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Monday 4:19 CST, August 3, 2015

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Standards FAQ

Collecting the Patient’s Preferred Language

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Are organizations required to use the term “preferred” language in order to comply with Standards RC.02.01.01, EP 1 (medical record contains the patient’s communication needs, including preferred language for discussing health care) and PC.02.01.21, EP 1 (identification of the patient’s communication needs, including the patient’s preferred language for discussing health care)? My organization is collecting the patient’s “primary” language – does this meet The Joint Commission’s requirement for the collection of “preferred” language?

Related Items: CMS , Hospital, Language, & Culture

04/28/2015
04/28/2015
Standards FAQ

Patient Flow and Boarding

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Where can I find more information on Patient Flow and Boarding?

04/28/2015
Standards FAQ

Format for collecting patient race and ethnicity data

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Q. Can the patient’s race and ethnicity data be collected in the same question?

04/28/2015
Standards FAQ

Patient Race and Ethnicity Data Collection

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Are there specific categories for race and ethnicity that hospitals should use in order to comply with Standard RC.02.01.01, EP 28 (The medical record contains the patient’s race and ethnicity)?

04/28/2015
Standards FAQ

Acid Fast Stain Result Reporting

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What is the expected turnaround time for result reporting of acid-fast stains for laboratories that refer acid-fast stains to a reference laboratory?

04/28/2015
Standards FAQ

Method verification of instruments on loan

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Is it necessary to perform method verification studies before using an non-waived instrument on loan from the manufacturer (“loaner” instrument)?

04/28/2015
Standards FAQ

Laboratory Director for Waived Testing

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What are the suggested minimum qualifications for the Laboratory Director on a CLIA Certificate of Waiver?

04/28/2015
Standards FAQ

Proficiency Testing - When to Notify The Joint Commission

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Is it required or recommended to notify the Joint Commission of unsatisfactory performance or unsuccessful status in proficiency testing?

Related Items: Standards FAQs

04/28/2015
Standards FAQ

CLIA Certificates - Specialties and Subspecialties

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One of the specialties reviewed during our most recent laboratory survey is not listed on the new CLIA Certificate of Accreditation. How should we have this corrected?

04/28/2015
Standards FAQ

Laboratory Director Of Record

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Please explain the title of “Laboratory Director”.

04/28/2015
Standards FAQ

Tissue - Standards Applicability

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What tissue products are surveyed under the standards in the Transplant Safety chapter?

04/28/2015
Standards FAQ

Records Retention for Proficiency Testing

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How long should we keep proficiency testing records?

04/28/2015
Standards FAQ

Laboratory Reports - Date and Time of Reporting

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We are working with our software vendor to include the date and time of reporting on our laboratory reports, as required by DC.02.03.01 EP 10. If we receive a finding on survey and are unable to get the problem fixed before our evidence of standards compliance (ESC) or measure of success (MOS) due dates, will we fail the ESC or MOS?

04/28/2015
Standards FAQ

Rapid Group Strep A Strep Testing & Culture Follow-up

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Is it required to perform culture follow-up on all negative rapid Group A Strep screens?

04/28/2015
Standards FAQ

Test Complexity - Waived, Moderate and High

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How can I verify the test complexity designation for a particular laboratory test?

04/28/2015
Standards FAQ

Use of Self-Contained High Level Disinfection Units for Semi-Critical Devices

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What are the Joint Commission recommendations regarding Gluteraldehyde User Station's (GUS), disinfection soak station's (or similar self-contained high level disinfection units which often use 0.55% ortho-phthalaldehyde) for disinfecting devices ( such as vaginal probes and other endo-cavitiy probes) utilized in various settings ( such as radiology, outpatient procedure rooms in hospital, and ambulatory care settings). Specifically, are there any specific requirements for ventilation, use and processing locations (shared or separate) and can the unit share space with a sterilizer?

04/28/2015
Standards FAQ

Screening patients for MRSA with Active Surveillance Cultures

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Is MRSA screening required for all patients? If not, are there certain high-risk patients that must be screened?

04/28/2015
Standards FAQ

Laundering of surgical scrubs and other surgical attire

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Does the Joint Commission require employers to commercially launder surgical scrubs and other surgical attire?

04/28/2015
Standards FAQ

Endotracheal Tubes - How to clean, disinfect and store this device.

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Endotracheal Tubes - How to clean, disinfect and store this device.

04/28/2015
Blog

Flu preparedness, no matter the season

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Be prepared, be ready. Free Course: Influenza Pandemic Preparedness and Response in Ambulatory Settings.

Related Items: Influenza Pandemic , Ambulatory Health Care , Flu , AMBUZZ , Ambulatory

04/27/2015
Topics Library

Perinatal Care Certification Fees

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Perinatal Care Certification is on a two-year cycle. The certification fee consists of two parts: an annual subscription fee which is billed each January and an on-site fee, which is assessed following the on-site review.

Related Items: Fees , Perinatal Care Certification

04/27/2015
Standards FAQ

Strength and Dosage Form Listing

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Q:  Must formulary listings (or the list of medications available for dispensing and administration) include strength and dosage form)?  

04/27/2015
Standards FAQ

Human Resources Management

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Do the Human Resources Management standards apply to Contract and Volunteer Personnel?

04/27/2015
Standards FAQ

Monitoring Patient Response

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Q: How do we monitor patient response to a newly added medication before we make it available for dispensing or ordering?

04/27/2015