Accreditation Hot Topics CMS TJC DNV

This course will provide an overview of areas of focus for accreditation surveyors, such as those associated with the Centers for Medicare & Medicaid Services (CMS), The Joint Commission (TJC), Det Norske Veritas (DNV), and other accreditation agencies.  These topics are based on National Patient Safety goals.  Hot topics include medication management and administration, blood administration, nurse staffing, use of care plans, and discharge planning.  Other topics include infection prevention and control, antibiotic stewardship, Emergency Medical Treatment and Labor Act (EMTALA), restraints and seclusion, and suicide prevention. The topics will be reviewed based on potential deficiencies.

Hospitals must follow the Centers for Medicare & Medicaid Services (CMS) conditions of participation (CoP) for all patients to receive Medicare and Medicaid reimbursement.  Specific requirements must be upheld to address patient safety needs and services provided within a facility.  Facilities included are acute care facilities, critical access hospitals, and health systems.  Facilities that are accredited by the Joint Commission (TJC), Healthcare Facilities Accreditation Program (HFAP), Center for Improvement in Healthcare Quality (CIHQ), or Det Norske Veritas (DNV) Healthcare must follow regulations and requirements.

This training will provide insight into components of accreditation surveys that may be at risk for citations or deficiencies. Attending this course would be beneficial for anyone working in healthcare, especially those involved in accreditation and surveying processes. The session will provide valuable knowledge that can help you positively contribute to your organization and improve patient outcomes.

After completion of this program, the participant will be able to:

• Identify the importance of accreditation compliance in a hospital setting 
• Discuss National Patient Safety Goals
• Describe the areas of risk based on failure to uphold safety standards
• Identify commonly cited deficiencies in accreditation surveys
• Discuss strategies that focus on hot topics
• Describe monitoring requirements for upholding standards 

• Medication Management and Administration
• Blood Administration
• Nurse Staffing
• Care Plans
• Discharge Planning
• Infection Prevention and Control
• Antibiotic stewardship
• Emergency Medical Treatment and Labor Act (EMTALA)
• Restraints and Seclusion
• Suicide Prevention

The following individuals or disciplines will benefit from attending this Webinar:

• CEO, COO
• Compliance Officer
• Chief Medical Officer (CMO), Chief Nursing Officer (CNO)
• Nurse Educator, Nurses, Nurse Directors, Nurse Supervisors
• Nurse Managers, Board Members, Physicians, Medical Staff Coordinator
• Patient Safety Officer, Senior Leadership, Hospital Legal Counsel
• Risk Manager, Chief Risk Officer, PI Director
• Joint Commission or DNV Coordinator
• Director of Health Information Management
• Director of Anesthesia, Pastoral Care, Patient Advocates, Ethics Committee 
• Others responsible for compliance with hospital regulations and persons responsible for rewriting policy and procedure on informed consent