Arizona ASHE
September  2016 Newsletter

Joint Commission News

JC releases the top five most challenging requirements for first half of 2016.


The Top 5 Joint Commission requirements identified most frequently as "not  compliant" during the reviews form Jan. 1 through June 30 categorized by facility type.   Hospitals still struggling with LS.02.01.20  Maintains the integrity of the means of egress and LS.02.01.35  Provides and maintains systems for extinguishing fires.   All facility types struggle with IC.02.02.01  The Hospital reduces the risk of infections associated with medical equipment, devices and supplies.


JC asks hospitals to use new fire drill matrix


The Joint Commission (JC) is asking hospital to use the new fire drill matrix to track when fire drills were conducted in an effort to ensure they comply with the JC and Centers for Medicare & Medicaid (CMS) requirements to conduct drills varying times and days.


Joint Commission surveyors are giving the matrix to facility managers when first arriving for survey, asking that it is completed by the first or second day of survey. The matrix was created after surveyors noticed that hospital often conducted drills at the same time but didn't realize the patterns. .

              CMS ALERT!
CMS finalizes emergency preparedness rule
Centers for Medicare & Medicaid Services (CMS) has issued the new emergency preparedness requirements, to go in effect in 60 days. 
ASHE, a personal membership group of the AHA, will be thoroughly analyzing the rule in coming days and will be providing additional member resources. ASHE is currently working to produce a crosswalk showing members the differences between the new CMS rule, NFPA 99 requirements, and Joint Commission emergency preparedness standards.

Medicare and Medicaid participating providers and suppliers to meet the following four common and well-known industry best-practice standards. 

Emergency plan. Based on a risk assessment, develop an emergency plan using an all-hazards approach focusing on capacities and capabilities that are critical to preparedness for a full spectrum of emergencies or disasters specific to the location of a provider or supplier.
  • Policies and procedures. Develop and implement policies and procedures based on the plan and risk assessment.
  • Communication plan. Develop and maintain a communication plan that complies with both federal and state laws. Patient care must be well-coordinated within the facility, across health care providers and with state and local public health departments and emergency systems.
  • Training and testing program. Develop and maintain training and testing programs, including initial and annual trainings, and conduct drills and exercises or participate in an actual incident that tests the plan.

  • The rule applies to 17 different provider types, including hospitals, critical access hospitals, ambulatory surgical centers, long-term care facilities, intermediate care facilities and rural health clinics.

    The rule, which is 650 pages long, includes background on the original CMS proposal; a summary of public comments and CMS's response to those comments; and the final regulations. The regulations for hospitals begin on page 584. A section titled "provisions of the final regulations," which begins on page 269, outlines differences between the proposed rule and the final rule. 

    Interested in serving on the Arizona ASHE Board?
    We are taking nominees/volunteers  for Associate ASHE Board Member.

    Associate Board Member Criteria:

    • Must be an associate member of AZASHE.
    • Must be a national ASHE member or obtain.
    • Must be able to commit to meeting 1 hour each month.
    • Must be willing to work for free.
    • Term is 2 years.  2017-2018

    If you are interested please contact me.

    1st Annual AZ ASHE Golf Tournament
     Friday  Septembers 23, 2016
    Forty-niners Country Club
    Thank you Event Sponsors
    CRS,    American Fire,    Sun Mechanical,   AEI Engineering,  Bernhard TME
    Lunch Sponsor - ATI
    Hole in one Sponsor - TREMCO
    Cart Sponsor - Belfor Restoration
    Beverage/Beer Hole Sponsor - Siemens

    1st Annual Arizona ASHE Facilities Trade Show,  August 18, 2016

      September 21, 2016
    Chapter Meeting and Education session " CMS Infection Prevention Compliance training for Vendor Employees"
    University of Arizona Tech Park
    9070 S. Rita Road  Tucson AZ
    September 23, 2016
    AZ ASHE 1st Annual Golf Tournament
    Forty-Niners Country Club
    October 11, 2016
    Fire Door Inspection Seminar
    4888 N Stone (old Tucson Heart Hospital)
    October 28, 2016
    APIC Grand Canyon Infection Prevention Seminar
    St Joseph's Hospital &Medical Center
    350 W Thomas Road Phoenix AZ 



    You are invited to attend
    Above Ceiling Inspection in Healthcare Facilities
                             Wednesday, September 21, 2016 10:00 AM Central Time
    Abstract: The space above the acoustical tile ceilings in healthcare facilities is a world of potential Life Safety and Infection Control issues. This program discusses ways to organize and conduct above ceiling inspections, including what to look for and where to look. Help to keep your facility as safe as possible by including thorough, periodic inspections of the above ceiling spaces. 
    Seminar Objectives 
    Understand the following: 
    * How to safely and thoroughly inspect the areas above the ceiling in your facility. 
    * Infection Control Considerations 
    * What must be inspected and maintained 
    * The importance of quality drawings 
    * What to look for during inspections 
    * Effective Documentation 
    * Considering ILSM/ALSM in regards to discovered deficiencies

    Association for Professional Infection Control and Epidemiology (APIC) Conference
                                   October 28, 2016 7:00am-4:30pm
                            St Joseph's Hospital and Medical Center
                                  350 W Thomas Road Phoenix, AZ
    This program is designed for Infection Preventionist, nurses ad other healthcare  professionals interested in infection control, patient safety and performance improvements.

    Thanks to all of our  2016 Gold Sponsors
    Thanks to all of our 2016 Bronze Sponsors!

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