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ACE Blast: TJC Revises Nursing Care Center Requirements, Laboratory Requirements, and Outpatient Record Review Requirements for CAHs


Email Alert

July 20, 2015

By Douglas Moak*

This Accreditation, Certification, and Enrollment (ACE) Blast is a legal alert brought to you by the ACE Affinity Group (AG). The ACE AG provides an organized forum for members to learn about legal developments and best practices relating to the ACE of health care providers and health care professionals.

TJC Revises Nursing Care Center Requirements, Laboratory Requirements, and Outpatient Record Review Requirements for CAHs

On July 9, The Joint Commission (TJC) announced revised requirements, effective January 1, 2016, for nursing care centers and laboratories, in addition to revised requirements for outpatient record review for critical access hospitals (CAHs), which are effective as of July 1, 2015.

The nursing care center revisions affect smoking policies, information obtained from the National Practitioner Data Bank, and initial assessment of the skin condition of patients and residents; they also require the implementation of "a valid and reliable tool" to regularly evaluate the culture of safety and quality. TJC holds up the Agency for Healthcare Research and Quality's Nursing Home Survey on Patient Safety Culture as an example of a valid and reliable tool.

The laboratory requirements were revised to capture emerging trends in laboratory operation and maintain alignment with the Clinical Laboratory Improvement Amendments (CLIA) regulations. The first change applies to the Element of Performance (EP) requiring negative and positive reactivity control materials to check fluorescent and immunohistory stains and the EP requiring quality controls on histologic stains for intended reactivity. A note was added to these EPs to clarify that for polymer-based immunohistochemical methods a negative control is not required. The second change strikes an exception to quality control requirements that applied to laboratories specializing in microbiology, to conform with a January 9 revision to the CLIA interpretive guidelines.

The outpatient record review requirements for CAHs were revised to conform with the Centers for Medicare & Medicaid Services' January 16 revisions to its interpretive guidelines.1 The requirements have been clarified to state that a sample of outpatient records must be reviewed when required by state law. Previously a sample comprising 25% of cases was required, but the new requirements provide that each CAH must determine the size of the appropriate sample reviewed based on its own policy.

*We would like to thank Douglas L. Moak (Stevens & Lee PC, King of Prussia, PA) for providing this email alert. We also would like to thank the Accreditation, Certification, and Enrollment Affinity Group leadership for sharing this email alert with the Academic Medical Centers and Teaching Hospitals, Life Sciences, and Post-Acute and Long Term Services Practice Groups.

1 Survey and Certification Letter 15-19-CAH.
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