Ask the Expert Webinar

Transcription

1 Copyright, The Joint Commission Ask the Expert Webinar Answers to the Most Frequently Asked Questions (FAQs) From Nursing Care Centers Presenter: Lynette Gibbney, RN Associate Director, Standards Interpretation 1

2 Copyright, The Joint Commission GoToWebinar Housekeeping Your Participation Join audio: Choose Mic & Speakers to use VoIP Choose Telephone and dial using the information provided Questions/Comments: Submit questions and comments via the Questions panel. Note: Today s presentation is being recorded and will be posted on the Joint Commission website. 2

3 The Joint Commission Who We Are The leader in standards development promoting quality and safety in health care organizations for nearly 60 years Began accrediting nursing homes, including skilled nursing facilities, in 1966 Currently the nation s largest and only full continuum accreditor; with more than 20,000 accredited health care organizations Currently accredit over 90% of the nation s hospitals Our experience and expertise has propelled Joint Commission accreditation to become the most widely recognized quality and safety distinction across the continuum, among managed care contractors, liability insurers and other key stakeholders 3

4 How Accreditation and Specialty Certifications Help Your Organization Accreditation Builds the quality foundation Improves reliability and consistency Proactively mitigates risk Objective hands-on review Uses tracer to assess compliance, not policy alone Competitive, quality-focused advantage Specialty Certifications Post-Acute Care Memory Care 4

5 Copyright, The Joint Commission About our speaker Lynette Gibbney, RN Associate Director, Standards Interpretation 5

6 Today s objectives Review the most frequently asked questions (and answers!) about Joint Commission requirements Explore opportunities for sustaining compliance to those standards 6

7 What is primary source verification? Does it apply to all staff? Primary source verification Applies to all staff with license, certification or registration Verification is obtained from your state s secure web site Verification must be documented Oral can be accepted from the state with date and signature of individual accepting Copy of license is not enough 7

8 When should the governing body approve the reappointment and re-privileging of LIP s? Approval should: Be in advance of due date It is not necessary to change the approval dates to match the actual date the board met. 8

9 How do we determine the patients learning needs? Learning needs and provision of patient education is determined by a learning needs assessment. Cultural and religious beliefs Emotional barriers Desire or motivation to learn Physical or cognitive limitations Barriers to communication Documentation is key 9

10 What is required in 2016 in terms of hand hygiene monitoring? NPSG requires that Establish a base line based on data Formulate a goal to improve Customize the goals and improvement efforts Interventions based on CDC or WHO guidelines If goals not met --- Why? If goals met --- Set higher expectations 10

11 Is there a requirement to have a hazard vulnerability analysis for all nursing center sites? It depends based on unique internal or external environment Center located in low lying area flood Train tracks that run near that carry hazardous material 11

12 What are the requirements for electronic cigarettes? Environment of care standard Prohibit smoking regardless of type Special circumstances, designated smoking areas with appropriate exhaust and fire safety All smoking should be included in policy Electronic cigarettes have lithium battery 12

13 Are contracted services expected to comply with Joint Commission standards? Yes. The same level of care should be provided whether the care is provided directly or by contract. L.D Only applies to care treatment and services provided directly to patients 13

14 Where can we find more information on credentialing and privileging? On your ICM page, there is a tab for Booster Packs. There will be a pack for credentialing and privileging in non-hospital settings. You will need to scroll down to NCC. There will be flow charts, checklists and various tools to assure compliance. 14

15 What is meant by managing the patient s pain? Managing pain means An assessment passed on your policy evidence based Severity Location Quality Aggravating factors Relief Spiritual or emotional pain Follow-up 15

16 Frequently Scored Standards for Nursing Care Centers 36% HR The organization permits licensed independent practitioners to provide care, treatment and services 20% PC The organization manages the patient s or resident s pain 18% MM The organization safely stores medications 14% HR The organization verifies staff qualifications 14% PC The organization plans the patient s or resident s care 16

17 Frequently Scored Standards for Nursing Care Centers 12% NPSG Comply with either the current Centers for Disease Control and Prevention (CDC) hand hygiene guidelines or the current World Health Organization (WHO) hand hygiene guidelines 12% PC The organization provides patient or resident education and training based on each patient s or resident s needs and abilities 12% wt Staff and licensed independent practitioners performing waived tests are competent 17

18 Frequently Scored Standards for Nursing Care Centers 11% PC The organization assesses and reassesses the patient or resident and his or her condition according to defined time frames 11% IC The organization identifies risks for acquiring and spreading infections 11% EC The organization manages safety and security risks 18

19 Where can I find the FAQ s from Nursing Care Facilities? Go to Joint Commission home page Click on standards tab Click on Most Frequently Asked Questions link (circled in red below) Select Nursing Care Center manual to customize the view Questions listed by standards chapter 19

20 Copyright, The Joint Commission Now we d like to hear from you Questions? Attendee Participation Please continue to submit your text questions and comments using the Questions Panel Note: Today s presentation is being recorded and will be posted on the Joint Commission website. 20

21 Copyright, The Joint Commission Contact Us! Nursing Care Center Accreditation Program For more information about how to get started with accreditation, access our free standards, or to request an application for accreditation: Phone Website Standards Interpretation For questions about standards compliance