“Ask the Expert” Webinar - Joint...
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1 © Copyright, The Joint Commission © Copyright, The Joint Commission Answers to the Most Frequently Asked Questions (FAQs) From Nursing Care Centers Presenter: Lynette Gibbney, RN Associate Director, Standards Interpretation “Ask the Expert” Webinar
Transcript of “Ask the Expert” Webinar - Joint...
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Answers to the Most Frequently Asked Questions (FAQs)
From Nursing Care Centers
Presenter:
Lynette Gibbney, RN
Associate Director,
Standards Interpretation
“Ask the Expert” Webinar
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GoToWebinar Housekeeping
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 beingrecorded and will be posted on theJoint Commission website.
Your Participation
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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
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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
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Lynette Gibbney, RN
Associate Director,
Standards Interpretation
About our speaker…
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Today’s objectives
Review the most frequently asked questions (and
answers!) about Joint Commission requirements
Explore opportunities for sustaining compliance to
those standards
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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
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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.
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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
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What is required in 2016 in terms of hand
hygiene monitoring?
NPSG.07.01.01 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
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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
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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
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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.04.03.09 – Only applies to care treatment and
services provided directly to patients
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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.
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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
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Frequently “Scored” Standards for
Nursing Care Centers
36% HR.02.01.04 The organization permits licensed
independent practitioners to provide care, treatment
and services
20% PC.03.01.01The organization manages the
patient’s or resident’s pain
18% MM.03.01.01 The organization safely stores
medications
14% HR.01.02.05 The organization verifies staff
qualifications
14% PC.01.03.01The organization plans the patient’s
or resident’s care
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Frequently “Scored” Standards for
Nursing Care Centers
12% NPSG.07.01.01 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.02.03.01 The organization provides patient
or resident education and training based on each
patient’s or resident’s needs and abilities
12% wt.03.01.01 Staff and licensed independent
practitioners performing waived tests are competent
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Frequently “Scored” Standards for
Nursing Care Centers
11% PC.01.02.03 The organization assesses and
reassesses the patient or resident and his or her
condition according to defined time frames
11% IC.01.03.01 The organization identifies risks for
acquiring and spreading infections
11% EC.02.01.01 The organization manages safety
and security risks
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Where can I find the FAQ’s from Nursing
Care Facilities?
Go to Joint Commission home page
www.jointcommission.org
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
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• 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.
Attendee Participation
Now we’d like to hear from
you…Questions?
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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 630-792-5020
Email [email protected]
Website www.jointcommission.org/NCC
Standards Interpretation
For questions about standards compliance
630-792-5900
