Summary 1 AFT2: Accreditation Audit Task 4 Western Governors University ï‚· 2 Compliance Status A

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AFT2: Accreditation Audit Task 4




Western Governors University



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Compliance Status

An internal compliance audit was performed in preparation for the Joint Commission

survey. This audit found that of 18 Joint Commission standards, Nightingale Hospital needed to

make changes to comply with ten standards. This overwhelming non-compliance must be

addressed immediately for patient and employee safety. The standards and the hospital’s

compliance are listed below:

 Accreditation Participation Requirements (APR): compliant

 Environment of Care (EC): not compliant

 Emergency Management (EM): compliant

 Human Resources (HR): compliant

 Infection Prevention and Control (IC): compliant

 Information Management (IM): not compliant

 Leadership (LD): not compliant

 Life Safety (LS): not compliant

 Medication Management (MM): not compliant

 Medical Staff (MS): not compliant

 National Patient Safety Goals (NPSG): not compliant

 Nursing (NR): not compliant

 Provision of Care, Treatment, and Services (PC): not compliant

 Performance Improvement (PI): compliant

 Record of Care, Treatment, and Services (RC): not compliant

 Rights and Responsibilities of the Individual (RI): compliant

 Transplant Safety (TS): compliant