Western Governors University | AFT2 | Running Head: ACCREDITATION AUDIT |TASK 4 |Trellis Green | with 100% accuracy

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Western Governors University
Running Head: ACCREDITATION
AUDIT TASK 4 Trellis Green with
100% accuracy




Accreditation Audit

TASK 4

Trellis Green

Western Governors University




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, ACCREDITATION AUDIT TASK 4 For more exams
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INTRODUCTION



Nightingale Hospital is conducting a intracycle monitoring audit as

required by the Joint Commission to help accredited organization stay in

Compliance. In the review that follows there are positive areas and areas of

opportunities for improvement to adhere to Joint Commission standards.



COMPLIANCE STATUS



NCH was found to be compliant in 8 areas: Accreditation Participation,

Emergency Management, Human Resources, Infection Control,

Performance Improvement, Rights and

Responsibilities of the Individual, Transplant Safety and Waived Testing.

NCH was found to be non-complaint in 11 areas:



ENVIROMENT OF CARE

• EC .02.03.01, EC.02.05.0, EC.02.03.03 o Non-compliant with fire

protection and fire drills. Fire drills frequency does not meet

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