Comprehensive Comprehensive Accreditation Accreditation Manual

2012
CAMH
Update 2
Comprehensive Accreditation
Manual for Hospitals
Table of Changes
September 2012 CAMH Update 2
To update your manual, please remove and recycle the pages listed in this table of
changes, and insert the replacement pages included in this packet. Check boxes have
been provided in the table of changes for your convenience to track the removal and
addition of pages.
Major changes that appear in this update to requirements for accreditation, policies,
procedures, and other information include the following:
n
Revised and added elements of performance (EPs) applicable to hospitals that use
Joint Commission accreditation for deemed status purposes to maintain alignment
with requirements from the Centers for Medicare & Medicaid Services (CMS)
following the release of a final rule in 2012, effective September 1, 2012
2012. These
changes address, among other issues, qualifications of staff, use of pre-printed or
standing medication orders, authentication of verbal and written orders, and death
of a patient in restraints.
n
Revised requirements for hospitals in California that provide computed tomography
(CT) services, effective July 1, 2012
n
Revised and added requirements to address emergency department overcrowding,
effective January 1, 2013
n
Revised requirement for daily quality control checks of instruments used for waived
testing, effective May 23, 2012
n
A description of the new Intracycle Monitoring (ICM) process and the Focused
Standards Assessment (FSA) in “The Accreditation Process” (ACC) chapter
n
New risk icon throughout the requirements for accreditation to denote EPs that
must be assessed through the FSA process
n
Accreditation decision rules for 2013 in the ACC chapter, effective January 1, 2013
Refer to the table beginning on page 2 and the actual update pages for more details
about revisions included in this update. Revisions to content within this update are
highlighted in shaded text within your replacement pages.
CAMH Update 2, September 2012
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2012
CAMH
Update 2
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Comprehensive Accreditation Manual for
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Type of Change
Effective Date
Title Page and Contents Page
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Title page and
contents page
q
Updated title page and contents page
Effective
immediately
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Discontinued chapter
Effective
immediately
Foreword (FW)
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and do not
replace
How to Use This Manual (HM)
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Entire chapter
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2
Minor editorial changes
Effective
Revised Table 1. Acronyms Used in
immediately
This Manual
Changed references from “Periodic
Performance Review (PPR)” to “Focused Standards Assessment (FSA)”
and the Intracycle Monitoring (ICM)
process throughout chapter as applicable
Revised Figure 1. Components of a
requirements chapter
Updated the description of the indirect
impact requirement icon and added
the risk icon in the “Understanding
the Icons Used in the Manual” section
Revised tips for organizations in the
“Keys to Successfully Using This Manual” section
Included new resources and updated
existing resources listed in Sidebar 2.
Where Should I Go for More Information?
CAMH Update 2, September 2012
2012
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Update 2
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Type of Change
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Requirements for Accreditation
Accreditation Participation Requirements (APR)
q
Entire chapter
q
q
Updated chapter outline and revised
Effective
APR.03.01.01 to reflect change from January 1, 2013
“Periodic Performance Review (PPR)”
to “Focused Standards Assessment
(FSA)”
Made minor editorial changes
Environment of Care (EC)
q
Entire chapter
q
Added risk icon to the following:
q EC.01.01.01, EPs 1–3, 5, 7–8
q EC.02.01.01, EPs 3, 8
q EC.02.02.01, EPs 4, 7, 10
q EC.02.03.01, EP 1
q EC.02.03.05, EPs 4, 11, 19
q EC.02.04.01, EPs 1–6
q EC.02.04.03, EPs 1–5
q EC.02.05.01, EP 6
q EC.02.05.03, EP 6
q EC.02.05.05, EPs 3–4
q EC.02.05.07, EPs 4–8
q EC.02.05.09, EP 1
q EC.02.06.01, EP 20
q EC.02.06.05, EP 3
q EC.04.01.01, EPs 1, 15
Effective
January 1, 2013
q
Revised EC.02.04.03, EP 17, for hospitals in California that provide computed tomography (CT) services
Effective
July 1, 2012
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Type of Change
Effective Date
Emergency Management (EM)
q
Entire chapter
Added risk icon to the following:
q EM.02.01.01, EP 8
q EM.02.02.13, EP 5
q EM.02.02.15, EP 5
Effective
January 1, 2013
q
Added risk icon to the following:
q HR.01.02.01, EP 1
q HR.01.02.05, EPs 1–7, 10–16, 18
q HR.01.04.01, EPs 1–5
q HR.01.05.03, EPs 1, 4–5, 13
q HR.01.06.01, EPs 1–3, 5–6, 15
q HR.01.07.01, EPs 2, 5
Effective
January 1, 2013
q
Deleted HR.01.02.01, EP 19, on ad- Effective
ministration of blood transfusions and September 1, 2012
intravenous medications
q
Human Resources (HR)
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Entire chapter
Infection Prevention and Control (IC)
q
Entire chapter
q
q
Added risk icon to the following:
q IC.01.05.01, EPs 1–3, 5–8
q IC.02.01.01, EPs 3, 10–11
q IC.02.02.01, EPs 1–5
Made minor editorial changes
Effective
January 1, 2013
Information Management (IM)
q
Entire chapter
q
q
4
Added risk icon to the following:
q IM.01.01.01, EPs 1–4
q IM.01.01.03, EPs 1–6
q IM.02.01.01, EPs 1–5
q IM.02.01.03, EPs 1–8
q IM.02.02.01, EPs 1–3
q IM.02.02.03, EPs 1–3
q IM.04.01.01, EP 1
Made minor editorial changes
Effective
January 1, 2013
CAMH Update 2, September 2012
2012
CAMH
Update 2
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Comprehensive Accreditation Manual for
Hospitals
Type of Change
Effective Date
Leadership (LD)
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Entire chapter
q
q
q
q
q
q
Added risk icon to the following:
Effective
q LD.03.01.01, EP 5
January 1, 2013
q LD.03.02.01, EPs 1, 3–7
q LD.03.06.01, EPs 1, 3–6
q LD.04.01.05, EPs 1–6, 8
q LD.04.01.07, EPs 1–2
q LD.04.02.03, EP 5
q LD.04.03.01, EP 1
q LD.04.03.07, EPs 1–2
q LD.04.03.09, EPs 1–10, 23
q LD.04.03.11, EPs 1–8
q LD.04.04.03, EP 1
q LD.04.04.05, EPs 1–14
Revised LD.04.03.11 by adding Introduction; adding documentation requirement to EPs 4, 5, and 7; revising
EP 5, EP 6 (effective January 1, 2014),
and EPs 7–8; and adding EP 9 (effective January 1, 2014)
Made minor editorial changes
Updated LD.01.02.01, EP 4
Effective
Revised LD.01.05.01, EP 7, to include September 1, 2012
doctors of podiatric medicine
Revised LD.04.01.05, EP 8, regarding
supervision of outpatient services
CAMH Update 2, September 2012
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Type of Change
Effective Date
Life Safety (LS)
q
Entire chapter
q
q
Added risk icon to the following:
q LS.01.01.01, EP 2
q LS.01.02.01, EPs 1, 3–5
q LS.02.01.20, EP 22
q LS.02.01.34, EP 1
q LS.02.01.35, EPs 1–2
q LS.03.01.20, EP 15
q LS.03.01.34, EP 1
q LS.03.01.35, EP 1
Made minor editorial changes
Effective
January 1, 2013
Medication Management (MM)
q
Entire chapter
q
Added risk icon to the following:
q MM.01.01.03, EP 3
q MM.01.02.01, EP 2
q MM.02.01.01, EP 6
q MM.03.01.01, EPs 7, 10
q MM.03.01.03, EP 2
q MM.03.01.05, EP 2
q MM.04.01.01, EPs 8, 13
q MM.05.01.01, EP 11
q MM.05.01.07, EPs 1, 5
q MM.05.01.09, EP 1
q MM.05.01.13, EP 7
q MM.05.01.17, EP 2
q MM.06.01.03, EPs 6–7
q MM.06.01.05, EPs 2, 4
q MM.07.01.03, EPs 5–6
q
Added MM.04.01.01, EP 15, regard- Effective
ing pre-printed and standing orders
September 1, 2012
Updated MM.05.01.07, EP 5, on preparing and administering medication
Updated MM.07.01.03, EP 6
q
q
6
Effective
January 1, 2013
CAMH Update 2, September 2012
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Update 2
Comprehensive Accreditation Manual for
Hospitals
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Type of Change
Effective Date
Medical Staff (MS)
q
Entire chapter
q
q
Added risk icon to the following:
q MS.03.01.01, EPs 2, 16–17
q MS.03.01.03, EPs 1–6, 12
q MS.06.01.03, EP 6
q MS.06.01.05, EPs 2–3
q MS.08.01.01, EPs 1–9
q MS.08.01.03, EPs 1–3
q MS.09.01.01, EPs 1–2
q MS.13.01.01, EP 1
Made minor editorial changes
Effective
January 1, 2013
National Patient Safety Goals (NPSG)
q
Entire chapter
q
q
Added risk icon to all EPs in the
chapter
Deleted NPSG.07.06.01, EP 1, and
renumbered EPs 2–4 as EPs 1–3 on
catheter-associated urinary tract infections (CAUTIs)
Effective
January 1, 2013
Added risk icon to the following:
q NR.02.02.01, EPs 1–5
q NR.02.03.01, EPs 1–4, 6–7
Effective
January 1, 2013
Nursing (NR)
q
Entire chapter
q
Provision of Care, Treatment, and Services (PC)
q
Entire chapter
q
Added risk icon to the following:
q PC.01.01.01, EP 7
q PC.01.02.01, EPs 1–4, 23
q PC.01.02.03, EPs 1–8
q PC.01.02.05, EP 1
q PC.01.02.07, EPs 1–4
q PC.01.02.08, EPs 1–2
q PC.01.02.09, EPs 1–7
CAMH Update 2, September 2012
Effective
January 1, 2013
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Type of Change
Effective Date
PC.01.02.11, EPs 1–7
PC.01.02.13, EPs 1–7
q PC.01.02.15, EPs 1–3
q PC.01.03.01, EPs 1, 5, 23
q PC.01.03.03, EP 4
q PC.01.03.05, EP 6
q PC.02.01.01, EP 1
q PC.02.01.03, EPs 1, 7
q PC.02.01.05, EP 1
q PC.02.01.21, EPs 1–2
q PC.02.02.01, EPs 1–3, 10, 17
q PC.02.03.01, EP 1
q PC.03.01.01, EPs 1–2, 5–8, 10
q PC.03.01.03, EPs 1–2, 7–8, 18
q PC.03.01.07, EPs 1–2, 4, 6–8
q PC.03.01.09, EP 2
q PC.03.02.07, EPs 2–3
q PC.03.03.15, EP 1
q PC.03.03.19, EPs 2–3
q PC.03.03.23, EP 1
q PC.03.03.25, EP 1
q PC.03.05.01, EP 1
q PC.03.05.03, EP 1
q PC.03.05.05, EPs 5–6
q PC.03.05.07, EP 1
q PC.03.05.11, EPs 1–3
q PC.04.01.01, EPs 1–4, 22–26
q PC.04.01.03, EPs 1–4, 10–11
q PC.04.01.05, EPs 1–3, 5, 7–8
q PC.04.02.01, EP 1
q PC.05.01.09, EP 1
Revised PC.01.01.01 by adding crossreference to EP 4 and adding EP 24 on
the boarding of patients with behavioral health issues
q
q
q
8
CAMH Update 2, September 2012
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Comprehensive Accreditation Manual for
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Type of Change
Effective Date
q
Changed “accreditation” to “Joint
Commission accreditation” in several
requirements
q
Revised PC.01.02.15, EPs 5–7, for
Effective
hospitals in California that provide CT July 1, 2012
services
q
Updated PC.02.01.03, EP 1, on orders Effective
obtained or renewed from practitioners September 1, 2012
Clarified PC.03.05.19, EPs 1–2, on
deaths related to restraint or seclusion,
and added documentation requirement
to EP 2
Added PC.03.05.19, EP 3, on situations that include soft restraints but
not seclusion
q
q
Performance Improvement (PI)
q
Entire chapter
q
q
Added risk icon to the following:
q PI.02.01.01, EPs 1–5, 7–8, 12–14
Made minor editorial changes
Effective
January 1, 2013
Record of Care, Treatment, and Services (RC)
q
Entire chapter
q
q
q
Added risk icon to the following:
q RC.01.01.01, EP 8
q RC.01.02.01, EPs 1–5
q RC.02.01.01, EPs 1–2, 4, 10, 21,
28
q RC.02.01.03, EPs 1–3, 5–11
q RC.02.04.01, EP 3
Added documentation requirement to
RC.02.01.01, EP 1
Changed “accreditation” to “Joint
Commission accreditation” in
RC.02.01.05
CAMH Update 2, September 2012
Effective
January 1, 2013
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Type of Change
q
q
Effective Date
Updated RC.01.02.01, EP 4, Note 3, Effective
on dating and authenticating orders,
September 1, 2012
and added documentation requirement
Deleted RC.02.03.07, EP 4, Notes 1
and 2, on authenticating verbal orders
Rights and Responsibilities of the Individual (RI)
q
Entire chapter
q
Added risk icon to the following:
Effective
q RI.01.01.01, EPs 2, 4–6, 9–10,
January 1, 2013
28–29
q RI.01.01.03, EPs 1–3
q RI.01.02.01, EPs 1–3, 6–8, 20–22
q RI.01.03.01, EPs 1–7, 9, 11–13
q RI.01.05.01, EPs 1, 4–6, 8–13,
15–17, 19–20
q RI.01.06.03, EPs 2–3
Transplant Safety (TS)
q
Entire chapter
q
q
Added risk icon to the following:
q TS.01.01.01, EPs 1–12
q TS.02.01.01, EPs 1–2
q TS.03.01.01, EPs 1–11
q TS.03.02.01, EPs 1–7
q TS.03.03.01, EPs 1–5
Made minor editorial changes
Effective
January 1, 2013
Added risk icon to the following:
q WT.01.01.01, EP 6
q WT.03.01.01, EP 5
q WT.04.01.01, EPs 3–4
Made minor editorial changes
Effective
January 1, 2013
Revised WT.04.01.01, EP 4, on quality control checks of instruments
Effective
May 23, 2012
Waived Testing (WT)
q
Entire chapter
q
q
q
10
CAMH Update 2, September 2012
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Type of Change
Effective Date
Policies, Procedures, and Other Information
The Accreditation Process (ACC)
q
q
ACC-1–ACC72
ACC-75–
ACC-104 with
ACC-75–
ACC-104b
q
q
q
q
q
q
q
q
q
Made minor editorial changes and
Effective
policy clarifications
January 1, 2013
Updated “Eligibility Requirements for
Initial Surveys” section to address hospitals that do not use The Joint Commission for deemed status purposes
Added footnote addressing laboratories
to “Tailored Survey Policy” section
Added footnote defining complex organization to “Complex Organization
Survey Process” section
Changed references from “Periodic
Performance Review (PPR)” to “Focused Standards Assessment (FSA)”
throughout chapter as applicable
Reformatted and made minor editorial
changes to “Public Information Policy”
section
Updated Sidebar 1. Early Survey Policy and “Eligibility for Preliminary
Accreditation” section to reflect that an
organization’s Preliminary Accreditation decision will change to Unaccredited if it is not ready for a second
survey at six months
Added Note addressing Medicare certification to Sidebar 1. Early Survey
Policy
Updated “Forfeiture of Survey Deposit” section
CAMH Update 2, September 2012
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Type of Change
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Effective Date
Added new or revised subprocesses to
PFA categories Communication, Infection Control, Orientation & Training,
and Physical Environment
Revised Table 1. Exceptions to Unannounced Surveys
Revised “ISO Certification Option”
section
Moved “Second Generation Tracers”
section, deleted high-risk topics “Assessment” and “Staffing,” and added
high-risk topics “Therapeutic radiation” and “Clinical/health information”
Revised definition of Contingent Accreditation in “Accreditation Decision
Categories” section
Added new “Intracycle Monitoring”
section to the “Between Accreditation
Surveys” section
Replaced “Periodic Performance Review (PPR)” section with new “Focused Standards Assessment (FSA)”
section
Updated “Accreditation Status of
Organizations That Cease Provision of
Services for a Period of Time” regarding the need to notify The Joint
Commission if an organization ceases
to provide services
Updated “On-site Follow-up Survey
for a Condition-level Deficiency” section
CAMH Update 2, September 2012
2012
CAMH
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Comprehensive Accreditation Manual for
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Type of Change
q
Effective Date
Updated “2013 Accreditation Decision
Rules” section, including
q revising Contingent Accreditation
(CONT) decision rule CONT04
q adding CONT06
q adding CONT07
q deleting “On-site MOS Survey”
section and decision rule MOS02
Standards Applicability Grid (SAG)
q
Entire chapter
q
q
q
q
q
q
q
q
Deleted applicability to Long Term
Acute Care services for APR.04.01.01,
EPs 11–12, 17–24, 26
Deleted HR.01.02.01, EP 19
Added LD.04.03.11, EP 9 (with applicability to Acute and Psychiatric services)
Added MM.04.01.01, EP 15 (with
applicability to all four services)
Deleted NPSG.07.06.01, EP 4
Added applicability to Psychiatric services for UP.01.01.01, EPs 1–3;
UP.01.02.01, EPs 1–5; and
UP.01.03.01, EPs 1–5
Added PC.01.01.01, EP 24 (with applicability to Acute and Psychiatric
services)
Added PC.03.05.19, EP 3 (with applicability to all four services)
Effective
January 1, 2013 (except as noted elsewhere in this Table
of Changes)
The Joint Commission Quality Report (QR)
q
Entire chapter
q
Minor editorial changes
CAMH Update 2, September 2012
Effective
January 1, 2013
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Effective Date
Performance Measurement and the ORYX® Initiative (PM)
q
PM-7–PM-12
q
Replaced Figures 1 through 5
Effective
January 1, 2013
Required Written Documentation (RWD)
q
Entire chapter
q
Added the following:
q LD.04.03.11, EPs 4, 5, 7
q MM.04.01.01, EP 15
q PC.03.05.19, EPs 2, 3
q RC.01.02.01, EP 4
q RC.02.01.01, EP 1
Effective
January 1, 2013 (except as noted elsewhere in this Table
of Changes)
Early Survey Policy Option (ESP)
q
ESP-3–ESP-4
q
Added LS.02.01.30, EP 24
Effective
January 1, 2013
Appendix A: Medicare Requirements for Hospitals (AXA)
q
Entire chapter
q
Revised standard 482.22(a) regarding
eligibility and appointment to the
medical staff and reformatted chapter
Effective
September 1, 2012
q
Revised definitions for the terms AcEffective
credited and Contingent Accreditation
January 1, 2013
within the accreditation decisions entry
and for accreditation survey
Expanded behavioral health care definition to include developmental disabilities and community-based settings
Added new terms Focused Standards
Assessment (FSA) and Intracycle Monitoring (ICM)
Glossary
q
Entire chapter
q
q
14
CAMH Update 2, September 2012
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Comprehensive Accreditation Manual for
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q
Deleted the definition for the term
Periodic Performance Review (PPR) and
in its place created a cross-reference to
the new term Focused Standards Assessment (FSA)
Deleted the term ratio
Revised surveyor definition to include
additional information that the type of
surveyor assigned is determined by the
program and its services
Made minor editorial changes
q
Updated index
q
q
q
Effective Date
Index
q
Entire chapter
CAMH Update 2, September 2012
Effective
immediately
15
◤Comprehensive Accreditation Manual for Hospitals
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CAMH Update 2, September 2012