JCR CAMHC 2022

$178.21

Comprehensive Accreditation Manual for Home Care (CAMHC)

Published By	Publication Date	Number of Pages
Joint Commission	2022

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Category: Joint Commission

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Description

Continuous compliance starts with staff who know what The Joint Commission requires. The 2022 Comprehensive Accreditation Manual for Home Care (CAMHC) provides the key information your organization needs to power performance improvement and maintain continuous standards compliance. It features the official Joint Commission standards, National Patient Safety Goals, and other accreditation requirements, including standards and elements of performance for the optional Community-Based Palliative Care certification. The CAMHC includes color-coded tabs that allow you to find exactly what you need for standards compliance or survey readiness when you need it. Inside you’ll find descriptions of the survey and decision process and checklists of the elements of performance that require written documentation. Get ready to power performance improvement and excellence in your organization! Please note: Beginning in 2022, this hard-copy manual will no longer have an Update Service. The CAMHC is now delivered annually. For the most up-to-date standards throughout 2022, access E-dition® on your Joint Commission Connect® extranet site or consider purchasing the E-dition® Home Care version. Understanding Which Standards Apply. The Joint Commission Home Care Accreditation Program serves organizations providing care in the patient’s place of residence or those offering community-based services. The types of settings most commonly served include home health, hospice, pharmacies, durable medical equipment providers (including DMEPOS), and personal care and support. (See the section on Settings below for a longer list of services.) Eligibility requirements will differ based on the services provided and survey option you select; more information is available on the Joint Commission’s website. Standards for all these settings and services appear in the 2022 CAMHC. The goal of this manual’s “Standards Applicability Grid” chapter is to help each organization determine which specific standards and EPs in the manual apply to its setting(s) and service(s). These applicability grids allow you to quickly identify the services and settings, as you identified them in your E-App, and find related standards that apply to your organization. In contrast, the E-dition® on an accredited organization’s Joint Commission Connect® extranet site provides a customized manual based on the settings and services checked on your E-App. (That is, the E-dition® only displays an organization-specific compliment of standards and EPs). Key Topics: “Gold tab” accreditation requirements including the standards, National Patient Safety Goals®, and Accreditation Participation Requirements effective January 1, 2022 “Blue tab” 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 Standards and elements of performance for optional community-based palliative care certification Keys to successfully using the manual for survey preparedness 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 made since the last edition Color-coded blue and gold tabs allow you to find exactly what you need when you need it 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 responsible for accreditation, compliance, patient safety, or quality improvement

PDF Catalog

PDF Pages	PDF Title
1	What’s New 2022 CAMHC
21	Cover
22	Copyright
23	Contents
25	Introduction: How Joint Commission Accreditation Can Help on the Road to High Reliability (INTRO)
26	I. Introduction to Joint Commission Accreditation The Value of Joint Commission Accreditation
28	The Joint Commission’s Home Care Accreditation Program
29	Addressing Complex Issues in Home Care
30	Table 1. Standards That Address Complex Issues in Home Care Settings
31	II. About the
32	How Is This Manual Organized?
33	Table 2. Acronyms Used in This Manual
34	Table 2.
35	Accreditation Requirements
37	Accreditation Process Information
38	Identifying Applicable Standards
41	Understanding the Organization of the Standards Chapters
43	Understanding the Icons Used in the Manual
44	III. Steps to Achieving and Maintaining Compliance
45	Become Familiar with the Standards Assess Compliance with the Standards
47	Stimulate Improvement
49	Accelerate PI™
50	Keep Current with Standards Changes via Perspectives
52	IV. Get Extra Help Getting Started with Accreditation Account Executive Contacting The Joint Commission
53	Standards Questions Requesting Permission to Share Content from the Manual
55	Patient Safety Systems (PS) Quality and Safety in Health Care Sidebar 1. Key Terms
56	Sidebar 1.
57	Goals of This Chapter
58	Becoming a Learning Organization
59	The Role of Leaders in Patient Safety
60	Safety Culture
63	Sidebar 2. Assessing Staff Accountability
65	Data Use and Reporting Systems
66	Effective Use of Data
67	Table 1. Defining and Comparing Analytical Tools
68	A Proactive Approach to Preventing Harm
70	Sidebar 3. Strategies for an Effective Risk Assessment
71	Sidebar 3. Encouraging Patient Activation
72	Beyond Accreditation: The Joint Commission Is Your Patient Safety Partner
74	References
77	Accreditation Participation Requirements (APR) Overview
78	Chapter Outline
79	Requirements, Rationales, and Elements of Performance APR.01.01.01 Elements of Performance for APR.01.01.01 APR.01.02.01
80	Rationale for APR.01.02.01 Elements of Performance for APR.01.02.01 APR.01.03.01
81	Elements of Performance for APR.01.03.01 APR.02.01.01
82	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
83	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
84	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
85	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
86	APR.11.03.01 Elements of Performance for APR.11.03.01
87	Accreditation Participation Requirements (APR)
89	Environment of Care (EC) Overview About This Chapter
90	Other Issues for Consideration
92	Chapter Outline
93	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
94	Standard EC.02.01.03 Elements of Performance for EC.02.01.03
95	Standard EC.02.02.01 Rationale for EC.02.02.01 Elements of Performance for EC.02.02.01
96	Standard EC.02.03.01 Elements of Performance for EC.02.03.01 Standard EC.02.03.03
97	Rationale for EC.02.03.03 Elements of Performance for EC.02.03.03
98	Standard EC.02.03.05 Elements of Performance for EC.02.03.05
102	This page is blank due to revisions through the update.
104	Standard EC.02.05.01
105	Elements of Performance for EC.02.05.01
106	Standard EC.02.05.03 Rationale for EC.02.05.03 Elements of Performance for EC.02.05.03
107	Standard EC.02.05.05
108	Elements of Performance for EC.02.05.05 Standard EC.02.05.07 Rationale for EC.02.05.07
109	Elements of Performance for EC.02.05.07
111	Standard EC.02.05.09 Elements of Performance for EC.02.05.09
114	Introduction to Standard EC.02.06.01 Standard EC.02.06.01 Elements of Performance for EC.02.06.01
116	Standard EC.04.01.01 Elements of Performance for EC.04.01.01
117	Standard EC.04.01.03 Elements of Performance for EC.04.01.03
119	Environment of Care (EC)
127	Emergency Management (EM) Overview About This Chapter
129	Chapter Outline
130	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
131	Standard EM.02.01.01
132	Rationale for EM.02.01.01 Elements of Performance for EM.02.01.01
135	Standard EM.02.02.01 Rationale for EM.02.02.01 Elements of Performance for EM.02.02.01
137	Standard EM.02.02.03 Rationale for EM.02.02.03 Elements of Performance for EM.02.02.03
138	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
140	Standard EM.02.02.09 Rationale for EM.02.02.09 Elements of Performance for EM.02.02.09
141	Standard EM.02.02.11 Rationale for EM.02.02.11 Elements of Performance for EM.02.02.11
143	Introduction to Standard EM.03.01.03 Exercise Scope
144	Standard EM.03.01.03 Rationale for EM.03.01.03
146	Elements of Performance for EM.03.01.03
149	Introduction to Standard EM.04.01.01
150	Standard EM.04.01.01 Elements of Performance for EM.04.01.01
153	Emergency Management (EM)
160	This page is blank due to revisions through the update.
167	Equipment Management (EQ) Overview About This Chapter Applicability
168	Chapter Outline
169	Standards, Rationales, and Elements of Performance Standard EQ.01.01.01 Elements of Performance for EQ.01.01.01
170	Standard EQ.01.02.01 Elements of Performance for EQ.01.02.01
172	Standard EQ.01.03.01 Elements of Performance for EQ.01.03.01
173	Standard EQ.01.04.01 Elements of Performance for EQ.01.04.01
174	Standard EQ.01.05.01 Elements of Performance for EQ.01.05.01
175	Standard EQ.02.01.01 Elements of Performance for EQ.02.01.01
177	Equipment Management (EQ)
179	Human Resources (HR) Overview About This Chapter
180	Chapter Outline
181	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
186	Standard HR.01.02.05 Elements of Performance for HR.01.02.05
187	Standard HR.01.02.07 Elements of Performance for HR.01.02.07
190	Standard HR.01.03.01 Elements of Performance for HR.01.03.01
193	Standard HR.01.04.01 Rationale for HR.01.04.01 Elements of Performance for HR.01.04.01
195	Standard HR.01.05.01 Elements of Performance for HR.01.05.01
198	Standard HR.01.05.03 Rationale for HR.01.05.03 Elements of Performance for HR.01.05.03
199	Introduction to Standards HR.01.06.01 and HR.01.07.01
200	Standard HR.01.06.01 Elements of Performance for HR.01.06.01
204	Standard HR.01.07.01 Elements of Performance for HR.01.07.01
205	Human Resources (HR)
211	Infection Prevention and Control (IC) Overview
212	About This Chapter
213	Chapter Outline
214	Standards, Rationales, and Elements of Performance Introduction to Standards IC.01.01.01 Through IC.01.06.01 – Planning Standard IC.01.01.01
215	Elements of Performance for IC.01.01.01 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
216	Elements of Performance for IC.01.04.01 Standard IC.01.05.01 Elements of Performance for IC.01.05.01
217	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
218	Elements of Performance for IC.02.01.01
219	Standard IC.02.02.01 Rationale for IC.02.02.01
220	Elements of Performance for IC.02.02.01 Standard IC.02.03.01
221	Elements of Performance for IC.02.03.01 Introduction to Standard IC.02.04.01
222	Standard IC.02.04.01 Elements of Performance for IC.02.04.01
223	Introduction to Standard IC.03.01.01– Evaluation and Improvement Standard IC.03.01.01 Elements of Performance for IC.03.01.01
225	Infection Control (IC)
227	Information Management (IM) Overview About This Chapter
228	Chapter Outline
229	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
230	Introduction to Standard IM.01.01.03 Standard IM.01.01.03 Elements of Performance for IM.01.01.03
231	Introduction to Standard IM.02.01.01 Standard IM.02.01.01 Elements of Performance for IM.02.01.01
233	Introduction to Standard IM.02.01.03 Standard IM.02.01.03 Elements of Performance for IM.02.01.03
234	Standard IM.02.02.01 Rationale for IM.02.02.01 Elements of Performance for IM.02.02.01
235	Introduction to Standard IM.02.02.03 Standard IM.02.02.03
236	Rationale for IM.02.02.03 Elements of Performance for IM.02.02.03
237	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
239	Information Management (IM)
241	Leadership (LD) Overview
242	Proactive Risk Assessment
243	About This Chapter
244	Chapter Outline
245	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
246	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
247	Standard LD.01.04.01 Elements of Performance for LD.01.04.01
248	Standard LD.01.06.01 Elements of Performance for LD.01.06.01
250	This page is blank due to revisions through the update.
251	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
252	Introduction to Organization Culture and System Performance Expectations, Standards LD.03.01.01 Through LD.03.06.01
254	Standard LD.03.01.01 Rationale for LD.03.01.01
255	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
256	Standard LD.03.03.01 Rationale for LD.03.03.01 Elements of Performance for LD.03.03.01 Standard LD.03.04.01 Rationale for LD.03.04.01 Elements of Performance for LD.03.04.01
257	Standard LD.03.05.01 Rationale for LD.03.05.01 Elements of Performance for LD.03.05.01 Standard LD.03.06.01
258	Rationale for LD.03.06.01 Elements of Performance for LD.03.06.01
259	Standard LD.03.07.01 Elements of Performance for LD.03.07.01
262	Standard LD.03.08.01 Elements of Performance for LD.03.08.01
263	Introduction to Standard LD.03.09.01 Standard LD.03.09.01 Elements of Performance for LD.03.09.01
265	Standard LD.03.10.01
266	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
267	Standard LD.04.01.03 Elements of Performance for LD.04.01.03
269	Standard LD.04.01.05 Rationale for LD.04.01.05 Elements of Performance for LD.04.01.05
270	Standard LD.04.01.07 Elements of Performance for LD.04.01.07 Standard LD.04.01.11
271	Rationale for LD.04.01.11 Elements of Performance for LD.04.01.11
272	This page is blank due to revisions through the update.
273	Standard LD.04.02.01 Elements of Performance for LD.04.02.01 Standard LD.04.02.03 Elements of Performance for LD.04.02.03
274	Standard LD.04.02.05
275	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
276	Standard LD.04.03.03 Elements of Performance for LD.04.03.03
282	Standard LD.04.03.07 Rationale for LD.04.03.07
283	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
284	Standard LD.04.03.09 Elements of Performance for LD.04.03.09
289	Standard LD.04.03.13 Elements of Performance for LD.04.03.13
291	Leadership (LD)
299	Life Safety (LS) Overview Applicability of the Standards About This Chapter
302	Chapter Outline
303	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
304	Standard LS.01.02.01 Elements of Performance for LS.01.02.01
307	Standard LS.02.01.10 Rationale for LS.02.01.10 Elements of Performance for LS.02.01.10
310	Standard LS.02.01.20 Rationale for LS.02.01.20 Elements of Performance for LS.02.01.20
317	Standard LS.02.01.30 Rationale for LS.02.01.30 Elements of Performance for LS.02.01.30
323	Standard LS.02.01.34 Elements of Performance for LS.02.01.34
325	Standard LS.02.01.35 Elements of Performance for LS.02.01.35
328	This page is blank due to revisions through the update.
329	Standard LS.02.01.40 Elements of Performance for LS.02.01.40 Standard LS.02.01.50 Elements of Performance for LS.02.01.50
332	Standard LS.02.01.70 Elements of Performance for LS.02.01.70
335	Life Safety (LS)
337	Medication Compounding (MC) Overview About This Chapter
338	What is Compounding?
339	Chapter Outline
340	Standards, Rationales, and Elements of Performance Standard MC.01.01.01 Elements of Performance for MC.01.01.01
341	Standard MC.01.01.03 Elements of Performance for MC.01.01.03
342	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
343	Standard MC.02.01.03
344	Elements of Performance for MC.02.01.03 Standard MC.02.01.05 Elements of Performance for MC.02.01.05
345	Standard MC.02.01.07 Elements of Performance for MC.02.01.07
346	Standard MC.02.01.09 Elements of Performance for MC.02.01.09
347	Standard MC.02.01.11 Elements of Performance for MC.02.01.11
348	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
349	Standard MC.03.02.01 Elements of Performance for MC.03.02.01
350	Standard MC.03.03.01 Elements of Performance for MC.03.03.01 Standard MC.03.04.01
351	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
352	Elements of Performance for MC.03.05.03
354	Standard MC.03.06.01 Elements of Performance for MC.03.06.01
355	Standard MC.03.06.03
356	Elements of Performance for MC.03.06.03 Standard MC.03.06.05 Elements of Performance for MC.03.06.05
358	Standard MC.03.06.07 Elements of Performance for MC.03.06.07
359	Standard MC.03.06.09 Elements of Performance for MC.03.06.09
360	Standard MC.03.06.11 Elements of Performance for MC.03.06.11
362	Standard MC.03.07.01 Elements of Performance for MC.03.07.01
363	Standard MC.03.08.01 Elements of Performance for MC.03.08.01 Standard MC.03.08.03
364	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
365	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
367	Standard MC.04.01.01 Elements of Performance for MC.04.01.01
368	Standard MC.04.01.03 Elements of Performance for MC.04.01.03
369	Standard MC.04.02.01 Elements of Performance for MC.04.02.01
372	Standard MC.04.02.03 Elements of Performance for MC.04.02.03
373	Standard MC.05.01.01 Elements of Performance for MC.05.01.01
374	Standard MC.05.01.03 Elements of Performance for MC.05.01.03
376	Standard MC.05.02.01 Elements of Performance for MC.05.02.01
377	Standard MC.05.02.03 Elements of Performance for MC.05.02.03
379	Standard MC.05.03.01 Elements of Performance for MC.05.03.01
380	Standard MC.05.04.01 Elements of Performance for MC.05.04.01
381	Standard MC.05.05.01 Elements of Performance for MC.05.05.01
383	Standard MC.05.06.01 Elements of Performance for MC.05.06.01
385	Medication Management (MM) Overview
386	About This Chapter
388	Chapter Outline
389	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
390	Elements of Performance for MM.01.01.03
391	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
392	Standard MM.03.01.01 Rationale for MM.03.01.01 Elements of Performance for MM.03.01.01
395	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
396	Introduction to Standard MM.04.01.01 Standard MM.04.01.01 Elements of Performance for MM.04.01.01
398	Standard MM.05.01.01 Elements of Performance for MM.05.01.01
399	Standard MM.05.01.07 Elements of Performance for MM.05.01.07 Standard MM.05.01.09
400	Rationale for MM.05.01.09 Elements of Performance for MM.05.01.09
401	Standard MM.05.01.11 Elements of Performance for MM.05.01.11 Standard MM.05.01.13 Rationale for MM.05.01.13
402	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
403	Rationale for MM.05.01.19 Elements of Performance for MM.05.01.19
404	Standard MM.06.01.01 Elements of Performance for MM.06.01.01
405	Standard MM.06.01.03 Elements of Performance for MM.06.01.03
406	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
407	Standard MM.07.01.03 Rationale for MM.07.01.03 Elements of Performance for MM.07.01.03 Standard MM.08.01.01
408	Elements of Performance for MM.08.01.01
411	Medication Management (MM)
415	National Patient Safety Goals (NPSG) Chapter Outline National Patient Safety Goals
416	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
417	Goal 3 Introduction to Reconciling Medication Information
418	NPSG.03.06.01 Rationale for NPSG.03.06.01 Elements of Performance for NPSG.03.06.01
419	Goal 7 NPSG.07.01.01 Rationale for NPSG.07.01.01
420	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
421	Goal 15 NPSG.15.02.01 Rationale for NPSG.15.02.01 Elements of Performance for NPSG.15.02.01
423	National Patient Safety Goals (NPSG)
425	Provision of Care, Treatment, and Services (PC) Overview
426	About This Chapter
427	Chapter Outline
428	Standards, Rationales, and Elements of Performance Standard PC.01.01.01 Elements of Performance for PC.01.01.01
429	Introduction to Standard PC.01.02.01
430	Standard PC.01.02.01 Rationale for PC.01.02.01
431	Elements of Performance for PC.01.02.01
437	Standard PC.01.02.03
438	Elements of Performance for PC.01.02.03
439	Standard PC.01.02.05 Elements of Performance for PC.01.02.05
440	Introduction to Standard PC.01.02.07
441	Standard PC.01.02.07 Elements of Performance for PC.01.02.07
442	Introduction to Standard PC.01.02.09 Standard PC.01.02.09 Elements of Performance for PC.01.02.09
443	Introduction to Standard PC.01.03.01 Standard PC.01.03.01
444	Elements of Performance for PC.01.03.01
449	Standard PC.02.01.01 Elements of Performance for PC.02.01.01
451	Standard PC.02.01.03 Elements of Performance for PC.02.01.03
453	Standard PC.02.01.05 Rationale for PC.02.01.05 Elements of Performance for PC.02.01.05
456	Standard PC.02.01.07 Elements of Performance for PC.02.01.07
457	Introduction to Standard PC.02.02.01 Standard PC.02.02.01 Elements of Performance for PC.02.02.01
461	Standard PC.02.02.03 Elements of Performance for PC.02.02.03 Standard PC.02.02.05
462	Elements of Performance for PC.02.02.05 Introduction to Standard PC.02.02.13 Standard PC.02.02.13
463	Elements of Performance for PC.02.02.13 Introduction to Standard PC.02.03.01 Standard PC.02.03.01 Elements of Performance for PC.02.03.01
467	Standard PC.03.05.01 Elements of Performance for PC.03.05.01
468	Standard PC.03.05.03 Elements of Performance for PC.03.05.03 Standard PC.03.05.05 Elements of Performance for PC.03.05.05
469	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
470	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
471	Elements of Performance for PC.03.05.17
472	Standard PC.03.05.19 Elements of Performance for PC.03.05.19
473	Standard PC.04.01.01 Elements of Performance for PC.04.01.01
474	Standard PC.04.01.03
475	Elements of Performance for PC.04.01.03 Standard PC.04.01.05 Elements of Performance for PC.04.01.05
476	Standard PC.04.02.01 Elements of Performance for PC.04.02.01
479	Provision of Care, Treatment, and Services (PC)
495	Performance Improvement (PI) Overview About This Chapter
497	Chapter Outline
498	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
500	Standard PI.02.01.01
501	Rationale for PI.02.01.01 Elements of Performance for PI.02.01.01
502	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
503	Rationale for PI.04.01.01 Elements of Performance for PI.04.01.01
505	Performance Improvement (PI)
509	Record of Care, Treatment, and Services (RC) Overview About This Chapter
510	Chapter Outline
511	Standards, Rationales, and Elements of Performance Standard RC.01.01.01 Elements of Performance for RC.01.01.01
512	Standard RC.01.02.01 Elements of Performance for RC.01.02.01
513	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
514	Standard RC.02.01.01 Elements of Performance for RC.02.01.01
518	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
519	Record of Care, Treatment, and Services (RC)
523	Rights and Responsibilities of the Individual (RI) Overview About This Chapter
525	Chapter Outline
526	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
528	Introduction to Standard RI.01.01.03
529	Standard RI.01.01.03 Elements of Performance for RI.01.01.03
530	Standard RI.01.02.01 Rationale for RI.01.02.01 Elements of Performance for RI.01.02.01
533	Standard RI.01.02.03 Elements of Performance for RI.01.02.03
534	Standard RI.01.03.01 Rationale for RI.01.03.01 Elements of Performance for RI.01.03.01
535	Standard RI.01.03.05 Elements of Performance for RI.01.03.05
536	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
537	Standard RI.01.06.03 Rationale for RI.01.06.03 Elements of Performance for RI.01.06.03
538	Standard RI.01.06.05
539	Elements of Performance for RI.01.06.05 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
541	Standard RI.01.07.05 Elements of Performance for RI.01.07.05
542	Introduction to Standard RI.02.01.01
543	Standard RI.02.01.01 Elements of Performance for RI.02.01.01
545	Rights and Responsibilities of the Individual (RI)
551	Waived Testing (WT) Overview
552	About This Chapter
554	Chapter Outline
555	Standards, Rationales, and Elements of Performance Standard WT.01.01.01 Elements of Performance for WT.01.01.01
557	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
558	Standard WT.04.01.01 Elements of Performance for WT.04.01.01
559	Standard WT.05.01.01 Elements of Performance for WT.05.01.01
561	Waived Testing (WT)
565	The Accreditation Process (ACC) Notices ACC Chapter Contents
567	Overview General Eligibility Requirements
569	Eligibility for Home Care Accreditation
573	Eligibility Requirements for Community-Based Palliative Care Certification
575	Scope of Accreditation Surveys
576	This page is blank due to revisions through the update.
577	Accreditation Policies Tailored Survey Policy
578	Organizational and Functional Integration
580	This page is blank due to revisions through the update.
583	System Accreditation Option Table 1. Sampling for System Surveys by Risk
584	Table 2. Sampling for System Surveys by Size
585	Concurrent Survey Option Contracted Services Integrated Care Certification Option
586	Home Health and Hospice Deemed Status Option
587	Home Infusion Therapy Deemed Status Option
588	Initial Surveys
589	Information Accuracy and Truthfulness Policy
591	Good Faith Participation in Accreditation/ Certification
592	Public Information Policy# Process for Responding to a Complaint
593	Early Survey Policy Sidebar 1. Early Survey Policy
594	Sidebar 1.
596	Before the Survey
597	An Organization’s Secure Joint Commission Connect Extranet Site
598	Role of the Account Executive Electronic Application for Accreditation (E-App)
600	Accreditation/Certification Contract and Business Associate Agreement Annual and Survey Fees
602	During the Survey
603	Survey Notification Table 3. Exceptions to Unannounced Surveys
606	Initial and Full Survey Team Composition
607	Survey Agenda
611	Tracer Methodology
612	Table 4. Home Care–Specific Tracer Applicability and Objectives
616	Immediate Threat to Health or Safety
620	Summary of the Accreditation Reports
621	After the Survey The Scoring Process
627	Evidence of Standards Compliance (ESC) Process
631	Accreditation Award Display and Use
632	Recommendation Letter for Organizations That Elect to Use The Joint Commission Deemed Status Option
633	Between Accreditation Surveys Duration of Accreditation Award Continuous Compliance
634	Intracycle Monitoring (ICM) Focused Standards Assessment (FSA)
635	Sidebar 2. Focused Standards Assessment (FSA) Options
636	Sidebar 2.
637	Sentinel Event Follow-up Notifying The Joint Commission About Organization Changes
639	Accreditation Status of Organizations That Cease Services After a Disaster\|\|
641	Accreditation Status of Organizations That Cease Services or Do Not Have Patients for a Period of Time
642	Reentering the Accreditation Process Additional Surveys
645	Decision Rules for Organizations Seeking Initial Accreditation Accredited
646	Community-Based Palliative Care Certification Limited, Temporary Accreditation
647	Evidence of Standards Compliance (ESC) Medicare Deficiency Follow-up Survey Denial of Accreditation
649	Decision Rules for Organizations Seeking Reaccreditation Accredited Community-Based Palliative Care Certification
650	Evidence of Standards Compliance (ESC) Medicare Deficiency Follow-up Survey Accreditation with Follow-up Survey
652	Preliminary Denial of Accreditation
653	Denial of Accreditation
654	Process for Organizations That Meet Decision Rule PDA02 for Patients Placed at Risk for Serious Adverse Outcomes Due to Signific
656	Process for Organizations That Meet Decision Rule PDA04
657	Review and Appeal Procedures I. Evaluation by Joint Commission Staff
658	II. Accreditation with Follow-up Survey
659	III. Review Hearings
660	IV. Following a Review Hearing
661	V. Final Review &Appeal Request
663	Standards Applicability Grid (SAG)
664	Abbreviations Used for Services in Applicability Grid
694	This page is blank due to revisions through the update.
720	This page is blank due to revisions through the update.
725	Sentinel Event Policy (SE)
726	Goals of the Sentinel Event Policy
727	Identifying Sentinel Events
729	Sidebar 1. Key Terms
730	Sidebar 1.
731	Determining That a Sentinel Event Is Subject to Review
732	Relationship to the Survey Process
733	Required Organization Response to a Sentinel Event
734	Reporting a Sentinel Event to The Joint Commission
736	Conducting a Comprehensive Systematic Analysis
737	Developing a Corrective Action Plan
738	Submitting the Comprehensive Systematic Analysis and Corrective Action Plan
739	Table 1. Options for a Joint Commission Review of an Organization’s Response to a Sentinel Event
740	Table 1.
741	The Joint Commission’s Response Review of Comprehensive Systematic Analyses and Corrective Action Plans
742	Follow-up Activities
744	Disclosable Information Handling Sentinel Event–Related Documents The Sentinel Event Database
745	Overseeing the Sentinel Event Policy
747	The Joint Commission Quality Report (QR) Introduction What Is The Joint Commission Quality Report?
748	What Will My Quality Report Contain? What Is Quality Check?
749	Is a Quality Report Available for My Accredited Home Care Organization? Can My Home Care Organization Comment on Its Quality Report?
750	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?
751	Guidelines for Publicizing Compliance with the National Patient Safety Goals
753	Required Written Documentation (RWD)
754	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)
755	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)
756	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)
757	Environment of Care (EC) Emergency Management (EM) Human Resources (HR) Infection Prevention and Control (IC) Information Management (IM) Leadership (LD)
758	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)
759	Equipment Management (EQ) Human Resources (HR) Infection Prevention and Control (IC) Information Management (IM) Leadership (LD) Medication Management (MM)
760	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)
761	Environment of Care (EC) Emergency Management (EM) Equipment Management (EQ) Human Resources (HR) Infection Prevention and Control (IC) Information Management (IM)
762	Leadership (LD) Medication Management (MM) National Patient Safety Goals (NPSG) Provision of Care, Treatment and Services (PC) Performance Improvement (PI)
763	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)
764	Emergency Management (EM) Equipment Management (EQ) Human Resources (HR) Infection Prevention and Control (IC) Information Management (IM) Leadership (LD)
765	Life Safety (LS) Medication Management (MM) National Patient Safety Goals (NPSG) 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) Waived Testing (WT) Pharmacy—Dispensing Accreditation Participation Requirements (APR) Environment of Care (EC) Emergency Management (EM)
767	Equipment Management (EQ) Human Resources (HR) Infection Prevention and Control (IC) Information Management (IM) Leadership (LD) Medication Compounding (MC)
768	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)
769	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)
770	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)
771	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)
772	Information Management (IM) Leadership (LD) Medication Compounding (MC) Medication Management (MM)
773	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)
774	Emergency Management (EM) Equipment Management (EQ) Human Resources (HR) Infection Prevention and Control (IC) Information Management (IM) Leadership (LD)
775	Medication Compounding (MC) Medication Management (MM) National Patient Safety Goals (NPSG) Provision of Care, Treatment, and Services (PC)
776	Performance Improvement (PI) Record of Care, Treatment, and Services (RC) 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)
777	Equipment Management (EQ) Human Resources (HR) Infection Prevention and Control (IC) Information Management (IM) Leadership (LD) Medication Compounding (MC)
778	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)
779	Clinical Respiratory Accreditation Participation Requirements (APR) Environment of Care (EC) Emergency Management (EM) Human Resources (HR) Infection Prevention and Control (IC) Information Management (IM)
780	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)
781	Rights and Responsibilities of the Individual (RI) Respiratory Equipment Accreditation Participation Requirements (APR) Environment of Care (EC) Emergency Management (EM) Equipment Management (EQ) Human Resources (HR)
782	Infection Prevention and Control (IC) 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)
783	Rights and Responsibilities of the Individual (RI) Orthotics and Prosthetics—Facility Based Accreditation Participation Requirements (APR) Environment of Care (EC) Emergency Management (EM) Equipment Management (EQ) Human Resources (HR)
784	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)
785	Orthotics and Prosthetics—Patient Residence Accreditation Participation Requirements (APR) Environment of Care (EC) Emergency Management (EM) Equipment Management (EQ) Human Resources (HR) Infection Prevention and Control (IC)
786	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)
787	Supplies—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)
788	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) Supplies—Patient Residence Accreditation Participation Requirements (APR)
789	Environment of Care (EC) Emergency Management (EM) Equipment Management (EQ) Human Resources (HR) Infection Prevention and Control (IC) Information Management (IM) Leadership (LD)
790	Provision of Care, Treatment, and Services (PC) Performance Improvement (PI) 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)
791	Emergency Management (EM) Equipment Management (EQ) Human Resources (HR) Infection Prevention and Control (IC) Information Management (IM) Leadership (LD)
792	Provision of Care, Treatment, and Services (PC) Performance Improvement (PI) Record of Care, Treatment, and Services (RC) Rights and Responsibilities of the Individual (RI) Rehabilitation Technology—Patient Residence Accreditation Participation Requirements (APR) Environment of Care (EC)
793	Emergency Management (EM) Equipment Management (EQ) Human Resources (HR) Infection Prevention and Control (IC) Information Management (IM) Leadership (LD)
794	Provision of Care, Treatment, and Services (PC) Performance Improvement (PI) Record of Care, Treatment, and Services (RC) Rights and Responsibilities of the Individual (RI) Durable Medical Equipment—Patient Residence Accreditation Participation Requirements (APR) Environment of Care (EC) Emergency Management (EM)
795	Equipment Management (EQ) Human Resources (HR) Infection Prevention and Control (IC) Information Management (IM) Leadership (LD) National Patient Safety Goals (NPSG)
796	Provision of Care, Treatment, and Services (PC) Performance Improvement (PI) Record of Care, Treatment, and Services (RC) Rights and Responsibilities of the Individual (RI) Durable Medical Equipment—Facility Based Accreditation Participation Requirements (APR) Environment of Care (EC)
797	Emergency Management (EM) Equipment Management (EQ) Human Resources (HR) Infection Prevention and Control (IC) Information Management (IM) Leadership (LD) Provision of Care, Treatment, and Services (PC)
798	Performance Improvement (PI) Record of Care, Treatment, and Services (RC) Rights and Responsibilities of the Individual (RI) Durable Medical Equipment—Mail Order Accreditation Participation Requirements (APR) Environment of Care (EC) Emergency Management (EM)
799	Equipment Management (EQ) Human Resources (HR) Infection Prevention and Control (IC) Information Management (IM) Leadership (LD) Provision of Care, Treatment, and Services (PC)
800	Performance Improvement (PI) Record of Care, Treatment, and Services (RC) Rights and Responsibilities of the Individual (RI)
801	Early Survey Policy (ESP) Accreditation Participation Requirements (APR) Environment of Care (EC) Emergency Management (EM)
802	Equipment Management (EQ) Human Resources (HR) Infection Prevention and Control (IC) Information Management (IM)
803	Leadership (LD) Life Safety (LS) Medication Compounding (MC)
804	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)
805	Waived Testing (WT)
807	Community-Based Palliative Care Certification (CBPC) Overview
808	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
809	Standard APR.06.01.01 Elements of Performance for APR.06.01.01 Standard APR.11.01.01
810	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
811	Elements of Performance for APR.11.03.01 Human Resources (HR) Standard HR.01.01.01 Elements of Performance for HR.01.01.01
812	Standard HR.01.02.07 Elements of Performance for HR.01.02.07
813	Standard HR.01.04.01 Elements of Performance for HR.01.04.01
814	Standard HR.01.05.03 Elements of Performance for HR.01.05.03
815	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
816	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
817	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
818	Standard LD.03.04.01 Elements of Performance for LD.03.04.01 Standard LD.03.06.01 Elements of Performance for LD.03.06.01
819	Standard LD.03.07.01 Elements of Performance for LD.03.07.01 Standard LD.03.08.01 Elements of Performance for LD.03.08.01 Standard LD.03.10.01
820	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
821	Standard LD.04.01.11 Elements of Performance for LD.04.01.11 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
822	Elements of Performance for PC.01.01.01 Standard PC.01.02.01 Elements of Performance for PC.01.02.01
823	Standard PC.01.02.03 Elements of Performance for PC.01.02.03
824	Standard PC.01.03.01 Elements of Performance for PC.01.03.01
825	Standard PC.02.01.01 Elements of Performance for PC.02.01.01
826	Standard PC.02.01.05 Elements of Performance for PC.02.01.05
827	Standard PC.02.02.01 Elements of Performance for PC.02.02.01
828	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
829	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
830	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
831	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
832	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
833	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
834	Standard RI.02.01.01 Elements of Performance for RI.02.01.01
835	Appendix A: Medicare Requirements for Hospice (AXA) Subpart I Advance Directives
848	This page is blank due to revisions through the update.
849	Additional Regulations
861	Glossary (GL)
917	Index (IX)