Accreditation & Regulatory Journal
April 2024

Partner Spotlight

National Association of Long-Term Hospitals (NALTH) • 240-403-0154
NALTH, the National Association of Long-Term Hospitals is the premier association representing long term acute care hospitals (LTCHs) and associated professional staff committed to advancing the health, well-being and quality of care for medically complex patients who require prolonged hospital stays. Included in care are specialized programs to help achieve medical stability and maximum function.

New to the Journal! Partner Compliance Tips

April 2024 Compliance Tips of the Month

Financial News Update – provided by David Balat, Healthcare Finance Specialist

In the 88th Texas Legislature a rare occurrence happened. House Bill 2002, authored by two Members in the House (Dr. Tom Oliverson & Four Price) and one in the Senate (Kelly Hancock) was passed through every committee and both chambers unanimously before being signed into law by Governor Abbott.
The title enrolled is "Relating to preferred provider benefit plan out-of-pocket expense credits for payments made by an insured directly to a physician or health care provider."
In plain language, this very short bill basically says that if a patient wants to pay cash to a health care provider for a service that is typically covered and less than the average discounted rate, the insurer must apply that payment to the insured's deductible and annual maximum out-of-pocket expense.
This helps patients of course but the opportunity to help employers and even hospitals are available as well. As high as deductible are today and the fact that most Americans never hit their deductible renders most as cash patients. The new law in Texas allows for those cash payments to now count. This helps employers (those that are self-funded) because it now creates another incentive for people to shop for cash options.
Hospitals may benefit as well with the help of a good broker/advisor. In the way of example, I was working with a hospital in a smaller market. The hospital I was consulting was lamenting the loss of a contract with the area's school district. A heavy loss to the hospital. I referenced the new law as an opportunity to attract patients from the school district. Phase 1 would be to offer an affordable Labor & Delivery cost that is bundled that is below the negotiated rate of the new insurer for the School District. This legislation may have inadvertently created an environment for increased competition among hospitals in certain markets.
How would this type of legislation work in your state? Visit the website at

Continuing Education Tip - provided by Pretaa

Educate Yourself About Addiction

The first step in helping someone with a substance use disorder is to educate yourself about addiction. Understanding that addiction is a chronic brain disorder, rather than a moral failing or a choice, is essential in fostering empathy and providing effective support. Familiarize yourself with the signs and symptoms of addiction, the factors that contribute to substance use disorders, and the various treatment options available. By gaining knowledge about addiction, you will be better prepared to assist your loved one in their recovery journey.
Resources such as the National Institute on Drug Abuse (NIDA) ( and the Substance Abuse and Mental Health Services Administration (SAMHSA) ( offer valuable information about addiction, treatment options, and support services.
You can also visit our Education Center to learn more.

Wound care Tip - provided by WoundVision

Check out the published evidence below to see why both hospitals are turning to handheld imaging solution to help decrease hospital-acquired pressure injury rates and increase pressure injury healing rates.
Acute Care Hospital Study Results: After incorporating LWIT into their existing on-admission skin assessment, researchers reported a significant decline in the incidence of DTPIs. As a result, the HAPI rate was reduced to 0%, improving the quality of patient care and preserving a significant amount of revenue related to both payor reimbursements and legal liability. READ THE FULL STUDY HERE.
Want to learn more? Contact WoundVision to see if their solution can help your organization.

Care Environment Tip - provided by Healthcare Services Group

Small Changes for Lasting Results
Jessica Tupa, RD, LD | We all have a relationship with eating, and the goal is to make it a positive one. Choosing and enjoying foods should be a beneficial experience for the mind and body. If we avoid labeling foods as “good” or “bad,” it can help us understand the concept of balance.
Drastic diet changes often prove unsuccessful in the long run. Familiarize yourself with the key terms and use these small changes to examine your eating habits and make adjustments to make nutritious choices and achieve health goals.

CMS Update Tip - provided by Tracy Swoboda of UT Health Houston

More Intensive Focus on Health Equity by CMS in 2024 and Social Determinants of Health:
The CMS Framework for Health Equity is structured to align with HHS initiatives that seek to achieve health equity and reduce disparities among minority and underserved populations. This includes achieving health and well-being by eliminating health disparities, achieving health equity, and attaining health literacy by assessing a Social Determinants of Health (SDOH) with five domains including economic stability, education access and quality, health care access and quality, neighborhood and built environment, and social and community context. Hospitals and stakeholders across the health care spectrum have a role to play in addressing social determinants of health.
CMS mandated that hospitals reporting to the Inpatient Quality Reporting (IQR) program submit two brand new measures: SDOH-1 and SDOH-2. These measures were voluntarily reported in 2023 and now required in 2024. The web links below identify the health equity priorities of care, Z-codes for coding and reporting, and SDOH data measures and specifications for reducing disparities in health. SDOH data can include information on health literacy, transportation, social isolation, housing insecurity, food insecurity, geography, and more.
For additional information, please review:

Sterilization and Disinfection Tip – provided by Dr. SPD

Risk Management and Error Prevention: Quality practices within sterile processing help mitigate risks and prevent errors that could compromise patient safety. Implementing robust quality management systems, including risk assessment, error reporting, and corrective action protocols, can identify potential hazards and ensure continuous improvement in sterilization processes.

NFPA Compliance Tip – provided by Covent Rock Consulting

Taylor Vaughn, Covenant Rock
We’ve gotten down fire door testing, but are you testing your access doors in rated walls? NFPA 80, 2010, requires all fire doors, fire windows, and other opening protectives must be inspected annually. This includes rated access doors.
During the inspection, ensure that the access door is self-closing and self-latching, is appropriately rated, and has a legible label listing the rating.
Remember, you don’t have to be certified to perform inspections, only qualified. A documented training class for the inspector will suffice.

Instrument and Equipment Tip - provided by Inventory Solutions Plus

What do you do after a surgeon disassociates with the hospital? Often, surgeons have instruments and/or surgical supply requirements unique to them so the hospital dutifully supplies what is requested. When they are no longer associated with the hospital, what happens to these instruments?
Staff often just leave everything because they don’t want to discard perfectly good medical inventory. A valid point. Why not give them a chance at a new life? First:
  • Make sure they are no longer going to be ordered
  • Remove the PPC from all files.
  • Remove the inventory from the stockroom.
  • Contact Inventory Solutions Plus for free removal.
For more information or to schedule a pickup, please contact