Achieve Accreditation Blog

  • Jessica Prucha

Arely Franco is a Senior Consultant celebrating a ten-year career in the health care field. She is passionate about person-centered care and quality of life for residents. Arely has spent her professional career in the skilled nursing industry in advancing leadership roles. She holds a master's degree in Social Work and she is a licensed clinical social worker. Arely began working with Achieve Accreditation in 2017.

Arely’s passion for working with older adults prompted her to work in the skilled nursing industry. She appreciates the opportunity consulting provides to impact the skilled nursing industry on a larger scale by assisting clients in maintaining a safe and supportive environment.

“The nursing home industry is a tight-knit community and it’s amazing to see everyone come together to serve the older adult population,” Arely said. “I feel fortunate to be a part of the community through Achieve Accreditation.”

Arely’s favorite part of working as a consultant is getting to meet a variety of people across different skilled nursing home settings and communities, as well as working on a wide range of projects.

“I enjoy the different projects that I get to work on and the challenges that come along,” Arely said. “They are all unique which gives me the opportunity to continue to develop my expertise in the industry.”

Vice President of Achieve Accreditation Kerri Hackstock appreciates Arely’s detail-oriented approach to working with clients.

“She is not afraid to roll up her sleeves and assist her clients in any way possible,” Kerri said.

Outside of work, Arely enjoys spending time outdoors, reading and listening to podcasts. Her bucket list includes riding in a hot air balloon and seeing the northern lights in Iceland. Arely said spending time with family and friends is the most important thing to her.

Jessica Prucha, BAJ is the Operations Manager at Achieve Accreditation. Achieve Accreditation has helped skilled nursing providers and assisted living organizations to obtain and maintain their Joint Commission Accreditation for over 30 years.


Effective July 1, 2022, The Joint Commission will be introducing 29 new and 55 revised requirements for the Nursing Care Accreditation Program at The Joint Commission. They will also be releasing 10 new and 4 revised Memory Care Certification requirements.

The requirements address several topics, such as: infection prevention and control, dementia/memory care, staff recruitment, and medication safety. The purpose of these revisions is to ensure the Nursing Care Center and Memory Care Certifications remain scientifically current. These new and updated requirements can be found on the Joint Commission’s Prepublication Standards page of their website.

Achieve Accreditation has been assisting senior living providers with obtaining and maintaining their Joint Commission Accreditation for over 30 years. We can help you fast track the new Joint Commission requirements as a part of your ongoing compliance program.

Kathleen O’Connor, MA is President & Founder of Achieve Accreditation. Achieve Accreditation has helped skilled nursing providers and assisted living organizations to obtain and maintain their Joint Commission Accreditation for over 30 years.


Here are some of the Joint Commission’s most frequently cited recommendations for nursing care centers. By highlighting common areas and providing practical suggestions, we can help your organization avoid these pitfalls.

In 2021, EC.02.02.01, managing risk related to hazardous materials and waste, was the most frequently cited recommendation. This standard addresses a variety of items including, but not limited to, Safety Data Sheets (SDS), eye wash stations and proper credentials for signing for hazardous waste pick-ups. To help avoid receiving a recommendation for this environment of care standard, ensure that you have Safety Data Sheets for every product used in the building and that staff are following the safety protocols within the SDS such as using proper PPE (Personal Protective Equipment) when in contact with that product. Educate your staff on the purpose and location of Safety Data Sheets and ensure the needed personal protective equipment is available for staff. Eye wash stations should be accessible where chemicals are used and/or stored. By accessible, we mean within 10 seconds or 50 feet and not behind a locked door. Eye wash stations should be inspected weekly for items such as water pressure, dust caps and mixing valves and solution bottles should be monitored for expiration dates. Another area that is frequently identified as non-compliant under this standard is that the individual signing manifests for the hazardous waste pick-ups is not certified through the Department of Transportation.

Credentialing recommendations are near the top of the most frequently cited list. Ensuring that each file complies not only requires that you have the required documents from each practitioner, but also that all information is current and that each step of the process is completed in the proper order. Frequent credentialing recommendations include not having a query from the National Practitioner Data Bank, expired DEA certifications, not conducting the primary source license verification in a timely manner and having more than 2 years between the credentialing re-appointments.

The next frequently cited recommendation makes it to the top five list every year. Two forms of competency testing are required both upon hire and annually for nurses for any waived test being conducted on site. The most common waived test in nursing care centers is blood glucose monitoring. Nurses must complete a written test and perform a return demonstration using the glucometers. If there are other waived tests occurring on-site (i.e., rapid antigen testing, PT/INR, urine dipstick, fecal occult), the need for two forms of competency testing applies as well. The best ways to avoid this recommendation is to ensure the written and observational tests are part of the new hire orientation process for nurses and part of the training calendar at least annually. Going together with this requirement is the need to conduct quality control checks for instrument-based waived testing per manufacturer guidelines. For glucometers, the best practice is to assign quality control checks to a particular shift on a set frequency (often this is done daily but could be less based on manufacturer guidelines and corresponding organization policy). It is essential to conduct random audits of employee files to ensure the competencies are completed on record as required and assign an individual to check the quality control logs at least weekly to avoid recommendations for these standards. When auditing the quality control logs, check for the following: the serial number or other device identifier is included on the log and updated if the device is taken out of use, no omissions in the documentation, ensure the acceptable range for results is written on the log, and verify if documented actions were taken when/if readings were out of range. Finally, look at the quality control solution to ensure it is labeled with the open date and the discard date.

The last standard is regarding the organization implementing its infection prevention and control plan. Annually, each organization should conduct an infection control risk assessment which will identify the highest risk areas to prioritize. Your infection control plan should outline the activities you will do to limit the risk of those areas for which you are most at risk. Hand hygiene is the basis for your infection prevention and control plan and should always be an area of focus. Conducting hand hygiene competency testing upon hire and annually for all staff should be the protocol for all nursing care centers. A job specific hand hygiene training is recommended as well. For example, a new cook should be provided with examples of when hand hygiene should occur specific to food preparation. Conducting ongoing surveillance audits of staff and contractors will provide knowledge of compliance with the hand hygiene protocols in place. Try to observe staff without them knowing as they perform their job duties to ensure they are washing or sanitizing their hands each time it is required, using proper techniques. Analyzing the data collected during these audits will help determine if additional education is needed or if there are other potential barriers to achieving compliance.

Focusing on these four frequently cited standards will help prepare an organization for their next Joint Commission survey!

Gerrianne Hartman, LNHA, MA, is a Senior Consultant at Achieve Accreditation. Achieve Accreditation has helped skilled nursing providers and assisted living organizations to obtain and maintain their Joint Commission Accreditation for over 30 years.