JCR CAMHC 2023

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Comprehensive Accreditation Manual for Home Care (CAMHC)

Published By	Publication Date	Number of Pages
Joint Commission	2023

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Category: Joint Commission

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Description

Now in PDF format! The 2023 Comprehensive Accreditation Manual for Home Care (CAMHC) provides all the official Joint Commission standards, elements of performance (EPs), National Patient Safety Goals®, and other accreditation requirements, including those for the optional Community-Based Palliative Care certification. Please note: This PDF manual is a digital version of the hard-copy 2023 Comprehensive Accreditation Manual for Home Care with standards effective January 1, 2023. As such, it is not updated. Key Topics: Standards, EPs, National Patient Safety Goals®, and Accreditation Participation Requirements effective January 1, 2023 Accreditation process information about Joint Commission policies and procedures and practical survey preparation information on the Early Survey Policy, documentation requirements, standards applicability, and more Key Features: Integrated regulatory requirements for home health and hospice deemed status Survey readiness tools, including compliance prompts, documentation checklists, and action planning worksheets in every standards chapter Icons to help navigate documentation requirements as well as risk areas “What’s New” summary of changes PDF format—printable, downloadable, and accessible Standards: All home care standards Setting: Organizations accredited under the Home Care Accreditation Program, including those that provide home health services, personal care and support services, pharmacy services including infusion services and/or mail order and specialty pharmacies, long-term care pharmacies and freestanding infusion centers, durable medical equipment services, and hospice services Key Audience: Staff working on accreditation, compliance, patient safety, or quality improvement

PDF Catalog

PDF Pages	PDF Title
1	What’s New 2023 CAMHC
9	Cover
10	Copyright
11	Contents
13	Introduction: How Joint Commission Accreditation Can Help on the Road to High Reliability (INTRO)
14	I. Introduction to Joint Commission Accreditation The Value of Joint Commission Accreditation
16	The Joint Commission’s Home Care Accreditation Program
17	Addressing Complex Issues in Home Care
18	Table 1. Standards That Address Complex Issues in Home Care Settings
19	II. About the
20	How Is This Manual Organized?
21	Table 2. Acronyms Used in This Manual
22	Table 2.
23	Accreditation Requirements
25	Accreditation Process Information
26	Identifying Applicable Standards
29	Understanding the Organization of the Standards Chapters
31	Understanding the Icons Used in the Manual
32	III. Steps to Achieving and Maintaining Compliance
33	Become Familiar with the Standards Assess Compliance with the Standards
35	Stimulate Improvement
37	Accelerate PI™
38	Keep Current with Standards Changes via Perspectives
39	IV. Get Extra Help
40	Getting Started with Accreditation Account Executive Contacting The Joint Commission
41	Standards Questions Requesting Permission to Share Content from the Manual
43	Patient Safety Systems (PS) Quality and Safety in Health Care Sidebar 1. Key Terms
44	Sidebar 1.
45	Goals of This Chapter
46	Becoming a Learning Organization
47	The Role of Leaders in Patient Safety
48	Safety Culture
51	Sidebar 2. Assessing Staff Accountability
53	Data Use and Reporting Systems
54	Effective Use of Data
55	Table 1. Defining and Comparing Analytical Tools
56	A Proactive Approach to Preventing Harm
58	Sidebar 3. Strategies for an Effective Risk Assessment
59	Sidebar 3. Encouraging Patient Activation
60	Beyond Accreditation: The Joint Commission Is Your Patient Safety Partner
62	References
65	Accreditation Participation Requirements (APR) Overview
66	Chapter Outline
67	Requirements, Rationales, and Elements of Performance APR.01.01.01 Elements of Performance for APR.01.01.01 APR.01.02.01
68	Rationale for APR.01.02.01 Elements of Performance for APR.01.02.01 APR.01.03.01
69	Elements of Performance for APR.01.03.01 APR.02.01.01
70	Elements of Performance for APR.02.01.01 APR.04.01.01 Elements of Performance for APR.04.01.01 APR.05.01.01 Rationale for APR.05.01.01 Elements of Performance for APR.05.01.01
71	APR.06.01.01 Elements of Performance for APR.06.01.01 APR.07.01.01 Elements of Performance for APR.07.01.01 APR.08.01.01 Elements of Performance for APR.08.01.01 APR.09.01.01
72	Elements of Performance for APR.09.01.01 APR.09.02.01 Rationale for APR.09.02.01 Elements of Performance for APR.09.02.01
73	APR.09.03.01 Elements of Performance for APR.09.03.01 APR.09.04.01 Elements of Performance for APR.09.04.01 APR.11.01.01 Elements of Performance for APR.11.01.01 APR.11.02.01 Elements of Performance for APR.11.02.01
74	APR.11.03.01 Elements of Performance for APR.11.03.01
75	Accreditation Participation Requirements (APR)
77	Environment of Care (EC) Overview About This Chapter
78	Other Issues for Consideration
80	Chapter Outline
81	Standards, Rationales, and Elements of Performance Standard EC.02.01.01 Rationale for EC.02.01.01 Elements of Performance for EC.02.01.01
82	Standard EC.02.01.03 Elements of Performance for EC.02.01.03
83	Standard EC.02.02.01 Rationale for EC.02.02.01 Elements of Performance for EC.02.02.01
84	Standard EC.02.03.01 Elements of Performance for EC.02.03.01 Standard EC.02.03.03
85	Rationale for EC.02.03.03 Elements of Performance for EC.02.03.03
86	Standard EC.02.03.05 Elements of Performance for EC.02.03.05
91	Standard EC.02.05.01 Elements of Performance for EC.02.05.01
93	Standard EC.02.05.03 Rationale for EC.02.05.03 Elements of Performance for EC.02.05.03
95	Standard EC.02.05.05 Elements of Performance for EC.02.05.05 Standard EC.02.05.07 Rationale for EC.02.05.07
96	Elements of Performance for EC.02.05.07
98	Standard EC.02.05.09 Elements of Performance for EC.02.05.09
101	Introduction to Standard EC.02.06.01 Standard EC.02.06.01 Elements of Performance for EC.02.06.01
103	Standard EC.04.01.01 Elements of Performance for EC.04.01.01
104	Standard EC.04.01.03 Elements of Performance for EC.04.01.03
105	Environment of Care (EC)
113	Emergency Management (EM) Overview About This Chapter
115	Chapter Outline
116	Standards, Rationales, and Elements of Performance Standard EM.01.01.01 Rationale for EM.01.01.01 Elements of Performance for EM.01.01.01
117	Standard EM.02.01.01
118	Rationale for EM.02.01.01 Elements of Performance for EM.02.01.01
121	Standard EM.02.02.01 Rationale for EM.02.02.01 Elements of Performance for EM.02.02.01
123	Standard EM.02.02.03 Rationale for EM.02.02.03 Elements of Performance for EM.02.02.03
124	Standard EM.02.02.05 Elements of Performance for EM.02.02.05 Standard EM.02.02.07 Rationale for EM.02.02.07 Elements of Performance for EM.02.02.07
126	Standard EM.02.02.09 Rationale for EM.02.02.09 Elements of Performance for EM.02.02.09
127	Standard EM.02.02.11 Rationale for EM.02.02.11 Elements of Performance for EM.02.02.11
128	Introduction to Standard EM.03.01.03 Exercise Scope
130	Standard EM.03.01.03 Rationale for EM.03.01.03
132	Elements of Performance for EM.03.01.03
134	Introduction to Standard EM.04.01.01
135	Standard EM.04.01.01 Elements of Performance for EM.04.01.01
137	Emergency Management (EM)
151	Equipment Management (EQ) Overview About This Chapter Applicability
152	Chapter Outline
153	Standards, Rationales, and Elements of Performance Standard EQ.01.01.01 Elements of Performance for EQ.01.01.01
154	Standard EQ.01.02.01 Elements of Performance for EQ.01.02.01
156	Standard EQ.01.03.01 Elements of Performance for EQ.01.03.01
157	Standard EQ.01.04.01 Elements of Performance for EQ.01.04.01
158	Standard EQ.01.05.01 Elements of Performance for EQ.01.05.01
159	Standard EQ.02.01.01 Elements of Performance for EQ.02.01.01
161	Equipment Management (EQ)
163	Human Resources (HR) Overview About This Chapter
164	Chapter Outline
165	Standards, Rationales, and Elements of Performance Standard HR.01.01.01 Rationale for HR.01.01.01 Elements of Performance for HR.01.01.01
170	Standard HR.01.02.05 Elements of Performance for HR.01.02.05
171	Standard HR.01.02.07 Elements of Performance for HR.01.02.07
174	Standard HR.01.03.01 Elements of Performance for HR.01.03.01
177	Standard HR.01.04.01 Rationale for HR.01.04.01 Elements of Performance for HR.01.04.01
179	Standard HR.01.05.01 Elements of Performance for HR.01.05.01
182	Standard HR.01.05.03 Rationale for HR.01.05.03 Elements of Performance for HR.01.05.03
183	Introduction to Standards HR.01.06.01 and HR.01.07.01
184	Standard HR.01.06.01 Elements of Performance for HR.01.06.01
188	Standard HR.01.07.01 Elements of Performance for HR.01.07.01
189	Human Resources (HR)
195	Infection Prevention and Control (IC) Overview
196	About This Chapter
197	Chapter Outline
198	Standards, Rationales, and Elements of Performance Introduction to Standards IC.01.01.01 Through IC.01.06.01 – Planning Standard IC.01.01.01 Elements of Performance for IC.01.01.01
199	Standard IC.01.02.01 Elements of Performance for IC.01.02.01 Standard IC.01.03.01 Elements of Performance for IC.01.03.01 Standard IC.01.04.01 Elements of Performance for IC.01.04.01
200	Standard IC.01.05.01 Elements of Performance for IC.01.05.01
201	Standard IC.01.06.01 Elements of Performance for IC.01.06.01 Introduction to Standards IC.02.01.01 Through IC.02.03.01 – Implementation Standard IC.02.01.01 Elements of Performance for IC.02.01.01
203	Standard IC.02.02.01 Rationale for IC.02.02.01
204	Elements of Performance for IC.02.02.01 Standard IC.02.03.01 Elements of Performance for IC.02.03.01
205	Introduction to Standard IC.02.04.01
206	Standard IC.02.04.01 Elements of Performance for IC.02.04.01
207	Standard IC.02.04.02 Rationale for IC.02.04.02 Elements of Performance for IC.02.04.02
210	Introduction to Standard IC.03.01.01– Evaluation and Improvement Standard IC.03.01.01 Elements of Performance for IC.03.01.01
211	Infection Control (IC)
217	Information Management (IM) Overview About This Chapter
218	Chapter Outline
219	Standards, Rationales, and Elements of Performance Introduction to Standard IM.01.01.01 Standard IM.01.01.01 Elements of Performance for IM.01.01.01
220	Introduction to Standard IM.01.01.03 Standard IM.01.01.03 Elements of Performance for IM.01.01.03
221	Introduction to Standard IM.02.01.01 Standard IM.02.01.01 Elements of Performance for IM.02.01.01
223	Introduction to Standard IM.02.01.03 Standard IM.02.01.03 Elements of Performance for IM.02.01.03
224	Standard IM.02.02.01 Rationale for IM.02.02.01 Elements of Performance for IM.02.02.01
225	Introduction to Standard IM.02.02.03 Standard IM.02.02.03
226	Rationale for IM.02.02.03 Elements of Performance for IM.02.02.03
227	Standard IM.03.01.01 Elements of Performance for IM.03.01.01 Standard IM.04.01.01 Rationale for IM.04.01.01 Elements of Performance for IM.04.01.01
229	Information Management (IM)
231	Leadership (LD) Overview
232	Proactive Risk Assessment
233	About This Chapter
234	Chapter Outline
235	Standards, Rationales, and Elements of Performance Introduction to Leadership Structure, Standards LD.01.01.01 Through LD.01.04.01 Standard LD.01.01.01 Rationale for LD.01.01.01
236	Elements of Performance for LD.01.01.01 Standard LD.01.03.01 Rationale for LD.01.03.01 Elements of Performance for LD.01.03.01
237	Standard LD.01.04.01 Elements of Performance for LD.01.04.01
238	Standard LD.01.06.01 Elements of Performance for LD.01.06.01
239	Introduction to Leadership Relationships, Standard LD.02.01.01 Standard LD.02.01.01 Rationale for LD.02.01.01 Elements of Performance for LD.02.01.01
240	Introduction to Organization Culture and System Performance Expectations, Standards LD.03.01.01 Through LD.03.06.01
242	Standard LD.03.01.01 Rationale for LD.03.01.01
243	Elements of Performance for LD.03.01.01 Standard LD.03.02.01 Rationale for LD.03.02.01 Elements of Performance for LD.03.02.01
244	Standard LD.03.03.01 Rationale for LD.03.03.01 Elements of Performance for LD.03.03.01 Standard LD.03.04.01
245	Rationale for LD.03.04.01 Elements of Performance for LD.03.04.01 Standard LD.03.05.01 Rationale for LD.03.05.01 Elements of Performance for LD.03.05.01
246	Standard LD.03.06.01 Rationale for LD.03.06.01 Elements of Performance for LD.03.06.01
247	Standard LD.03.07.01 Elements of Performance for LD.03.07.01
250	Standard LD.03.08.01 Elements of Performance for LD.03.08.01
251	Introduction to Standard LD.03.09.01 Standard LD.03.09.01 Elements of Performance for LD.03.09.01
254	Standard LD.03.10.01 Elements of Performance for LD.03.10.01 Introduction to Operations, Standards LD.04.01.01 Through LD.04.03.07 Standard LD.04.01.01 Elements of Performance for LD.04.01.01
256	Standard LD.04.01.03 Elements of Performance for LD.04.01.03
257	Standard LD.04.01.05
258	Rationale for LD.04.01.05 Elements of Performance for LD.04.01.05 Standard LD.04.01.07 Elements of Performance for LD.04.01.07
259	Standard LD.04.01.11 Rationale for LD.04.01.11 Elements of Performance for LD.04.01.11 Standard LD.04.02.01
260	Elements of Performance for LD.04.02.01 Standard LD.04.02.03 Elements of Performance for LD.04.02.03
261	Standard LD.04.02.05
262	Rationale for LD.04.02.05 Elements of Performance for LD.04.02.05 Standard LD.04.03.01 Elements of Performance for LD.04.03.01
263	Standard LD.04.03.03 Elements of Performance for LD.04.03.03
269	Standard LD.04.03.07 Rationale for LD.04.03.07
270	Elements of Performance for LD.04.03.07 Introduction to Oversight of Care, Treatment, or Services Provided Through Contractual Agreement, Standard LD.04.03.09 Monitoring Contracted Services
271	Standard LD.04.03.09 Elements of Performance for LD.04.03.09
276	Standard LD.04.03.13 Elements of Performance for LD.04.03.13
277	Leadership (LD)
285	Life Safety (LS) Overview Applicability of the Standards About This Chapter
288	Chapter Outline
289	Standards, Rationales, and Elements of Performance Introduction to Standard LS.01.01.01 Standard LS.01.01.01 Elements of Performance for LS.01.01.01
290	Standard LS.01.02.01 Elements of Performance for LS.01.02.01
293	Standard LS.02.01.10 Rationale for LS.02.01.10 Elements of Performance for LS.02.01.10
296	Standard LS.02.01.20 Rationale for LS.02.01.20 Elements of Performance for LS.02.01.20
303	Standard LS.02.01.30 Rationale for LS.02.01.30 Elements of Performance for LS.02.01.30
309	Standard LS.02.01.34 Elements of Performance for LS.02.01.34
311	Standard LS.02.01.35 Elements of Performance for LS.02.01.35
313	Standard LS.02.01.40 Elements of Performance for LS.02.01.40 Standard LS.02.01.50
314	Elements of Performance for LS.02.01.50
316	Standard LS.02.01.70 Elements of Performance for LS.02.01.70
319	Life Safety (LS)
321	Medication Compounding (MC) Overview About This Chapter
322	What is Compounding?
323	Chapter Outline
324	Standards, Rationales, and Elements of Performance Standard MC.01.01.01 Elements of Performance for MC.01.01.01
325	Standard MC.01.01.03 Elements of Performance for MC.01.01.03
326	Standard MC.01.02.01 Elements of Performance for MC.01.02.01 Standard MC.02.01.01 Elements of Performance for MC.02.01.01
327	Standard MC.02.01.03
328	Elements of Performance for MC.02.01.03 Standard MC.02.01.05 Elements of Performance for MC.02.01.05
329	Standard MC.02.01.07 Elements of Performance for MC.02.01.07
330	Standard MC.02.01.09 Elements of Performance for MC.02.01.09
331	Standard MC.02.01.11 Elements of Performance for MC.02.01.11
332	Standard MC.02.01.13 Elements of Performance for MC.02.01.13 Standard MC.03.01.01 Elements of Performance for MC.03.01.01
333	Standard MC.03.02.01 Elements of Performance for MC.03.02.01
334	Standard MC.03.03.01 Elements of Performance for MC.03.03.01 Standard MC.03.04.01
335	Elements of Performance for MC.03.04.01 Standard MC.03.05.01 Elements of Performance for MC.03.05.01 Standard MC.03.05.03
336	Elements of Performance for MC.03.05.03
338	Standard MC.03.06.01 Elements of Performance for MC.03.06.01
339	Standard MC.03.06.03
340	Elements of Performance for MC.03.06.03 Standard MC.03.06.05 Elements of Performance for MC.03.06.05
342	Standard MC.03.06.07 Elements of Performance for MC.03.06.07
343	Standard MC.03.06.09 Elements of Performance for MC.03.06.09
344	Standard MC.03.06.11 Elements of Performance for MC.03.06.11
346	Standard MC.03.07.01 Elements of Performance for MC.03.07.01
347	Standard MC.03.08.01 Elements of Performance for MC.03.08.01 Standard MC.03.08.03
348	Elements of Performance for MC.03.08.03 Standard MC.03.08.05 Elements of Performance for MC.03.08.05 Standard MC.03.08.07 Elements of Performance for MC.03.08.07
349	Standard MC.03.08.09 Elements of Performance for MC.03.08.09 Standard MC.03.08.11 Elements of Performance for MC.03.08.11
351	Standard MC.04.01.01 Elements of Performance for MC.04.01.01
352	Standard MC.04.01.03 Elements of Performance for MC.04.01.03
353	Standard MC.04.02.01 Elements of Performance for MC.04.02.01
356	Standard MC.04.02.03 Elements of Performance for MC.04.02.03
357	Standard MC.05.01.01 Elements of Performance for MC.05.01.01
358	Standard MC.05.01.03 Elements of Performance for MC.05.01.03
360	Standard MC.05.02.01 Elements of Performance for MC.05.02.01
361	Standard MC.05.02.03 Elements of Performance for MC.05.02.03
363	Standard MC.05.03.01 Elements of Performance for MC.05.03.01
364	Standard MC.05.04.01 Elements of Performance for MC.05.04.01
365	Standard MC.05.05.01 Elements of Performance for MC.05.05.01
367	Standard MC.05.06.01 Elements of Performance for MC.05.06.01
369	Medication Management (MM) Overview
370	About This Chapter
372	Chapter Outline
373	Standards, Rationales, and Elements of Performance Standard MM.01.01.01 Rationale for MM.01.01.01 Elements of Performance for MM.01.01.01 Standard MM.01.01.03 Rationale for MM.01.01.03
374	Elements of Performance for MM.01.01.03
375	Standard MM.01.02.01 Elements of Performance for MM.01.02.01 Standard MM.02.01.01 Elements of Performance for MM.02.01.01
376	Standard MM.03.01.01 Rationale for MM.03.01.01 Elements of Performance for MM.03.01.01
379	Standard MM.03.01.03 Rationale for MM.03.01.03 Elements of Performance for MM.03.01.03 Standard MM.03.01.05 Rationale for MM.03.01.05 Elements of Performance for MM.03.01.05
380	Introduction to Standard MM.04.01.01 Standard MM.04.01.01 Elements of Performance for MM.04.01.01
382	Standard MM.05.01.01 Elements of Performance for MM.05.01.01
383	Standard MM.05.01.07 Elements of Performance for MM.05.01.07 Standard MM.05.01.09
384	Rationale for MM.05.01.09 Elements of Performance for MM.05.01.09
385	Standard MM.05.01.11 Elements of Performance for MM.05.01.11 Standard MM.05.01.13 Rationale for MM.05.01.13
386	Elements of Performance for MM.05.01.13 Standard MM.05.01.15 Elements of Performance for MM.05.01.15 Standard MM.05.01.17 Elements of Performance for MM.05.01.17 Standard MM.05.01.19
387	Rationale for MM.05.01.19 Elements of Performance for MM.05.01.19
388	Standard MM.06.01.01 Elements of Performance for MM.06.01.01
389	Standard MM.06.01.03 Elements of Performance for MM.06.01.03
390	Standard MM.06.01.05 Rationale for MM.06.01.05 Elements of Performance for MM.06.01.05 Standard MM.07.01.01 Elements of Performance for MM.07.01.01
391	Standard MM.07.01.03 Rationale for MM.07.01.03 Elements of Performance for MM.07.01.03 Standard MM.08.01.01
392	Elements of Performance for MM.08.01.01
395	Medication Management (MM)
399	National Patient Safety Goals (NPSG) Chapter Outline National Patient Safety Goals®
400	Requirements, Rationales, and Elements of Performance Goal 1 NPSG.01.01.01 Rationale for NPSG.01.01.01 Elements of Performance for NPSG.01.01.01
401	Goal 3 Introduction to Reconciling Medication Information
402	NPSG.03.06.01 Rationale for NPSG.03.06.01 Elements of Performance for NPSG.03.06.01
403	Goal 7 NPSG.07.01.01 Rationale for NPSG.07.01.01
404	Elements of Performance for NPSG.07.01.01 Goal 9 NPSG.09.02.01 Rationale for NPSG.09.02.01 Elements of Performance for NPSG.09.02.01
405	Goal 15 NPSG.15.02.01 Rationale for NPSG.15.02.01 Elements of Performance for NPSG.15.02.01
407	National Patient Safety Goals (NPSG)
409	Provision of Care, Treatment, and Services (PC) Overview
410	About This Chapter
411	Chapter Outline
412	Standards, Rationales, and Elements of Performance Standard PC.01.01.01 Elements of Performance for PC.01.01.01
413	Introduction to Standard PC.01.02.01
414	Standard PC.01.02.01 Rationale for PC.01.02.01
415	Elements of Performance for PC.01.02.01
421	Standard PC.01.02.03
422	Elements of Performance for PC.01.02.03
423	Standard PC.01.02.05 Elements of Performance for PC.01.02.05
425	Introduction to Standard PC.01.02.07 Standard PC.01.02.07 Elements of Performance for PC.01.02.07
426	Introduction to Standard PC.01.02.09 Standard PC.01.02.09
427	Elements of Performance for PC.01.02.09
428	Introduction to Standard PC.01.03.01 Standard PC.01.03.01 Elements of Performance for PC.01.03.01
434	Standard PC.02.01.01 Elements of Performance for PC.02.01.01
435	Standard PC.02.01.03
436	Elements of Performance for PC.02.01.03
437	Standard PC.02.01.05 Rationale for PC.02.01.05 Elements of Performance for PC.02.01.05
441	Standard PC.02.01.07 Elements of Performance for PC.02.01.07
442	Introduction to Standard PC.02.02.01 Standard PC.02.02.01 Elements of Performance for PC.02.02.01
445	Standard PC.02.02.03 Elements of Performance for PC.02.02.03
446	Standard PC.02.02.05 Elements of Performance for PC.02.02.05
447	Introduction to Standard PC.02.02.13 Standard PC.02.02.13 Elements of Performance for PC.02.02.13
448	Introduction to Standard PC.02.03.01 Standard PC.02.03.01 Elements of Performance for PC.02.03.01
452	Standard PC.03.05.01 Elements of Performance for PC.03.05.01 Standard PC.03.05.03
453	Elements of Performance for PC.03.05.03 Standard PC.03.05.05 Elements of Performance for PC.03.05.05
454	Standard PC.03.05.07 Elements of Performance for PC.03.05.07 Standard PC.03.05.11 Elements of Performance for PC.03.05.11
455	Standard PC.03.05.13 Elements of Performance for PC.03.05.13 Standard PC.03.05.15 Elements of Performance for PC.03.05.15 Standard PC.03.05.17 Elements of Performance for PC.03.05.17
457	Standard PC.03.05.19 Elements of Performance for PC.03.05.19
458	Standard PC.04.01.01 Elements of Performance for PC.04.01.01
459	Standard PC.04.01.03 Elements of Performance for PC.04.01.03
460	Standard PC.04.01.05 Elements of Performance for PC.04.01.05 Standard PC.04.02.01
461	Elements of Performance for PC.04.02.01
463	Provision of Care, Treatment, and Services (PC)
479	Performance Improvement (PI) Overview About This Chapter
481	Chapter Outline
482	Standards, Rationales, and Elements of Performance Introduction to Standard PI.01.01.01 Standard PI.01.01.01 Elements of Performance for PI.01.01.01
484	Standard PI.02.01.01
485	Rationale for PI.02.01.01 Elements of Performance for PI.02.01.01
486	Introduction to Standard PI.03.01.01 Standard PI.03.01.01 Elements of Performance for PI.03.01.01 Standard PI.04.01.01
487	Rationale for PI.04.01.01 Elements of Performance for PI.04.01.01
489	Performance Improvement (PI)
493	Record of Care, Treatment, and Services (RC) Overview About This Chapter
494	Chapter Outline
495	Standards, Rationales, and Elements of Performance Standard RC.01.01.01 Elements of Performance for RC.01.01.01
496	Standard RC.01.02.01 Elements of Performance for RC.01.02.01
497	Standard RC.01.03.01 Elements of Performance for RC.01.03.01 Standard RC.01.04.01 Elements of Performance for RC.01.04.01 Standard RC.01.05.01 Elements of Performance for RC.01.05.01
498	Standard RC.02.01.01 Elements of Performance for RC.02.01.01
502	Standard RC.02.02.01 Elements of Performance for RC.02.02.01 Standard RC.02.03.07 Elements of Performance for RC.02.03.07
503	Record of Care, Treatment, and Services (RC)
507	Rights and Responsibilities of the Individual (RI) Overview About This Chapter
509	Chapter Outline
510	Standards, Rationales, and Elements of Performance Introduction to Standard RI.01.01.01 Standard RI.01.01.01 Elements of Performance for RI.01.01.01
512	Introduction to Standard RI.01.01.03
513	Standard RI.01.01.03 Elements of Performance for RI.01.01.03
514	Standard RI.01.02.01 Rationale for RI.01.02.01
515	Elements of Performance for RI.01.02.01
517	Standard RI.01.02.03
518	Elements of Performance for RI.01.02.03 Standard RI.01.03.01 Rationale for RI.01.03.01 Elements of Performance for RI.01.03.01
519	Standard RI.01.03.05 Elements of Performance for RI.01.03.05
520	Standard RI.01.04.01 Elements of Performance for RI.01.04.01 Standard RI.01.05.01 Elements of Performance for RI.01.05.01
521	Standard RI.01.06.03 Rationale for RI.01.06.03 Elements of Performance for RI.01.06.03
522	Standard RI.01.06.05 Elements of Performance for RI.01.06.05
523	Standard RI.01.06.09 Elements of Performance for RI.01.06.09 Standard RI.01.07.01 Elements of Performance for RI.01.07.01
525	Standard RI.01.07.05 Elements of Performance for RI.01.07.05
526	Introduction to Standard RI.02.01.01
527	Standard RI.02.01.01 Elements of Performance for RI.02.01.01
529	Rights and Responsibilities of the Individual (RI)
535	Waived Testing (WT) Overview
536	About This Chapter
538	Chapter Outline
539	Standards, Rationales, and Elements of Performance Standard WT.01.01.01 Elements of Performance for WT.01.01.01
541	Standard WT.02.01.01 Elements of Performance for WT.02.01.01 Standard WT.03.01.01 Elements of Performance for WT.03.01.01
542	Standard WT.04.01.01 Elements of Performance for WT.04.01.01
543	Standard WT.05.01.01 Elements of Performance for WT.05.01.01
545	Waived Testing (WT)
549	The Accreditation Process (ACC) Notices ACC Chapter Contents
551	Overview General Eligibility Requirements
553	Eligibility for Home Care Accreditation
557	Eligibility Requirements for Community-Based Palliative Care Certification
559	Scope of Accreditation Surveys Accreditation Policies
560	Tailored Survey Policy
561	Organizational and Functional Integration
564	System Accreditation Option Table 1. Sampling for System Surveys by Risk
565	Table 2. Sampling for System Surveys by Size
566	Concurrent Survey Option Contracted Services Integrated Care Certification Option
567	Home Health and Hospice Deemed Status Option
568	Home Infusion Therapy Deemed Status Option
569	Initial Surveys
570	Information Accuracy and Truthfulness Policy
572	Good Faith Participation in Accreditation/ Certification
573	Public Information Policy\|\| Process for Responding to a Complaint
574	Early Survey Policy Sidebar 1. Early Survey Policy
575	Sidebar 1.
577	Before the Survey
578	An Organization’s Secure Joint Commission Connect Extranet Site
579	Role of the Account Executive Electronic Application for Accreditation (E-App)
580	Accreditation/Certification Contract and Business Associate Agreement
581	Annual and Survey Fees
582	During the Survey
583	Survey Notification Table 3. Exceptions to Unannounced Surveys‡‡
584	Table 3.
587	Initial and Full Survey Team Composition
588	Survey Agenda
592	Tracer Methodology Table 4. Home Care–Specific Tracer Applicability and Objectives
593	Table 4.
595	Immediate Threat to Health or Safety
599	Summary of the Accreditation Reports
600	After the Survey The Scoring Process
606	Evidence of Standards Compliance (ESC) Process
610	Accreditation Award Display and Use
611	Recommendation Letter for Organizations That Elect to Use The Joint Commission Deemed Status Option
612	Between Accreditation Surveys Duration of Accreditation Award Continuous Compliance
613	Intracycle Monitoring (ICM) Focused Standards Assessment (FSA)
614	Sidebar 2. Focused Standards Assessment (FSA) Options
615	Sidebar 2.
616	Sentinel Event Follow-up Notifying The Joint Commission About Organization Changes
618	Accreditation Status of Organizations That Cease Services After a Disaster
620	Accreditation Status of Organizations That Cease Services or Do Not Have Patients for a Period of Time
621	Reentering the Accreditation Process Additional Surveys
624	Decision Rules for Organizations Seeking Initial Accreditation
625	Accredited Community-Based Palliative Care Certification
626	Limited, Temporary Accreditation Evidence of Standards Compliance (ESC) Medicare Deficiency Follow-up Survey Denial of Accreditation
628	Decision Rules for Organizations Seeking Reaccreditation Accredited Community-Based Palliative Care Certification
629	Evidence of Standards Compliance (ESC) Medicare Deficiency Follow-up Survey Accreditation with Follow-up Survey
631	Preliminary Denial of Accreditation
632	Denial of Accreditation
633	Process for Organizations That Meet Decision Rule PDA02 for Patients Placed at Risk for Serious Adverse Outcomes Due to Signific
635	Process for Organizations That Meet Decision Rule PDA04
636	Review and Appeal Procedures I. Evaluation by Joint Commission Staff
637	II. Accreditation with Follow-up Survey
638	III. Review Hearings
639	IV. Following a Review Hearing
640	V. Final Review &Appeal Request
643	Standards Applicability Grid (SAG)
644	Abbreviations Used for Services in Applicability Grid
701	Sentinel Event Policy (SE)
702	Goals of the Sentinel Event Policy
703	Identifying Sentinel Events
705	Sidebar 1. Key Terms
706	Sidebar 1.
708	Determining That a Sentinel Event Is Subject to Review Relationship to the Survey Process
709	Required Organization Response to a Sentinel Event
711	Reporting a Sentinel Event to The Joint Commission
713	Conducting a Comprehensive Systematic Analysis
714	Developing a Corrective Action Plan
715	Submitting the Comprehensive Systematic Analysis and Corrective Action Plan
716	Table 1. Options for a Joint Commission Review of an Organization’s Response to a Sentinel Event
717	Table 1.
718	The Joint Commission’s Response Review of Comprehensive Systematic Analyses and Corrective Action Plans
719	Follow-up Activities
721	Disclosable Information Handling Sentinel Event–Related Documents The Sentinel Event Database
722	Overseeing the Sentinel Event Policy
723	The Joint Commission Quality Report (QR) Introduction What Is The Joint Commission Quality Report?
724	What Will My Quality Report Contain? What Is Quality Check?
725	Is a Quality Report Available for My Accredited Home Care Organization? Can My Home Care Organization Comment on Its Quality Report?
726	How Does My Home Care Organization Submit a Commentary? Are There Any Criteria That Must Be Met in a Commentary? What Are the Marketing and Communication Guidelines for Publicizing Your Accreditation and Commitment to Quality?
727	Guidelines for Publicizing Compliance with the National Patient Safety Goals
729	Required Written Documentation (RWD)
730	List of EPs Requiring Written Documentation for Home Care by Service Delivery Mode Home Health Accreditation Participation Requirements (APR) Environment of Care (EC) Emergency Management (EM) Equipment Management (EQ) Human Resources (HR)
731	Infection Prevention and Control (IC) Information Management (IM) Leadership (LD) Medication Management (MM) National Patient Safety Goals (NPSG) Provision of Care, Treatment, and Services (PC)
732	Performance Improvement (PI) Record of Care, Treatment, and Services (RC) Rights and Responsibilities of the Individual (RI) Waived Testing (WT) Personal Care and Support Services Accreditation Participation Requirements (APR)
733	Environment of Care (EC) Emergency Management (EM) Human Resources (HR) Infection Prevention and Control (IC) Information Management (IM) Leadership (LD)
734	Provision of Care, Treatment, and Services (PC) Performance Improvement (PI) Record of Care, Treatment, and Services (RC) Rights and Responsibilities of the Individual (RI) Home Infusion Accreditation Participation Requirements (APR) Environment of Care (EC) Emergency Management (EM)
735	Equipment Management (EQ) Human Resources (HR) Infection Prevention and Control (IC) Information Management (IM) Leadership (LD) Medication Management (MM)
736	National Patient Safety Goals (NPSG) Provision of Care, Treatment, and Services (PC) Performance Improvement (PI) Record of Care, Treatment, and Services (RC) Rights and Responsibilities of the Individual (RI) Waived Testing (WT) Hospice—Patient Residence Accreditation Participation Requirements (APR)
737	Environment of Care (EC) Emergency Management (EM) Equipment Management (EQ) Human Resources (HR) Infection Prevention and Control (IC) Information Management (IM)
738	Leadership (LD) Medication Management (MM) National Patient Safety Goals (NPSG) Provision of Care, Treatment and Services (PC) Performance Improvement (PI)
739	Record of Care, Treatment, and Services (RC) Rights and Responsibilities of the Individual (RI) Waived Testing (WT) Hospice—Facility Based Accreditation Participation Requirements (APR) Environment of Care (EC)
740	Emergency Management (EM) Equipment Management (EQ) Human Resources (HR) Infection Prevention and Control (IC) Information Management (IM) Leadership (LD)
741	Life Safety (LS) Medication Management (MM) National Patient Safety Goals (NPSG) Provision of Care, Treatment, and Services (PC) Performance Improvement (PI)
742	Record of Care, Treatment, and Services (RC) Rights and Responsibilities of the Individual (RI) Waived Testing (WT) Pharmacy—Dispensing Accreditation Participation Requirements (APR) Environment of Care (EC) Emergency Management (EM)
743	Equipment Management (EQ) Human Resources (HR) Infection Prevention and Control (IC) Information Management (IM) Leadership (LD) Medication Compounding (MC)
744	Medication Management (MM) Provision of Care, Treatment, and Services (PC) Performance Improvement (PI) Record of Care, Treatment, and Services (RC) Rights and Responsibilities of the Individual (RI)
745	Pharmacy—Clinical/Consultant Pharmacist Accreditation Participation Requirements (APR) Emergency Management (EM) Equipment Management (EQ) Human Resources (HR) Infection Prevention and Control (IC) Information Management (IM)
746	Leadership (LD) Medication Management (MM) National Patient Safety Goals (NPSG) Provision of Care, Treatment, and Services (PC) Performance Improvement (PI) Record of Care, Treatment, and Services (RC) Rights and Responsibilities of the Individual (RI)
747	Pharmacy—Specialty Pharmacy Accreditation Participation Requirements (APR) Environment of Care (EC) Emergency Management (EM) Equipment Management (EQ) Human Resources (HR) Infection Prevention and Control (IC)
748	Information Management (IM) Leadership (LD) Medication Compounding (MC) Medication Management (MM)
749	National Patient Safety Goals (NPSG) Provision of Care, Treatment, and Services (PC) Performance Improvement (PI) Record of Care, Treatment, and Services (RC) Rights and Responsibilities of the Individual (RI) Pharmacy—Freestanding Ambulatory Infusion Accreditation Participation Requirements (APR) Environment of Care (EC)
750	Emergency Management (EM) Equipment Management (EQ) Human Resources (HR) Infection Prevention and Control (IC) Information Management (IM) Leadership (LD) Medication Compounding (MC)
751	Medication Management (MM) National Patient Safety Goals (NPSG) Provision of Care, Treatment, and Services (PC) Performance Improvement (PI) Record of Care, Treatment, and Services (RC)
752	Rights and Responsibilities of the Individual (RI) Waived Testing (WT) Pharmacy—Long Term Care Pharmacy Dispensing Accreditation Participation Requirements (APR) Environment of Care (EC) Emergency Management (EM) Equipment Management (EQ)
753	Human Resources (HR) Infection Prevention and Control (IC) Information Management (IM) Leadership (LD) Medication Compounding (MC)
754	Medication Management (MM) Provision of Care, Treatment, and Services (PC) Performance Improvement (PI) Record of Care, Treatment, and Services (RC) Rights and Responsibilities of the Individual (RI) Clinical Respiratory Accreditation Participation Requirements (APR) Environment of Care (EC)
755	Emergency Management (EM) Human Resources (HR) Infection Prevention and Control (IC) Information Management (IM) Leadership (LD) Medication Management (MM)
756	National Patient Safety Goals (NPSG) Provision of Care, Treatment, and Services (PC) Performance Improvement (PI) Record of Care, Treatment, and Services (RC) Rights and Responsibilities of the Individual (RI) Respiratory Equipment Accreditation Participation Requirements (APR)
757	Environment of Care (EC) Emergency Management (EM) Equipment Management (EQ) Human Resources (HR) Infection Prevention and Control (IC) Information Management (IM) Leadership (LD)
758	National Patient Safety Goals (NPSG) Provision of Care, Treatment, and Services (PC) Performance Improvement (Pi) Record of Care, Treatment, and Services (RC) Rights and Responsibilities of the Individual (RI) Orthotics and Prosthetics—Facility Based Accreditation Participation Requirements (APR)
759	Environment of Care (EC) Emergency Management (EM) Equipment Management (EQ) Human Resources (HR) Infection Prevention and Control (IC) Information Management (IM) Leadership (LD)
760	Provision of Care, Treatment, and Services (PC) Performance Improvement (PI) Record of Care, Treatment, and Services (RC) Rights and Responsibilities of the Individual (RI) Orthotics and Prosthetics—Patient Residence Accreditation Participation Requirements (APR) Environment of Care (EC)
761	Emergency Management (EM) Equipment Management (EQ) Human Resources (HR) Infection Prevention and Control (IC) Information Management (IM) Leadership (LD)
762	Provision of Care, Treatment, and Services (PC) Performance Improvement (PI) Record of Care, Treatment, and Services (RC) Rights and Responsibilities of the Individual (RI) Supplies—Mail Order Accreditation Participation Requirements (APR) Environment of Care (EC) Emergency Management (EM)
763	Equipment Management (EQ) Human Resources (HR) Infection Prevention and Control (IC) Information Management (IM) Leadership (LD) Provision of Care, Treatment, and Services (PC)
764	Performance Improvement (PI) Record of Care, Treatment, and Services (RC) Rights and Responsibilities of the Individual (RI) Supplies—Patient Residence Accreditation Participation Requirements (APR) Environment of Care (EC) Emergency Management (EM) Equipment Management (EQ)
765	Human Resources (HR) Infection Prevention and Control (IC) Information Management (IM) Leadership (LD) Provision of Care, Treatment, and Services (PC) Performance Improvement (PI)
766	Record of Care, Treatment, and Services (RC) Rights and Responsibilities of the Individual (RI) Rehabilitation Technology—Facility Based Accreditation Participation Requirements (APR) Environment of Care (EC) Emergency Management (EM) Equipment Management (EQ)
767	Human Resources (HR) Infection Prevention and Control (IC) Information Management (IM) Leadership (LD) Provision of Care, Treatment, and Services (PC) Performance Improvement (PI) Record of Care, Treatment, and Services (RC)
768	Rights and Responsibilities of the Individual (RI) Rehabilitation Technology—Patient Residence Accreditation Participation Requirements (APR) Environment of Care (EC) Emergency Management (EM) Equipment Management (EQ) Human Resources (HR)
769	Infection Prevention and Control (IC) Information Management (IM) Leadership (LD) Provision of Care, Treatment, and Services (PC) Performance Improvement (PI) Record of Care, Treatment, and Services (RC) Rights and Responsibilities of the Individual (RI)
770	Durable Medical Equipment—Patient Residence Accreditation Participation Requirements (APR) Environment of Care (EC) Emergency Management (EM) Equipment Management (EQ) Human Resources (HR) Infection Prevention and Control (IC)
771	Information Management (IM) Leadership (LD) National Patient Safety Goals (NPSG) Provision of Care, Treatment, and Services (PC) Performance Improvement (PI) Record of Care, Treatment, and Services (RC)
772	Rights and Responsibilities of the Individual (RI) Durable Medical Equipment—Facility Based Accreditation Participation Requirements (APR) Environment of Care (EC) Emergency Management (EM) Equipment Management (EQ) Human Resources (HR) Infection Prevention and Control (IC)
773	Information Management (IM) Leadership (LD) Provision of Care, Treatment, and Services (PC) Performance Improvement (PI) Record of Care, Treatment, and Services (RC) Rights and Responsibilities of the Individual (RI)
774	Durable Medical Equipment—Mail Order Accreditation Participation Requirements (APR) Environment of Care (EC) Emergency Management (EM) Equipment Management (EQ) Human Resources (HR) Infection Prevention and Control (IC) Information Management (IM)
775	Leadership (LD) Provision of Care, Treatment, and Services (PC) Performance Improvement (PI) Record of Care, Treatment, and Services (RC) Rights and Responsibilities of the Individual (RI)
777	Early Survey Policy (ESP) Accreditation Participation Requirements (APR) Environment of Care (EC) Emergency Management (EM)
778	Equipment Management (EQ) Human Resources (HR) Infection Prevention and Control (IC) Information Management (IM)
779	Leadership (LD) Life Safety (LS) Medication Compounding (MC)
780	Medication Management (MM) National Patient Safety Goals (NPSG) Provision of Care, Treatment, and Services (PC) Performance Improvement (PI) Record of Care, Treatment, and Services (RC) Rights and Responsibilities of the Individual (RI)
781	Waived Testing (WT)
783	Community-Based Palliative Care Certification (CBPC) Overview
784	Accreditation Participation Requirements (APR) Standard APR.01.02.01 Elements of Performance for APR.01.02.01 Standard APR.01.03.01 Elements of Performance for APR.01.03.01
785	Standard APR.06.01.01 Elements of Performance for APR.06.01.01 Standard APR.11.01.01
786	Elements of Performance for APR.11.01.01 Standard APR.11.02.01 Elements of Performance for APR.11.02.01 Standard APR.11.03.01
787	Elements of Performance for APR.11.03.01 Human Resources (HR) Standard HR.01.01.01 Elements of Performance for HR.01.01.01
788	Standard HR.01.02.07 Elements of Performance for HR.01.02.07
789	Standard HR.01.04.01 Elements of Performance for HR.01.04.01
790	Standard HR.01.05.03 Elements of Performance for HR.01.05.03
791	Standard HR.01.06.01 Elements of Performance for HR.01.06.01 Information Management (IM) Standard IM.02.01.03 Elements of Performance for IM.02.01.03 Standard IM.02.02.01 Elements of Performance for IM.02.02.01
792	Standard IM.03.01.01 Elements of Performance for IM.03.01.01 Leadership (LD) Standard LD.01.03.01 Elements of Performance for LD.01.03.01
793	Standard LD.02.01.01 Elements of Performance for LD.02.01.01 Standard LD.03.02.01 Elements of Performance for LD.03.02.01 Standard LD.03.04.01 Elements of Performance for LD.03.04.01
794	Standard LD.03.06.01 Elements of Performance for LD.03.06.01 Standard LD.03.07.01 Elements of Performance for LD.03.07.01
795	Standard LD.03.08.01 Elements of Performance for LD.03.08.01 Standard LD.03.10.01
796	Elements of Performance for LD.03.10.01 Standard LD.04.01.05 Elements of Performance for LD.04.01.05 Standard LD.04.01.07 Elements of Performance for LD.04.01.07 Standard LD.04.01.11 Elements of Performance for LD.04.01.11
797	Standard LD.04.03.03 Elements of Performance for LD.04.03.03 Standard LD.04.03.09 Elements of Performance for LD.04.03.09 Provision of Care, Treatment, and Services (PC) Standard PC.01.01.01 Elements of Performance for PC.01.01.01
798	Standard PC.01.02.01 Elements of Performance for PC.01.02.01
799	Standard PC.01.02.03 Elements of Performance for PC.01.02.03
800	Standard PC.01.03.01 Elements of Performance for PC.01.03.01
801	Standard PC.02.01.01 Elements of Performance for PC.02.01.01
802	Standard PC.02.01.05 Elements of Performance for PC.02.01.05
803	Standard PC.02.02.01 Elements of Performance for PC.02.02.01
804	Standard PC.02.02.05 Elements of Performance for PC.02.02.05 Standard PC.02.03.01 Elements of Performance for PC.02.03.01 Standard PC.04.01.01 Elements of Performance for PC.04.01.01
805	Standard PC.04.02.01 Elements of Performance for PC.04.02.01 Performance Improvement (PI) Standard PI.01.01.01 Elements of Performance for PI.01.01.01
806	Standard PI.03.01.01 Elements of Performance for PI.03.01.01 Standard PI.04.01.01 Elements of Performance for PI.04.01.01 Record of Care, Treatment, and Services (RC) Standard RC.02.01.01
807	Elements of Performance for RC.02.01.01 Rights and Responsibilities of the Individual (RI) Standard RI.01.01.01 Elements of Performance for RI.01.01.01
808	Standard RI.01.01.03 Elements of Performance for RI.01.01.03 Standard RI.01.02.01 Elements of Performance for RI.01.02.01
809	Standard RI.01.05.01 Elements of Performance for RI.01.05.01 Standard RI.01.07.01 Elements of Performance for RI.01.07.01
810	Standard RI.02.01.01 Elements of Performance for RI.02.01.01
811	Appendix A: Medicare Requirements for Hospice (AXA) Subpart I Advance Directives
823	Additional Regulations
837	Glossary (GL)
893	Index (IX)