Your Complete Policy Management Partner
Everything your healthcare organization needs to confidently maintain accreditation compliance.
Robust document control and workflow management software solution
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
What Our Customers are Saying
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.
Beverly McKenzie, Compliance Programs Director, IASIS Healthcare
Helpful MCN Healthcare Resources
The Inspector General of the Department of Health and Human Services (HHS OIG), the American Health Lawyers Association (AHLA), the Association of Healthcare Internal Auditors (AHIA) and the Health Care Compliance Association (HCCA) has released a joint educational resource, "Practical Guidance for Health Care Governing Boards on Compliance Oversight," to assist governing boards of health care organizations carry out their compliance plan oversight obligations. In addition to governing boards of health care organizations, the document will also assist internal auditors, lawyers, and compliance officers that report to those boards. According to OIG, this cross-disciplinary authorship highlights the complementary roles of the internal audit, compliance, and legal functions in any comprehensive compliance program.
This new educational resource provides practical ideas that boards may consider implementing in their organizations. The guidance includes:
- Processes for identifying risks
- Tools for improving adherence to program objectives
- Effective reporting tools for board meetings
The document also suggests diverse tools and tips that boards of varied sizes and resources may use as well as methods to identify compliance risks in a rapidly changing health care environment.
The issuing organizations state the guide is not intended to establish specific standards of conduct and should not be taken as legal or professional advice or opinion from any of the organizations. Rather the document provides examples of how boards may foster a corporate culture of compliance to meet the ultimate goals of protecting the integrity and viability of the nation's health care delivery system.
The Joint Commission (TJC) has released its annual list of top cited standards for their various accreditation programs. Today's notice reviews EC.02.03.05, which requires critical access hospitals (CAH) to maintain fire safety equipment and fire safety building features. According to TJC, 58% of CAHs surveyed in 2014 were deemed non-compliant with this standard.
There are twenty-five elements of performance with this standard but it is important to note that TJC does not require CAHs to have the different types of fire safety equipment and building features described within the EP's. Rather, it is only if a CAH has these types of features in existence within the building that they then must follow the maintenance, testing and inspection requirements described in the EPs.
In order to ensure compliance with this standard, CAHs should review each EP and determine if they have the equipment or building feature described. If so, then the testing interval should be determined and a process put into place to conduct the testing and ensure maintenance. CAHs should document the maintenance, testing, and inspection activities, including:
- Name of the activity
- Date of the activity
- Required frequency of the activity
- Name and contact information, including affiliation, of the person who performed the activity
- NFPA standard(s) referenced for the activity
- Results of the activity
Included with today's notice is an example inspection, testing and maintenance inventory.
The Joint Commission (TJC) has released its annual list of top cited standards for their various accreditation programs. Today's notice reviews PC.02.01.03 for Home Care organizations. This standard requires Home Care organizations to provide care, treatment or services in accordance with orders or prescriptions, as required by law and regulations. According to TJC, in 2014, 41% of Home Care organizations surveyed were found non-compliant with this standard.
Compliance with this standard relies on having a consistent process for following orders and prescriptions for patients and ensuring that policies and procedures accurately reflect the way in which orders and prescriptions are documented and followed.
Key elements for compliance with this standard include:
- Ensuring that the Home Health Agency (HHA) provides care, treatment and/or services to patients in accordance with current physician orders.
- Ensuring that there is a clear, documented process for the use of telephone/verbal/facsimile and/or written orders from physicians and other licensed independent practitioners (LIPs) whose credentials have been verified according to HHA policy.
- Ensuring that all orders for medication and treatment are documented in the patient's medical record, signed by the patient's licensed independent practitioner or non-physician practitioner as allowed by State law and hospital policy, and be legible.
- Ensuring that all orders for medical care, treatment and/or services are reviewed/evaluated for appropriateness and accuracy by an appropriately licensed individual (i.e., Registered Nurse, Licensed Therapist, Pharmacist) prior to providing care, treatment and/or services.
- Ensuring that the prescribing practitioner is contacted for clarification of any orders staff members feel are not legible.
- Ensuring that critical results of tests and diagnostic procedures are reported to the licensed independent practitioner (LIP) and/or clinician who is licensed by the State and approved by the Home Health organization to take clinical action pursuant to the results of critical results.
Included with today's notice are policies that reflect the requirements of PC.02.01.03 for Home Care.
Featured Policy Library Manuals
MCN’s Utilities and Equipment Management Policy and procedure Manual is a reference guide that is compliant with Joint Commission, NIAHO and CIHQ standards and CMS regulations. MCN provides easy-to-use policies and procedures that are field tested and proven - you need only to customize them to your healthcare organization. Policies and procedures include Utility Systems Management Plan, Alternative Equipment Maintenance Program, Clinical Alarms, Emergency Power and much more!Read more »
MCN Healthcare’s Administrative Manual for Critical Access Hospitals is specifically designed to assist critical access hospitals meet CMS, TJC and NIAHO standards for CAHs. This manual provides over 275 ready-to-implement policies, procedures and forms in an easy-to-customize Word format, and is designed to demonstrate compliance with CAH regulations. Transplant Safety polices are also included in this manual.Read more »
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 »