving comments on the proposal, OSHA issued the final rule that became effective January 1, 2017 (Occupational Safety and Health Administration 29 CFR Part 1904). For more information on the final rule, click here. Although ASCs are partially exempt from some of the requirements in that rule, they are subject to a requirement that prohibits employers from discouraging workers from reporting an injury or illness.

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Make HIPAA Compliance a Top Priority

Despite extensive media coverage regarding the Department of Health & Human Services Office of Civil Rights (OCR) Health Insurance Portability and Accountability Act of 1996 (HIPAA) compliance audits and penalties, HIPAA compliance programs still are not given top billing in some ASCs.

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