Surveyor Newsletter | 2024 No. 2 | Quality Review, ACH CAH

Volume 2024 | No. 2

SURVEYOR

TABLE OF CONTENTS

BOARD OF COMMISSIONERS Brock Slabach, MPH, FACHE I Chair CHIEF OPERATIONS OFFICER, NATIONAL RURAL HEALTH ASSOCIATION Maria (Sallie) Poepsel, PhD, MSN, CRNA, APRN Vice Chair OWNER AND CHIEF EXECUTIVE OFFICER, MSMP ANESTHESIA SERVICES, LLC Mark S. Defrancesco, MD, MBA, FACOG I Secretary PAST PRESIDENT, AMERICAN COLLEGE OF OBSTETRICIANS AND GYNECOLOGISTS Leonard S. Holman, Jr., RPh I Treasurer HEALTHCARE EXECUTIVE AND CONSULTANT Roy G. Chew, PhD I Immediate Past Chair PAST PRESIDENT, KETTERING HEALTH NETWORK John Barrett, MBA I Board Member-at-Large SENIOR CONSULTANT, QUALITY SYSTEMS ENGINEERING Gregory Bentley, Esq. PRINCIPAL, THE BENTLEY WASHINGTON LAW FIRM Jennifer Burch, PharmD PHARMACIST/OWNER, CENTRAL PHARMACY, CENTRAL COMPOUNDING CENTERS José Domingos PRESIDENT AND CHIEF EXECUTIVE OFFICER, ACCREDITATION COMMISSION FOR HEALTH CARE Richard A. Feifer, MD, MPH, FACP CHIEF MEDICAL OFFICER, INNOVAGE Denise Leard, Esq. ATTORNEY, BROWN & FORTUNATO Marshelle Thobaben, RN, MS, PHN, APNP, FNP PROFESSOR, HUMBOLDT STATE UNIVERSITY

03 CORNER VIEW

04 FROM THE PROGRAM DIRECTOR

06 FREQUENT DEFICIENCIES IN CLINICAL AND ADMINISTRATIVE STANDARDS IN ACUTE CARE HOSPITALS 20 FREQUENT DEFICIENCIES IN PHYSICAL ENVIRONMENT AND LIFE SAFETY IN ACUTE CARE HOSPITALS 28 FREQUENT DEFICIENCIES IN CLINICAL AND ADMINISTRATIVE STANDARDS IN CRITICAL ACCESS HOSPITALS 38 FREQUENT DEFICIENCIES IN PHYSICAL ENVIRONMENT AND LIFE SAFETY IN CRITICAL ACCESS HOSPITALS

LEADERSHIP TEAM

José Domingos PRESIDENT AND CHIEF EXECUTIVE OFFICER Patrick Horine, MHHA VICE PRESIDENT, ACUTE CARE SERVICES Matt Hughes VICE PRESIDENT, CORPORATE STRATEGY Barbara Sylvester, RN, BBA, MSOLQ DIRECTOR, REGULATORY AFFAIRS AND QUALITY

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