Home Events Governing Board and Contract Management: CMS, TJC and DNV Requirements

Governing Board and Contract Management: CMS, TJC and DNV Requirements

NDHA is an approved provider of continuing education by the North Dakota Board of Examiners for Nursing Home Administrators.

Date: 5/17/22

9:00 AM – Noon Central time


Registration fees:       $175 per NDHA member  |  $225 per non-member


The Centers for Medicare & Medicaid Services (CMS) has issued many citations related to the Governing Board and specifically, contract management. The governing board of a hospital is responsible for oversight of contracted services and ensuring compliance with standards set forth by accrediting bodies. This presentation will cover all the contract requirements for hospitals under the CMS Conditions of Participation and those accredited by the Joint Commission. This program will also cover the standards for hospitals accredited by DNV-GL.

Learning Objectives:

At the conclusion of this session, participants should be able to:

  • Describe the CMS, TJC and DNV standards for governing board and contract management.
  • Recite that the governing board is responsible for the operation and provision of care by the hospital.
  • Discuss that C-suite management is responsible to the governing board for implementation of policies and procedures and provision of safe care.
  • Recall that CMS requires that board ensure all services, including contracted services, are reviewed as part of the QAPI process.



Lena Browning, MHA, BSN, RNC-NIC, CSHA
Nash Healthcare Consulting

Lena Browning is a nurse leader and accreditation specialist with more than 25 years of experience in clinical leadership in acute care settings. As a principal consultant with Compass Clinical Consulting, Lena served as team lead for the accreditation and regulatory compliance survey team. Most recently, Lena has fulfilled three interim positions as director of accreditation and was responsible for restructuring accreditation departments and leading organizations in compliance. Additionally, Lena has successfully coached numerous organizations through Immediate Jeopardy (IJ) situations with all organizations getting the IJ lifted and no condition level findings noted on return surveys. Prior to consulting, Lena had over two decades of experience in accreditation and regulatory leadership. As an expert for CMS, TJC, and state regulations, she has performed system-wide tracers for continuous readiness and patient safety, coordinated accreditation and regulatory surveys, chaired continuous readiness committees, and coached staff and leadership in compliance and performance improvement strategies. Lena earned a Master of Healthcare Administration from the University of Southern Indiana and a Bachelor of Science in Nursing from Murray State University. She holds numerous certifications in basic life support, neonatal and pediatric advanced life support, and newborn resuscitation and post resuscitation stabilization. She is also a member of the Association for Professionals in Infection Control and Epidemiology (APIC).

This speaker has no real or perceived conflicts of interest that relate to this presentation.


May 17 2022


9:00 am - 11:00 am

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