Kim MaryniakPhD, MSN, BN, RNC-NIC, NEA-BC
Kim Maryniak, PhD, RNC-NIC, NEA-BC has over 33 years of nursing experience in medical/surgical, psychiatry, pediatrics, progressive care, long-term care, and adult and neonatal intensive care. She has been a staff nurse, charge nurse, educator, instructor, manager, director, and chief nursing officer.
Kim graduated with a nursing diploma from Foothills Hospital School of Nursing in Calgary, Alberta in 1989. She achieved her Bachelor in Nursing through Athabasca University, Alberta in 2000, her Master of Science in Nursing through University of Phoenix in 2005, and her PhD in Nursing through University of Phoenix in 2018.
Kim is certified in Neonatal Intensive Care Nursing and as a Nurse Executive, Advanced. She is active in the American Nurses Association and American Organization of Nurse Leaders. Her current and previous roles include nursing leadership, research utilization, nursing peer review and advancement, education, use of simulation, quality, process improvement, professional development, infection control, patient throughput, nursing operations, professional practice, and curriculum development.
Recorded-webinar by: Kim Maryniak
Restraint and Seclusion: Navigating a Problematic CMS Standard
The topic of restraints and seclusion is hot for CMS and accreditation agencies and is an area of high risk for hospital non-compliance. Solid policies, procedures, and processes are required for success with the use of restraints or seclusion. One of the most cited areas of deficiencies for CMS Conditions of Participation (CoP) is restraints and seclusion.
Long-Term Care: Bedrails and CMS Requirements
The overuse of bed rails, particularly in environments with vulnerable populations, have created incidents where resident safety has been compromised. The use of rails must be appropriate to the bed used and meet safety standards to prevent entrapment. Entrapment occurs when a person is entangled or trapped within a space in or around a bed rail. Resident injury or even death has occurred as a result of entrapment with bed rails. Standard or automatic use of bed rails without individualization to the resident can affect resident autonomy. Bed rails may also become a form of restraint when improperly used.
There are appropriate reasons for the use of bed rails for safety and mobility. Prior to use, assessment and alternative measures must be utilized. Additionally, the informed consent of the resident or representative is required before use. The beds and rails must be evaluated by the facility management department. Provider orders must also reflect the individualized need for bed rails. Ongoing assessments of the continued need, in addition to monitoring of the equipment are also required.
This webinar will provide an overview of CMS requirements for assessment, ordering, monitoring, and appropriate use of bed rails in long-term care facilities. Recommendations for policies, procedures, and assessment tools will be provided.
Accreditation Hot Topics CMS TJC DNV
This course will provide an overview of areas of focus for accreditation surveyors, such as those associated with the Centers for Medicare & Medicaid Services (CMS), The Joint Commission (TJC), Det Norske Veritas (DNV), and other accreditation agencies. These topics are based on National Patient Safety goals. Hot topics include medication management and administration, blood administration, nurse staffing, use of care plans, and discharge planning. Other topics include infection prevention and control, antibiotic stewardship, Emergency Medical Treatment and Labor Act (EMTALA), restraints and seclusion, and suicide prevention. The topics will be reviewed based on potential deficiencies.
2023 Nursing CMS COPs UpdatesHospitals must follow the Centers for Medicare & Medicaid Services (CMS) conditions of participation (CoP) for all patients to receive Medicare and Medicaid reimbursement. The CoP are the specified requirements that must be upheld to address patient safety needs and services provided within a facility. Facilities included are acute care facilities, critical access hospitals, and health systems. CMS updates the CoP on a regular basis and it is important for leaders and staff to have an understanding of these requirements. Facilities that are accredited by the Joint Commission (TJC), Healthcare Facilities Accreditation Program (HFAP), Center for Improvement in Healthcare Quality (CIHQ), or Det Norske Veritas (DNV) Healthcare must follow these regulations.
This program will review standards that have been updated since 2020. Essential standards that have changed or are at high risk for failure to uphold will be included. Examples are provider orders, medication management and administration, blood administration, nursing services and use of agency, nurse staffing, responsibilities of nursing leaders, discharge planning, visitation and grievances.
The program will additionally cover sections in the hospital CoP manual that are most frequently cited as deficiencies during accreditation surveys. These areas of risk include infection prevention and control, antibiotic stewardship, Emergency Medical Treatment and Labor Act (EMTALA), restraints and seclusion, and suicide prevention.
Performance improvement and quality strategies will also be discussed. Gap assessments will be included for all levels of staff. Best practices and preparation for surveys will also be discussed.