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The Joint Commission - The Joint Comission recently surveyed our state hospital and issued a 'Condition level finding' because

the Director of Nursing does not hold a Masters Degree in Nursing and the Supervising Nurse was apparently, believed to have the advanced nursing credentials for the hospitals she provided oversight but, upon investigation by The Joint Commission surveyors it was discovered this nurse did not hold a Masters Degree in Nursing. The surveyor asked for the Director of Nursing to produce the following; - Proof that they is someone who will provide supervision that possesses the required credentials of (MSN - Proof of continuing education -Proof of acceptance into a program to obtain a MSN or Masters in Nursing - A plan that includes a time frame The Director of Nursing was able to produce a signed document from the nurse that began the same night providing supervision and her diploma and license number demonstrating an active, unrestricted license in the state -The letter of acceptance into the school the DON was returning to and the start date (even through, the surveyors stated the start semester was not on the paperwork -in was indeed clearly listed as starting in the Summer Semester. - And the notation that the Supervising Nurse would be meeting on the upcoming weekend to develop the supervisory plan and review the educational plan. Since, the actual survey the DON has solidified the educational plan and time frame; met with the Supervising Nurse; and begins classes the first week of June. However, the Hospital deputy director states TJC requires the Supervising Nurse to be a part of the state hospital system. We have inquired other Director's of Nursing who have experienced the exact or similar situation. And, all state TJC has not dictated what system the Supervising Nurse is a part of just proof that it is happening. Please, explain why some surveyors require different standards? Is it the facility?; the person?; or the surveyors interpretation. There is no mention of this type of stringent requirement with CMS who TJC surveys for with hospitals seeking 'Deemed Status.' Please, cite the language in TJC standards requiring the Supervising Nurse be a part of the hospital or hospital system, Thank you
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#1545096 Review #1545096 is a subjective opinion of poster.