Your Complete Policy Management Partner
Everything your healthcare organization needs to confidently maintain accreditation compliance.
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Simplify & automate policy access, review and approval across your organization
Web-based library of more than 18,000 customizable policy documents
Instantly access up-to-date policies, procedures & forms authored by MCN experts
Automated regulatory notification system of daily email or mobile alerts
Keep current with regulatory changes from more than a dozen federal regulatory bodies, including TJC & NIAHO
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MCN Healthcare has been indispensable to our accreditation compliance efforts. With Policy Manager, Policy Library and StayAlert!, we have peace of mind that our policies will always be up-to-date and easy to locate.
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Helpful MCN Healthcare Resources
The Joint Commission is offering free replay of a webinar on the misuse of medication vials. The webinar is a follow-up to information provided in Sentinel Event Alert #52. The webinar includes guest speakers from American Society of Anesthesiologists, Centers for Disease Control and Prevention, Children's Hospital Colorado (Denver), Institute for Safe Medication Practices and the Food and Drug Administration.
According to TJC, the misuse of single-dose/single-use medication vials has adversely affected thousands of patients. Adverse events related to medication vial misuse can include the spread of infection and bloodborne pathogens. TJC's webinar reviews guiding principles for preventing infection from the misuse of vials, aseptic technique as well as policy statements for medication vial use. Follow the link below to access this free webinar.
StayAlert reviewed Sentinel Event #52, which alerted health care providers to the risks associated with medication vial misuse, in a notice published on June 18, 2014. The StayAlert! Notice, published on June 18, 2014, includes eight example policies related to the proper and safe use of medication vials.
U.S. Department of Health and Human Services Office for Civil Rights Issues Guidance on HIPAA and Same Sex Marriage
The U.S. Department of Health and Human Services Office for Civil Rights (OCR) has developed guidance to assist covered entities in understanding how the 2013 Supreme Court decision regarding the Defense of Marriage Act (DOMA) may affect certain of their HIPAA Privacy Rule obligations.
In United States v. Windsor, the Supreme Court held section 3 of DOMA to be unconstitutional. Section 3 of DOMA had provided that federal law would recognize only opposite-sex marriages. In light of the Windsor ruling, covered entities (and business associates, as applicable) must consider the following regarding lawfully married same-sex spouses and same-sex marriage:
- At 45 CFR 160.103, the Privacy Rule includes the terms spouse and marriage in the definition of family member. Consistent with the Windsor decision, the term spouse includes individuals who are in a legally valid same-sex marriage sanctioned by a state, territory, or foreign jurisdiction (as long as, as to marriages performed in a foreign jurisdiction, a U.S. jurisdiction would also recognize the marriage). The term marriage includes both same-sex and opposite-sex marriages, and family member includes dependents of those marriages. All of these terms apply to individuals who are legally married, whether or not they live or receive services in a jurisdiction that recognizes their marriage.
- The definition of a family member is relevant to the application of §164.510(b) Standard: Uses and disclosures for involvement in the individual's care and notification purposes. Under certain circumstances, covered entities are permitted to share an individual's protected health information with a family member of the individual. Legally married same-sex spouses, regardless of where they live, are family members for the purposes of applying this provision.
- The definition of a family member is also relevant to the application of §164.502(a)(5)(i), use and disclosure of genetic information for underwriting purposes. This provision prohibits health plans, other than issuers of long-term care policies, from using or disclosing genetic information for underwriting purposes. For example, such plans may not use information regarding the genetic tests of a family member of the individual, or the manifestation of a disease or disorder in a family member of the individual, in making underwriting decisions about the individual. This includes the genetic tests of a same-sex spouse of the individual, or the manifestation of a disease or disorder in the same-sex spouse of the individual.
Included with today's notice is an example policy regarding HIPAA and communication with family members
Additional Changes to Joint Commission Deemed Program Requirements for Hospitals, Effective September 29, 2014
The Joint Commission (TJC) recently approved revisions to several standards for hospitals that use TJC accreditation for deemed status purposes. Today's notice reviews revisions made to the Provision of Care, Treatment and Services Chapter.
For hospitals that have swing beds used for long term care, TJC has made the following changes:
- Added an Element of Performance to PC.01.02.09 that requires hospitals to report any knowledge of actions taken by a court of law against an employee that would indicate unfitness for service as a nurse aide or other facility staff to the appropriate State nurse aide registry or licensing authority.
- Under standard PC.02.02.01, TJC is requiring that hospitals:
- Provide activity services directly or through referral for both ambulatory and non-ambulatory residents at various functional levels.
- Provide services, either directly or through referral to facilitate family support, social work, nursing care, dental care, rehabilitation, primary physician care and/or discharge.
- Provide, directly or through arrangement with an external provider, 24-hour emergency dental services.
- Added standard PC.02.02.09 that requires that hospitals offer and assist residents to participate in social and recreational activities in accordance with their interests and abilities.
Featured Policy Library Manuals
MCN's NEW Ambulatory Surgical Center/Outpatient Surgery Department Policy and Procedure Manual is cross referenced to TJC standards, AAAHC standards and CMS regulations. Policies and procedures meet AORN and CDC recommendations and guidelines. This comprehensive reference guide has over 290 policies and procedures that are ready to customize to your organization. See also the Administrative Manual for Ambulatory Care Facilities and the Ambulatory Services EOC Manual.Read more »
MCN's Central Service Policy and Procedure Manual provides over 200 proven, up-to-date policies and procedures in a ready-to-customize format. This manual is cross referenced to federal regulations, as well as Joint Commission and NIAHO standards. References used include AAMI Recommended Practices, IAHCSMM Central Service Technical Manual, ASHCSP Training Manual for Health Care Central Service Technicians and AORN Recommended Practices.Read more »
MCN's Post Anesthesia Care Policy and Procedure Manual is a comprehensive resource that covers the latest "hot topic" regulatory and patient safety issues that are relevant to PACU! This manual includes administrative, operational, functional and patient-centered policies and procedures. Policies and procedures are cross-referenced to CMS regulations, Joint Commission standards and NIAHO standards.Read more »