Matt Mitchell, Director of Accreditation and Regulatory
Shelley Nina Young, Program Manager
The Joint Commission was onsite October 26th and 27th for our 45 Day Medicare Deficiency Follow Up Survey. This was not a typical follow up survey as TJC was unable to have 2 Surveyors to collaborate on one single survey day. We are pleased to announce that all findings from our triennial survey on June 29th to July 2nd were recommended to be cleared.
- There will be one new finding related to restraints: Our policy and CMS require physicians to do a 1-hour face to face follow-up on patients in violent restraints. This documentation was not evident in one of the tracers conducted on October 27th. This new finding will not require an additional site visit but will require an action plan and monitoring.
We wish to sincerely thank all who assisted in the survey and to THANK ALL OF UAMS STAFF for their help in a successful triennial accreditation survey. UAMS could not do this without you!
Arkansas Foundation for Medical Care (AFMC) Covid Clinic Vaccination Audit Update:
UAMS also recently underwent an audit for our COVID Vaccination Clinics by AFMC on behalf of the Arkansas Department of Health. We are again pleased to say this audit was successful with a few recommendations and simple requirements to update. Thank you to our Pharmacy partners, Infection Prevention partners, Clinic Staff and all who work so hard to ensure our safety here at UAMS and in our community.
As we have mentioned before, there are several departments due for certification review and as such UAMS is always in a window for surveyors. We all must stay continually ready!
Please see a tentative time frame for some of our surveys below: (*note these time frames are subject to change, and are often late, due to the availability of CMS, TJC, ADH and Survey Staff)
- Perinatal “Ready Date”: January 10th, 2022
- Behavioral Health: August 2021 – February 2022
- Comprehensive Stroke Center: July 2022 – December 2022
- CAST/Methadone Clinic: August 2022
- 2022 Vizient Unannounced Mock Survey
- Multiple Non TJC Surveys are also due in 2022 (CARF/CMS/ADH etc.)
For questions or concerns, please email Matthew Mitchell, Director of Accreditation and Regulatory Compliance: email@example.com.