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Compliance Mentor - May 2016

Changes to CAUTI Safety Goals Every Hospital Should Know

The Joint Commission (TJC) has finalized changes to the National Patient Safety Goal (NPSG) for catheter-associated urinary tract infections (CAUTIs) under NPSG.07.06.01. The standard went into effect January 1 and includes five revised elements of performance.

Hospitals must implement evidenced-based practices to prevent indwelling CAUTIs — one of the most common healthcare-associated infections. The CDC has had guidelines in place since December of 2009. The NPSG was amended, in part, due to changes published by the Society for Healthcare Epidemiology (SHEA), the Infectious Disease Society of America (IDSA), and APIC in the Compendium to Prevent Healthcare-Associated Infections in Acute Care Hospitals.

The NPSG requires staff education on the use of indwelling catheters and CAUTI prevention in addition to ongoing education, an annual skills lab, and competency assessment. TJC allows hospitals to choose their own testing intervals.

Patients and families also must be educated in CAUTI prevention and symptoms. FAQs about Catheter-Associated Urinary-Tract Infection is available for hospital use at

The hospital must develop written criteria on when it is appropriate for patients to have a Foley catheter. For example, criteria could include critically ill patients in which urinary output must be measured. It may be used perioperatively for certain surgeries.

A written policy must dictate how to insert and secure the catheter; maintain sterility of the urine collection system; and proper procedure for collecting specimen. Nursing education should include the revised standards in their education.

The medical record must contain a system of documentation for the use, insertion, and maintenance of the catheter. The hospital must measure and monitor prevention and outcomes.


CMS Adopts National Fire Protection Association’s 2012 Life Safety Code

CMS has adopted the updated provisions of the National Fire Protection Association’s 2012 edition of the Life Safety Code (LSC) and the 2012 edition of the Health Care Facilities Code. The new guidelines will apply to hospitals, critical access hospitals, inpatient hospice, and long-term care facilities. The rule was published in the Federal Register on May 4 and will go into effect July 5.

The new regulation protects patients from fire and smoke and ensures the safe design of facilities. Buildings taller than 75 feet will have 12 years to make sure automatic sprinkler systems are installed. Hospitals will have a fire watch if the sprinkler system is out of service for more than 10 hours.

Doors to corridors or rooms containing flammable or combustible materials must be provided with positive latching hardware. Roller latches are prohibited on such doors under the CMS rule. Aerosol and gel alcohol-based hand rub dispensers are permitted as long as safety requirements are met. Every sleeping room must have a window or outside door.

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The Joint Commission Eliminates 131 Requirements

The Joint Commission (TJC) will delete 131 elements of performance from its accreditation manual effective July 1. The selected requirements were chosen due to being duplicative of other elements, operational issues best left up to the organization to address, or were rarely scored as insufficient or noncompliant by TJC surveyors.

For example, one deleted EP involved a requirement that the hospital train external law enforcement and security on the difference between forensic restraints, seclusion. A requirement that infection control plans have written descriptions of the review process was also deleted.

For more information, visit TJC’s Prepublication Standards at:

CMS Rolls Back Two-Midnight Rule Payment Cuts

CMS will no longer enforce the inpatient payment cuts to the Two-Midnight Rule, according to the proposed rule published in the Federal Register on April 27.

The change in policy comes after 55 hospitals filed a lawsuit against the Department of Health and Human Services (HHS) in response to the 0.2% reimbursement cut for Medicare payments under the controversial Two-Midnight Rule. The American Hospital Association and other organizations also sued, claiming a violation of the Administrative Procedure Act. CMS now plans a 0.6% increase in 2017 to offset the cost of the Two-Midnight Rule. The proposed rule would increase payment to about 3,330 general acute care hospitals by 0.9%.

CMS will continue to penalize hospitals for high 30-day readmission rates, and will continue to penalize hospitals in the bottom 25% for hospital-acquired conditions (HACs).

The proposed rule also includes the Medicare Outpatient Observation Notice (MOON), which requires hospitals to give a copy of the CMS notice to any observation patient who is receiving observation services for more than 24 hours. The notice must be provided within 36 hours and before the patient is discharged. The rule also includes changes to the Hospital Value-Based Purchasing Program.


Upcoming Live Webinars
The Zika Virus: Separating Fact from Fiction – A Discussion with Experts
.5 CME & CE | Thursday, May 19th
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Restraint and Seclusion: The Most Problematic of All CMS Standards
1.5 CE | Wednesday, June 1st
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Avoiding Legal Hazards in Documentation: CMS and TJC Requirements for Hospitals and Nurses
2 CE | Thursday, June 2nd
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Order Sets, Protocols, Preprinted & Standing Orders: CMS Interpretive Guidelines and Regulations
1.5 CE | Tuesday, June 7th
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MRI Safety: Maneuvering the Maze of ACR, CMS and TJC Standards
2 CE & 2 ASRT Cat A | Wednesday, June 15th
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Outpatient Services: Complying with the CMS CoPs
1 CE | Monday, June 27th
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