...Accreditation Audit Task 1. A1. Communication, this is the key focus area that is evaluated in this summary. Communication is a key focus area of the joint commission audit and is also a key area in which Nightingale Community can make enhancements. Communications must be a two way free flow of information. The information exchanges occur between providers, staff, and patients or clients. This was an area that needed improvement was noted in the previous accreditation audit. Some noted prior issues from 2 years ago included patient and family education and information not being properly disseminated to the nursing staff. These are areas where we have targeted and currently meet. Some areas that we continue to work on are as follows. We currently need to address our time out policy. During the last year there were three months that Nightingale Community did poorly in this area. We must make sure that the time outs are not only conducted properly but more importantly documented in the patients chart. If the time out is not properly documented in the patients chart the organization will not receive credit, it will be as though it never occurred. We must make sure that all providers and clinical staff have appropriate training and training materials provided for the time out policy. We will continue to quantify our efforts monthly in this key area. We as an organization must make this goal monthly. Critical results are an issue of concern for the organization. Critical results...
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...3/11/2013 | | Memo | | | | To CEO From Elementary Division Manager Re Constructive Discharge Complaint Comments: Earlier this quarter a former employee voluntarily terminated their employment with our company but has since filed a claim against our company alleging that the employee’s rights under Title VII of the Civil Rights Act of 1964, specifically constructive discharge, were violated. Title VII of the Civil Rights Act of 1964 was designed to protect the rights of employees within the workplace from instances of discrimination with relation to race, religion, sex, national origin and religion (Title VII of the Civil Rights Act of 1964). With this law came about the Equal Employment Opportunity Commission (EEOC) whose responsibility it is to enforce the provisions within Title VII and provide oversight and guidance to employers and employees with regard to this law. The EEOC has sent us notification that this former employee has made a claim under the constructive discharge area of Title VII. Constructive discharge is an employment situation whereby the employee feels that due to changes their employer has made with regard to any Title VII covered entity; they have no option but to resign. This act is relevant to the claim in that the claim stated that the employee felt he had no alternative but to resign. The employee believed that with the company’s new policy reflecting work/shift changes he would not be able to observe the Holy days required by...
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...Jenny Windler Student ID: 000329547 Accreditation Audit (AFT2) Task 1 A. Compliance Status Nightingale Community Hospital is a complete and leading healthcare facility that believes in providing the best quality care to all of their patients. As part of Nightingale’s mission to put the patient first, the hospital must meet medication management standards set forth by the hospital and the Joint Commission. Medication management often involves the efforts of multiple services and disciplines. It is part of Nightingale’s policy that a patient’s information is accessible to a physician, pharmacist or nurse in the management of a patient’s medication. Nightingale Hospital has all the policies in place that the Joint Commission looks for to keep the hospital accredited. A1. Plan for Compliance In reviewing the safety of using medication associated with Anticoagulation Therapy, Nightingale Hospital needs some improvement. There was only one month out of the year that patients did not experience any adverse effects related to Anticoagulation Therapy. Numbers were high at the beginning of the year and tapered off by the end of the year, but Nightingale Hospital should be experiencing more months where there are no adverse events. In combination to the Joint Commission’s finding 2 years ago regarding the lack of documented evidence that the patient’s ability/readiness to learn, learning preference, or educational needs were assessed and documented in the file, we have much...
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...WGU AFT2 RAFT2 (Accreditation Audit) MBA Graduate Programe - Complete Course All 4 Tasks http://www.homeworkminutes.com/question/view/41054/AFT2-RAFT2-Accreditation-Audit-WGU-MBA-Graduate-Program-Complete-Course AFT2 Accreditation Audit Task 1 1. The purpose of this executive summary is to outline the current status of compliance of the organization for the priority focus area of communication, namely the standard UP.01.01.01 which is named the “Conduct a Pre-procedure Verification Process” as noted by the Joint Commission standards. A.2. The primary area of focus I chose to review was the communication aspect. I feel that communication is vital in any business, especially health care. Clear communication improves patient care and the quality of care. This is evident when time is taken to verify a patient or a procedure. When things go wrong due to misidentification of a patient, not only does that cost time and money for the patient as well as the extra burden of having that wrong fixed, but it also costs the hospitals too. Their costs are increased by trying to fix the issue and then legal issues to follow. The best way to avoid any mistake and/or injury is to adopt a more vigorous verification system. AFT2 Accreditation Audit Task 2 A.1. An unexpected occurrence that involves serious bodily or psychological harm including death or the risk leading to these is known as a sentinel event. (Sentinel event, 2013) A.2. Several people were...
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...Running head: ACCREDITATION AUDIT- TASK 4 COMPLAINCE STATUS Joint Commission clearly explained that a Periodic Performance Review is as an assessment tool designed to help in assisting the healthcare organization contributes greatly in the improvement and monitoring performance all through the year. The periodic performance focuses more on the measures that has to do with patients safety and care and at same time given the facility for unremitting standards fulfillment. NCH is 100% compliance with most standards of Joint Commission in the following area; Emergency Management, Human resources, Infection Prevention and Control, Performance Improvement, Right and Responsibilities of the Individuals, Transplant Safety. During the inspection at the facility, the hospital was found to be non- compliant in this listed areas; Environment of Care, Leadership, Life Safety, universal protocol, Medication Management, Medical Staff, National Patient Safety Goals, Nursing, Record of Care, Treatment and Services, and provision of care During the PPR, the hospital was found with an increase cluster in the hallways, it is a fire hazard and a safety issue. The nurses are not familiar with verbal order procedures, using the range of orders that received and the abbreviations that are prohibited in the documents. From the trend, there are areas at which the hospital needs to implement proper education and audit. An action plan needs to be implemented by the administration to address the fallout...
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...security activities and policies; assessing information security risk; and implementing and auditing information security management programs, information assurance certification programs, and security ethics. Watch the following video for an introduction to this course: Competencies This course provides guidance to help you demonstrate the following 3 competencies: Competency 427.3.2: Controls and Countermeasures The graduate evaluates security threats and identifies and applies security controls based on analyses and industry standards and best practices. Competency 427.3.3: Security Audits The graduate evaluates the practice of defining and implementing a security audit and conducts an information security audit using industry best practices. Competency 427.3.4: Certifications and Accreditations The graduate identifies and discusses the Information Assurance certification and accreditation (C&A) process. Course Mentor Assistance As you prepare to successfully demonstrate competency in this subject, remember that course mentors stand ready to help you reach your educational goals. As subject matter experts, mentors enjoy and take pride in helping...
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...Accreditation Audit: AFT Task 3 Western Governor’s University Abstract AFT Task 3 allows the examination of data from a patient while hospitalized at Nightingale Hospital and utilizes a tracer methodology to identify trends, patterns, and pertinent problems for healthcare improvement. We plan to develop a corrective action plan to address the organization’s improvement while maintaining compliance from a Joint Commission standard. Accreditation Audit: AFT Task 3 Nightingale Hospital is preparing to devise a mock tracer methodology to assess the organizations’ current compliance with Joint Commission Standards. A tracer methodology follows a patient through the course of care and evaluates all aspects of care (Joint Commission E-dition, 2014). This method allows a quick overview of a patient through the flow of a system in order to evaluate the effectiveness of the process flow. Our mock tracer patient is a sixty seven year old female whom recently underwent an open total abdominal hysterectomy secondary to menorrhagia and uterine fibroids. The patient presented back to the emergency room one week postoperatively with complaints of a subjective fever of 100.2 degrees Fahrenheit and incisional drainage described as yellowish-green in color. A CT scan of her abdomen was performed in the emergency room and revealed a peri-umbilical abscess. The surgical team was consulted and an incision and drainage of the abscess was performed. Infectious disease physicians determined...
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...Accreditation Audit: AFT2 task 2 1 Accreditation Audit: AFT2 Task 2 Confidential—For internal use only to support performance improvement activities. This information is provided within the confidentiality protections of state statute. It is not to be distributed outside the quality assurance, performance improvement, peer review process. Accreditation Audit: AFT2 task 2 2 Analysis of Key Components RCA: Child Abduction Please note that the root cause analysis and action plan must show evidence of an analysis within the key components as outlined on the root cause analysis matrix for the specific type of event. An area on the matrix that may not have an identified process breakdown should still be summarized to determine that the component was evaluated. Brief description of event Briefly summarize the circumstances surrounding the occurrence including the patient outcome (e.g., death, loss of function). A 3-‐year-‐old female pediatric patient...
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...[pic] Australian Government Department of Defence Information System Audit Guide VERSION 11.1 January 2012 Table of Contents 1. Introduction to Accreditation 4 2. The Information System Audit – Checklist 7 2.1. What is an Information System Audit? 7 2.2. Why is an Information System Certification needed? 7 2.3. Assessing an Information System’s Security Risks 7 2.4. Selecting an Information System’s Security Controls 7 3. Purpose of the Checklist 8 4. How to Use the Checklist 8 4.1. The Checklist Structure 8 4.2. Security Objectives 9 4.3. Guidance for IRAP Assessors 9 4.4. Information System Compliance 10 5. Guidance for IRAP Assessors 10 6. The Checklist 11 6.1. The Information Security Policy & Risk Management 11 6.2. Information Security Organisation 14 6.3. Information Security Documentation 17 6.4. Information Security Monitoring 20 6.5. Cyber Security Incidents 22 6.6. Physical & Environmental Security 24 6.7. Personnel Security for Information Systems 26 6.8. Product & Media Security 27 6.9. Software, Network & Cryptographic Security 30 6.10. Access Control & Working Off-site Security 33 Appendix A – Accreditation Governance 36 The ISM & Certification 36 Compliance Levels 37 Compliance Report 37 Compliance Comments 37 Audit Documentation Submissions 38 Appendix B – Standards 39 ...
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...Accreditation Audit AFT2 Task 1. Herman Big Mawanda Western Governors University Contents COMPLIANCE STATUS. 3 PLANS OF COMPLIANCE 7 JUSTIFICATION 8 BIBLIOGRAPHY 10 Nightingale Community Hospital provides leadership in quality health services. Its core values focus on safety, community, teamwork and accountability with a vision of being a hospital of choice for all and a mission to create a healing environment with a passionate commitment to health care excellence. This executive summary of the accreditation audit is presented to the senior leadership to outline the compliance, plan of compliance and institution of the hospital under the reviewed focus area of Information Management as per the Joint Commission Standards. COMPLIANCE STATUS. The Joint Commission Standard IM 02.02.01 requires that the hospital effectively manages the collection of health information. Nightingale Community Hospital is in compliance with this standard under its patient care policy which specifies prohibited abbreviations. Its policy states that the use of abbreviations and symbols in the medical record is discouraged to prevent errors; as these can be associated with misinterpretation resulting in medical errors, and patient harm. In case the intended meaning of the abbreviation or symbol in the context of a specific order is not clear, the ordering practitioner must be contacted for clarification. This procedure demands that the elements of performance under IM 02.02.01 of the...
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...Nightingale Community Hospital is compliant with The Joint Commission standards except the following areas: Accreditation function of environment of care and life safety, it was documented that more than 3 smoke wall penetrations were found on the 1st floor and one on the 4th floor. The hospital is to minimize the potential for harm from fire, and smoke (TJC, 2013). A review of documentation showed appropriate ILSM was not initiated during 3 construction projects this put employees and patients at risk. Education of fire safety equipment should have been completed before the project. The gift shop did not have the required 18 inch clearance from the sprinklers. All sprinklers must have at least 18 inches below and around of clearance for The Joint Commission standards. Review of department documentation shows that the master alarm panel for medical gasses was not tested annually per policy. This is a policy written by the hospital that is not being met. They are to follow the policies that they set for themselves. The Fire Drill History Report showed that the fire drill process is not adequate and does not meet standards. Quarterly fire drills are to be conducted as regulated by the Life Safety Code (TJC, 2013). Clutter was found in the hallways of 3E, 4E, OR and telemetry this could restrict people from leaving the floor safely in case of fire or smoke. Accreditations function of Nursing Leadership it was discovered that Nurses on 3E were not documenting in a timely manner....
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...Continuous Accreditation Compliance - Task 4 AFT2 Accreditation Audit October 31st, 2014 Continuous Accreditation Compliance - Task 4 Nightingale Community Hospital (NCH), like many other health care facilities, uses a Periodic Performance Review (PPR) as an assessment tool that assists in examining performance on a consistent basis to ensure compliance with Joint Commission standards. A PPR concentrates attention on procedures, methods, and processes that contribute an environment that provides for proper care and emphasizes patient safety. NCH has shown to be 100% compliant with the majority of standards including: Infection Prevention and Control, Right and Responsibilities to Patients, Human Resources, Transplant Safety, Emergency Management, and Performance Improvement. During the last inspection NCH was found to be non-compliant in the following areas: National Patient Safety Goals, Record of Care, Environment of Care, Nursing, Treatment and Services, Leadership, Life Safety, Provision of Care, and Universal Protocol. Trending Areas of Concern The PPR revealed numerous issues in all areas of NCH. In order to address issues that affect patient safety and accreditation it is necessary to focus on issues that are found to be present in several areas of the facility. These patterns and trends of non-compliance often expose a weakness in policy, procedure, or training that needs to be addressed in order to ensure patient safety and accreditation compliance...
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....................... 5 IV. NIST SP 800‐37 and FISMA .................................................................................................. 6 V. How Veracode Can Help ...................................................................................................... 7 VI. NIST SP 800‐37 Tasks & Veracode Solutions ....................................................................... 8 VII. Summary and Conclusions ............................................................................................... 10 About Veracode .................................................................................................................... 11 © 2008 Veracode, Inc. 2 Overview The Federal Information Security Management Act of 2002 ("FISMA", 44 U.S.C. § 3541, et seq.) is a United States federal law enacted in 2002 as Title III of the E‐ Government Act of 2002 (Pub.L. 107‐347, 116 Stat. 2899). The Act is meant to bolster computer and network security within the Federal Government and affiliated parties (such as government contractors) by mandating information security controls and periodic audits. I. The Role of NIST in FISMA Compliance The National Institute of Standards and...
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...Assurance Certification and Accreditation Process (DIACAP) (a) Subchapter III of Chapter 35 of title 44, United States Code, “Federal Information Security Management Act (FISMA) of 2002” (b) DoD Directive 8500.01E, “Information Assurance (IA),” October 24, 2002 (c) DoD Directive 8100.1, “Global Information Grid (GIG) Overarching Policy,” September 19, 2002 (d) DoD Instruction 8500.2, “Information Assurance (IA) Implementation,” February 6, 2003 (e) through (ab), see Enclosure 1 1. PURPOSE This Instruction: 1.1. Implements References (a), (b), (c), and (d) by establishing the DIACAP for authorizing the operation of DoD Information Systems (ISs). 1.2. Cancels DoD Instruction (DoDI) 5200.40; DoD 8510.1-M; and ASD(NII)/DoD CIO memorandum, “Interim Department of Defense (DoD) Information Assurance (IA) Certification and Accreditation (C&A) Process Guidance” (References (e), (f), and (g)). 1.3. Establishes or continues the following positions, panels, and working groups to implement the DIACAP: the Senior Information Assurance Officer (SIAO), the Principal Accrediting Authority (PAA), the Defense Information Systems Network (DISN)/Global Information Grid (GIG) Flag Panel, the IA Senior Leadership (IASL), the Defense (previously DISN) IA Security Accreditation Working Group (DSAWG), and the DIACAP Technical Advisory Group (TAG). 1.4. Establishes a C&A process to manage the implementation of IA capabilities and services and provide visibility of accreditation decisions regarding the operation...
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...WORK STATEMENT Table of Contents 1 OVERVIEW 1 2 CONTRACT REQUIREMENTS 1 2.1 Objectives Fulfillment 1 2.1.1 Business Objectives 1 2.1.2 Technical Objectives 2 2.1.3 Management Objectives 3 2.2 Assumptions and Constraints 3 2.2.1 Access Control 4 2.2.2 Authentication 4 2.2.3 HSPD-12 Personnel Security Clearances 4 2.2.4 Non-Disclosure Agreements 5 2.2.5 Accessibility 5 2.2.6 Data 5 2.2.7 Confidentiality, Security, and Privacy 5 2.3 Tasks/Sub-Tasks to Be Performed Related to Initiating the Service 6 2.3.1 Task 1: 6 2.3.2 Task 2: 7 2.4 Period of Performance 7 3 PERFORMANCE MANAGEMENT OF THE DELIVERED SERVICES 8 3.1 Modifications to Service Level Agreements 8 3.2 Changes to Key Performance Measures. 8 3.3 Quality Assurance Evaluation 8 3.4 Government Roles and Responsibilities. 9 3.4.1 Contracting Officer (CO) 9 3.4.2 Contract Specialist 9 3.4.3 Contracting Officer’s Technical Representative (COTR) 10 3.4.4 Other Key Government Personnel 10 3.5 Contractor Roles and Responsibilities 10 4 METHODS OF QUALITY ASSURANCE SURVEILLANCE 11 5 SECURITY REQUIREMENTS 11 5.1 Required Policies and Regulations for GSA Contracts 11 5.2 GSA Security Compliance Requirements 13 5.3 Certification and Accreditation (C&A) Activities 13 5.3.1 Certification...
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