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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
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Keep current with regulatory changes from more than a dozen federal regulatory bodies, including TJC & NIAHO
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Helpful MCN Healthcare Resources
The U.S. Department of Health and Human Services Office of Inspector General (OIG) recently released a report about the frequency and level of employee background checks performed by Medicare-certified home health agencies. The report is the result of a congressional request for an analysis on the extent to which Home Health Agencies employed individuals with criminal convictions and whether these convictions should have - according to State requirements - disqualified them from HHA employment.
Currently there are no Federal laws or regulations that require HHAs to conduct background checks after individuals have been hired. State requirements for background checks vary as to what sources of information must be checked, which job positions require background checks, and what types of convictions prohibit employment.
OIG conducted the study by requesting sample data from Medicare-certified HHAs regarding all individuals employed on January 1, 2014. OIG then compared the employee data with criminal history records from the Federal Bureau of Investigation. OIG found that all HHAs conduct some type of background check on prospective employees and approximately half also conduct periodic checks after date of hire.
OIG concluded and recommends that the Centers for Medicare and Medicaid Services promote minimum standards in background check procedures. According to OIG, CMS could promote minimum standards for HHA employee background checks by encouraging more States to participate in the National Background Check Program. CMS concurred with OIG's recommendation which suggests that Home Health Agencies may have minimal background check standards in the future.
Included with today's notice is an example policy on criminal background checks are well as a criminal background check release of information form.
The U.S. Food and Drug Administration (FDA) is warning health care professionals about the risk for dosing errors with the antibacterial drug Zerbaxa (ceftolozane and tazobactam) due to confusion about the drug strength displayed on the vial and carton labeling.
Zerbaxa's vial label was initially approved with a strength that reflects each individual active ingredient (e.g. 1 g/0.5 g); however, the product is dosed based on the sum of these ingredients (e.g. 1.5 g). To prevent future medication errors, the strength on the drug labeling has been revised to reflect the sum of the two active ingredients. Thus, one vial of Zerbaxa will now list the strength as 1.5 grams equivalent to ceftolozane 1 gram and tazobactam 0.5 gram (See label photos by following the link below).
Zerbaxa is approved to treat complicated urinary tract infections and for the treatment of complicated intra-abdominal infections in combination with metronidazole.
The FDA has evaluated seven reported cases of medication error that occurred during preparation of the dose in the pharmacy due to confusion with the display of the strength of individual ingredients on Zerbaxa's vial label and carton labeling. Listing the individual drug strengths led to confusion because it was different from labeling for other beta-lactam/beta-lactamase antibacterial drugs that express strength as the sum of the two active ingredients. In some cases, this led to administration of 50% more drug than was prescribed. No adverse events were reported among these seven cases.
The Centers for Medicare and Medicaid Services (CMS) has issued updated interpretive guidelines for hospital Radiologic Services (42 CFR 482.26) and Nuclear Medicine (42 CFR 482.53) Conditions of Participation (CoPs) to reflect current standards of practice as well as to provide more detailed instructions for compliance assessment.
For each of the two CoPs the guidance:
- Describes the types of radiologic/nuclear medicine services provided.
- Discusses safety precautions hospitals are expected to take to decrease radiation exposure risks including, but not limited to:
- Incorporation of the "As Low as Reasonably Achievable" (ALARA) principle of medical imaging, which optimizes image quality while minimizing radiation exposure in accordance with nationally recognized guidelines;
- Identification of high-risk patients for whom a diagnostic study might be contraindicated;
- Appropriate shielding of patients and personnel that is specific to the type of medical imaging device; and,
- Periodic inspection and calibration of equipment by appropriately trained personnel.
The updated guidance also contains a number of "blue boxes" with additional information and recommendations for optional actions which are not required under the regulations but do reflect best practice. StayAlert is currently reviewing the updated guidance in detail and will publish additional notices.
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 Healthcare’s Home Health Policy and Procedure Manual provides over 400 policies and procedures addressing administration, emergency management, human resources, medical records, infection control, safety and security, equipment management, medication management, performance improvement, patient rights and responsibilities, waived testing as well as patient care. The Home Health Policy and Procedure Manual is cross referenced to CMS regulations, TJC, ACHC, and CHAP standards.Read more »
The Medical Office Policy and Procedure Manual is cross referenced to Joint Commission standards for Ambulatory Care and Primary Care Medical Homes and NCQA standards for Patient Centered Medical Homes. This manual includes policies that meet OSHA requirements for safety and infection control, Human Resources policies and Medical Office Compliance Plan and much more!Read more »