Accreditation & Regulatory Journal
February 2024

News You Can Use

February’s Compliance Tip of the Month

February’s compliance tip of the month is focused on Governance and Leadership. If a facility is surveyed and cited at one or more condition-level findings, then it will also cause a condition level finding for the governing body or responsible persons. The question may arise as to why this occurs and what is expected in the corrective action plan.
The governing body or responsible persons are ultimately responsible for the care treatment and services provided to the patient it cares for; therefore, when there are single egregious or aggregate findings that result in condition-level deficiencies then it is felt that the governing body or legally responsible persons are not providing sufficient oversight.
The regulations state the following:

CMS Regulation

§482.12 Condition of Participation: Governing Body
There must be an effective governing body that is legally responsible for the conduct of the hospital. If a hospital does not have an organized governing body, the persons legally responsible for the conduct of the hospital must carry out the functions specified in this part that pertain to the governing body.
Regarding the corrective action plan, the specific actions taken to address those findings that resulted in the deficiency are submitted at the standard/requirement or regulation where the deficiency is cited. The corrective action plan at the governance level should address the actions that the governing body or responsible persons will take to assure that the organization has recognized the issue related to the non-compliance, that an acceptable plan of correction has been developed and implemented and that there is a mechanism established to assure that compliance is achieved and maintained. Lastly, there should be a mechanism identified to provide the governing body with information in order to provide oversight. The mechanism used to inform them, and the frequency are determined by the organization.

CIHQ Accreditation Survey Top Findings July 1 – December 31, 2023

CIHQ analyzes findings cited during accreditation surveys in order to track and trend the top findings. We do this primarily to evaluate whether or not ARS is supplying sufficient and effective resources to assist our facilities with compliance. This also guides the decision to add more tools and resources in order to facilitate compliance. This tracking is also used to evaluate the quality and consistency of how standards are applied and cited.
Below are the top condition-level deficiencies cited during the second half of 2023.
CIHQ Standard Number Title Level of Severity Percentage Cited
at Condition-Level
GL-04 Leadership Responsibilities Condition
*Note this standard is cited when condition-level deficiencies are cited regardless of the standard cited.
IC-07Disinfection & Sterilization Practices Condition 21%
CE-13Testing of Emergency Power Systems Condition 18%
CE-19 Inspection & Testing of Life Safety Systems Condition 18%
CE-14 Emergency Battery Powered Lighting Condition 11%
CE-15 Compliance to the NFPA Life Safety Code Condition 11%
CE-18 Fire Drills Condition 11%
MM-28 Administration of Medications Condition 7%
CE-11 Ventilation, Lighting & Temperature Control Condition 7%
CE-21 Compliance to the NFPA Health Care Facilities Code Condition 7%
Below are the top standard-level deficiencies cited during the second half of 2023.
CIHQ Standard Number Title Level of Severity Percentage of Surveys Cited at Standard-Level
CE-15 Compliance to the NFPA Life Safety Code Standard 82%
IC-03 Infection Prevention & Control Policies Standard 75%
CE-03 Provision of a Safe Environment Standard 57%
CE-13 Testing of Emergency Power Systems Standard 54%
CE-19 Inspection & Testing of Life Safety Systems Standard 54%
CE-21 Compliance to the NFPA Health Care Facilities Code Standard 50%
MR-05 Minimum Content of the Medical Record Standard 50%
CE-1 Provision of Facilities Standard 46%
HR-04 Management of Contract/Volunteer Staff Standard 39%
CE-10 Management of Utilities Standard 39%

Conferences and Sponsorships

Save the Date for 2024 Accreditation & Regulatory Summit
Save the dates: September 24 – 26, 2024
Location: San Antonio, Texas at Pedrotti’s Ranch
Each month we will publish fun facts about CIHQ and its history in our CIHQ Accreditation & Regulatory Journal. The facts will be in different locations within the Journal but will all be housed in a box with a game-themed border. Below is an example of the border. Search the Journal to learn interesting facts. At the Summit, teams will compete against each other for the level of knowledge and the team that knows the most will win a fun and exciting prize. Beginning in February the bordered box below will be traveling to different pages of the Journal.
Stay tuned in to your journal for facts and fun about us! We can’t wait to see all of you at the Summit! More Summit information will be sent as it is finalized and made available. This is the event that you won’t want to miss!

CIHQ to Attend Palooza in March
CIHQ’ longtime partner RLDatix is hosting their annual Palooza in Orlando, FL March 11-14, 2024. This is the official conference for RL Datix customers to come together to collaborate and grow. Rick Curtis will speak, participate in an executive roundtable discussion, and provide a warm introduction for panel guests.

Richard Curtis to be Featured Speaker at NALTH
CIHQ is a long-time supporter of The National Association for Long Term Hospitals. NALTH has a goal to support its members in the areas of advocacy, education & communication, research, and networking. CIHQ will take the booth to the SPRING 2024 LTCH Clinical Education Conference in Nashville, March 27-29. Rick is also slated to speak at their fall conference in October in National Harbor, MD.

CIHQ to Sponsor for TORCH
For the 3rd year in a row, CIHQ will attend the Texas Organization of Community and Rural Hospitals (TORCH) Spring conference in Arlington, TX on April 1-4, 2024. If you’re attending, stop by the booth!

CIHQ to Sponsor ASAM
We will also sponsor The American Society of Addiction Medicine (ASAM) Annual Conference in Grapevine, TX/ (DFW) April 4-7. For 55 years, ASAM has been convening the addiction treatment community to showcase best practices and the latest science, research, and innovations in the field. This is our first time attending ASAM; looking forward to it!
Richard Curtis to be Featured Speaker at TSMSS
Richard Curtis was asked to present at the Texas Society for Medical Services Specialists (TSMSS) on the Riverwalk in San Antonio, TX April 10-12. Their vision is to be recognized as a leading organization that promotes patient safety through education, certification, and professional growth of medical services specialists. We understand many HACP credential holders attend this event and look forward to seeing them! Stop by the booth and say hello!
CIHQ to Attend the Indiana Rural Health Association’s Annual Conference
CIHQ is able to accredit Critical Access Hospitals (CAH), and we look forward to attending Indiana RURAL Health Association’s Annual Conference in French Lick, IN on June 10- 12. A voice for rural residents of Indiana, the theme this year is, “Leveraging Opportunities for Change”.
CIHQ to Sponsor SIPS Scrub Ball
SIPS Consults has been a CIHQ partner since 2022. Each year, they celebrate and pay tribute to healthcare heroes at the ScrubBall in Dallas, TX June 20-22. Education, encouragement, and validation enhances job satisfaction and motivation. Ask for a tour of the SIPS training facility if you’re in the Dallas area; they are dedicated to training Sterile Processing Department staff.
Richard Curtis will be a Featured Speaker and ACRM’s Annual Conference The American College of Rehab Medicine (ACRM) Annual Conference, “Progress in Rehabilitation Research: Translation to Clinical Practice” will be held October 31 – Nov 4 in Dallas, TX. Attendees will have the opportunity to hear Rick Curtis and other highly acclaimed professionals present on all things rehabilitation.
Richard Curtis Keynote Speaker for Louisiana Rural Health Association’s Leadership Conference
Rick Curtis will be the keynote speaker for Louisiana Rural Health Association’s Leadership Conference, Nov 6-7 in Baton Rouge, LA. Their mission is to provide a unified voice that promotes and enhances the quality of rural health in Louisiana; their vision is to work toward ensuring all Louisiana residents have access to high quality healthcare and the opportunity to live a healthy life.