Comprehensive Comprehensive Accreditation Accreditation Manual
Transcription
Comprehensive Comprehensive Accreditation Accreditation Manual
2014 CAMBHC Comprehensive Accreditation Manual for Behavioral Health Care Summary of Changes 2014 Comprehensive Accreditation Manual for Behavioral Health Care Effective January 1, 2014 Standards and elements of performance (EPs) published in this manual are effective January 1, 2014. Note: Your organization is responsible for meeting all applicable changes to accreditation requirements for organizations accredited under the Behavioral Health Care Accreditation Program published in The Joint Commission Perspectives®, the official monthly newsletter of The Joint Commission. Major changes reflected in the 2014 CAMBHC include the following: n Updated “Accreditation Decision Rules” section to reflect 2014 decision rules. n Added the Behavioral Health Home Certification Option to the Behavioral Health Care Accreditation Program. The requirements are integrated throughout the standards chapters and are compiled in the new “Behavioral Health Home Certification Option” (BHH) chapter. n Added numerous standards and elements of performance to the “Standards Applicability Process” (SAP) chapter due to the addition of the BHH chapter. n Added numerous standards and elements of performance to the “Opioid Treatment Programs” (OTP) chapter. How to Use This Manual (HM) n n n n n n Updated “What Is This Manual's Purpose?” and “Changes to the Manual” sections Standardized use of the terms standard and requirement Added Behavioral Health Home (BHH) certification to Table 1. Acronyms Used in This Manual and revised table Clarified the description of rationale Revised Figure 1. Components of a standards chapter Added description of “Behavioral Health Home Certification Option” (BHH) chapter to “Policies, Procedures, and Other Information” section CAMBHC, January 2014 i 2014 CAMBHC n n n n n n n n Comprehensive Accreditation Manual for Behavioral Health Care Clarified behavioral health care and home care program descriptions in “Identifying Applicable Standards” section Updated the descriptions of the accreditation programs Rearranged the order of the icon descriptions in the requirements chapters Revised description of the risk icon Revised Sidebar 1. Icons in This Manual Renamed “Keys to Successfully Using This Manual” to “Keys to Successfully Achieving Standards Compliance” Revised tips for organizations in the “Keys to Successfully Achieving Standards Compliance" section Included new resources and updated existing resources listed in Sidebar 2. Where Should I Go for More Information? Accreditation Participation Requirements (APR) n Revised second and fourth bullet points in Note 1 to APR.01.02.01, EP 1, regarding information received by The Joint Commission Care, Treatment, and Services (CTS) n n n ii Revised Chapter Outline Added the following standards to the Behavioral Health Home Certification Option o CTS.01.01.01, EP 2 o CTS.02.01.05, EP 2 o CTS.02.02.01, EPs 6–8 o CTS.03.01.01, EPs 12, 13 o CTS.03.01.03, EPs 17–22 o CTS.04.01.01, EPs 7, 14, 15 o CTS.04.01.03, EPs 24–27 o CTS.04.01.07, EPs 1–6 o CTS.04.02.23, EPs 1–3 o CTS.04.02.25, EPs 1–5 o CTS.04.02.27, EPs 1–5 o CTS.06.01.05, EPs 1–6 o CTS.06.01.07, EPs 1–2 Changed numbering of EPs in CTS.01.01.01, EPs 3–24 CAMBHC, January 2014 2014 CAMBHC n n n n n n n Comprehensive Accreditation Manual for Behavioral Health Care Added note 2 to CTS.01.01.01, EP 11 Added standards cross reference in CTS.01.04.01 Added cross reference to standard with more information to CTS.02.01.05, EPs 3–4 Added note to CTS.02.02.01, EP 7 Changed standards cross-reference in rationale for CTS.05.05.19 Deleted standard cross reference for CTS.07.01.01, EP 1 Changed guidelines to practices in CTS.07.01.01, EP 4 Environment of Care (EC) n n n n n n n Revised chapter overview regarding intervals for completing tasks or functions related to maintenance expectations for organizations that provide care, treatment, or services in spaces they do not own Revised Chapter Outline Added the following standard to the Behavioral Health Home Certification Option o EC.02.04.03, EP 3 Revised NFPA reference in note in EC.02.03.05, EP 20 Revised the time frame for conducting emergency generator tests in EC.02.05.07, EP 4 Revised the time frame for conducting diesel-powered emergency generator tests and added note in EC.02.05.07, EP 5 Revised the time frame for conducting automatic transfer switch tests in EC.02.05.07, EP 6 Human Resources (HR) n Added the following standards to the Behavioral Health Home Certification Option o HR.01.04.01, EPs 25, 26 o HR.01.05.03, EP 24 Infection Prevention and Control (IC) n n Updated website address in IC.02.02.01, EP 1 footnote Changed health care practitioners to health care personnel in Introduction to IC.02.04.01 CAMBHC, January 2014 iii 2014 CAMBHC n n n n n Comprehensive Accreditation Manual for Behavioral Health Care Updated the introduction in IC.02.04.01 regarding the description and website link for the U.S. Department of Health and Human Services for influenza vaccination of licensed independent practitioners and staff Deleted information in the introduction to IC.02.04.01 regarding phasing in the requirements for influenza vaccination of licensed independent practitioners and staff Deleted Rationale for IC.02.04.01 Deleted information in IC.02.04.01, EPs 5, 6, and 8, regarding phasing in the requirements for influenza vaccination of licensed independent practitioners and staff Updated website link in IC.02.04.01, EP 5, for the U.S. Department of Health and Human Services for influenza vaccination of licensed independent practitioners and staff Information Management (IM) n n Added the following standard to the Behavioral Health Home Certification Option o IM.01.01.01, EP 6 Added name and website address for the Office of the National Coordinator for Health Information Technology in Introduction to IM.02.03.03 Leadership (LD) n n Added the following standards to the Behavioral Health Home Certification Option o LD.04.04.01, EPs 24, 25 o LD.04.04.09, EPs 1–5 Revised Chapter Outline Life Safety (LS) n n n n n n iv Updated website address for Life Safety Code in chapter overview Revised NFPA reference in LS.02.01.10, EP 2 Revised NFPA reference in LS.02.01.20, EPs 8, 19 Updated website address in LS.02.01.30, EP 25 Updated website address in LS.02.01.34, EP 1 Revised NFPA reference in LS.02.01.34, EP 2 CAMBHC, January 2014 2014 CAMBHC Comprehensive Accreditation Manual for Behavioral Health Care Medication Management (MM) n n n n Revised Chapter Outline Updated website address in MM.01.01.03, EP 1 footnote Added note to MM.04.01.01, EP 16 regarding the effects of opioid maintenance therapy Deleted “Store Medications” applicability for MM.01.01.01 in Applicability for Medication Management Type grid Performance Improvement (PI) n Added the following standards to the Behavioral Health Home Certification Option o PI.01.01.01, EPs 40–43 o PI.02.01.01, EP 9 o PI.03.01.01, EP 11 Record of Care, Treatment, and Services (RC) n Added the following standard to the Behavioral Health Home Certification Option o RC.02.01.01, EPs 28–30 Rights and Responsibilities of the Individual (RI) n n n Added the following standards to the Behavioral Health Home Certification Option o RI.01.02.01, EPs 31–33 o RI.01.04.01, EP 6 o RI.01.04.03, EPs 1–6 o RI.01.05.01, EPs 1, 4, 5, 8, 10, 11 Revised Chapter Outline Added note to RI.01.01.03, EP 2 regarding language interpreting options Waived Testing (WT) n Updated website addresses in chapter overview The Accreditation Process (ACC) n n n Made policy clarifications Updated descriptions in “Joint Commission Accreditation Programs” section Moved and updated “Tailored Survey Policy” section, including adding language for entities seeking separate accreditation CAMBHC, January 2014 v 2014 CAMBHC n n n n n n n n n n n n n n vi Comprehensive Accreditation Manual for Behavioral Health Care Changed percentage of organizations that undergo a random unannounced on-site validation survey from 5% to 2% in “Initial Surveys” section Made minor editorial changes to “Public Information Policy” section Updated “Available Accreditation Information” section to reflect that Denial of Accreditation decisions are not published in Quality Reports Updated “Early Survey Policy” section by deleting the statement that organizations may stay in Preliminary Accreditation for one year Revised “Early Survey Policy” section to reflect that organizations in Preliminary Accreditation cannot use The Joint Commission’s Gold Seal of Approval® Decreased billing time frame for on-site fees to within two days after survey in “Survey Fees” section Made minor edits to “Priority Focus Areas (PFAs)” and “Clinical/Service Groups (CSGs)” sections Updated medication management subprocesses to include disposal in “Priority Focus Areas (PFAs)” section Updated Table 1. Exceptions to Unannounced Surveys Clarified in the “Unannounced Surveys” section that avoid dates can be identified in the E-App and that the survey eligibility range is after the last full (rather than last full unannounced) survey Revised “Survey Agenda” section by deleting the statement that surveyors can review MOS during the planning session, revising the “Competence Assessment” and “Leadership” sections, and deleting bullet about ongoing professional practice evaluations and focused professional practice evaluations from competence assessment. Updated Table 2. Behavioral Health Care Accreditation–Specific Tracer Applicability and Objectives by adding youth to Continuity of Foster/ Therapeutic Foster Care row and revising violence prevention row Updated “Second Generation Tracers” section Deleted bullet stating corrective action is considered when an organization demonstrates that it prepared a root cause analysis from “Immediate Threat to Health or Safety” section CAMBHC, January 2014 2014 CAMBHC n n n n n n n n n n n Comprehensive Accreditation Manual for Behavioral Health Care Revised definition of Immediate Threat to Health or Safety to signify a threat of immediate risk rather than a threat of “the most” immediate risk and clarified that abatement survey results help determine the Accreditation Committee’s decision in “Immediate Threat to Health or Safety” section Updated “The Summary of Survey Findings Report” section Clarified that Evidence of Standards Compliance (ESCs) are required at 45 (direct impact) and 60 (indirect impact) calendar days in “How Accreditation Decisions Are Made” section Added statement that Quality Check® will show Requirements for Improvement (RFIs) for organizations that receive a decision of Accreditation with Follow-up Survey (AFS), Contingent Accreditation (CONT), or Preliminary Denial of Accreditation (PDA) to “Accreditation Effective Date” section Added cross-reference to “Random Validation of Evidence of Standards Compliance” to “Measure of Success (MOS) Report” Clarified that organizations have 10 business days to clarify RFIs in “The Process for Accreditation with Follow-up Survey, Contingent Accreditation, or Preliminary Denial of Accreditation” section Added statement that organizations have 5 days to submit postsurvey corrections in Figure 7. Process flow for a Preliminary Denial of Accreditation (PDA) decision and Figure 8. Process flow for a Contingent Accreditation (CONT) decision Clarified the options for and timing of Focused Standards Assessment (FSA) submission in the “Focused Standards Assessment (FSA)” section Updated Sidebar 3. Focused Standards Assessment Options by deleting the bullets stating that surveyors may review any required MOS at full survey and by making minor editorial changes Changed percentage of organizations that undergo a random unannounced on-site validation survey from 5% to 2% in “Random Validation of Evidence of Standards Compliance” section Revised “Changes to the Site of Care, Treatment, or Services” section to reflect that organizations must complete a new Statement of Conditions if offering services or programs at a new location or in a significantly altered physical plant that is not a business occupancy CAMBHC, January 2014 vii 2014 CAMBHC n n n n viii Comprehensive Accreditation Manual for Behavioral Health Care Deleted the 50% minimum of services offered at a new location or in a significantly altered physical plant previously required as a condition of conducting extension surveys from “Extension Surveys” section Deleted redundant information about when for-cause surveys may be conducted from “For-Cause Surveys” section Updated “2013 Accreditation Decision Rules” section, including o Changing “behavioral health care organization” to “organization” throughout o Changing “an individual” to “a person” and “health care services” to “care, treatment, or services” in Preliminary Denial of Accreditation (PDA) Accreditation decision rule PDA03, Contingent (CONT) Accreditation decision rule CONT06, and Accreditation with Follow-up Survey (AFS) decision rule AFS09 o Revising CONT01 to reflect that abatement survey results help determine the Accreditation Committee’s decision o Revising CONT05 to include failure to successfully address all RFIs o Added reference to CONT06 in AFS09 o Clarifying that standards compliance in a written Evidence of Standards Compliance (ESC) is validated on site in ESC02 (On-site ESC Survey) o Deleted reference to deemed status from the Note to Preliminary Accreditation (PA) decision rule PA01 o Adding “Behavioral Health Home Certification” section and decision rules BHH01 and BHH02 Updated “Review and Appeal Procedures” section, including o Changing “First Level Review & Appeal Committee” to “Review Hearing Panel” throughout o Changing time frame from six to four months in “III. Contingent Accreditation” section and stating that follow-up electronic survey will replace MOS submission o Adding “IV. Accreditation with Follow-up Survey” section o Replacing “IV. First Level Review & Appeal” section with “V. Review Hearings” o Replacing “V. Second Consideration by the Accreditation Committee” section with “VI. Accreditation Committee Review Following Review Hearing” CAMBHC, January 2014 2014 CAMBHC o o Comprehensive Accreditation Manual for Behavioral Health Care Revising “VI. Final Review & Appeal Request” and renumbering it as section VII Renumbering sections VII–X as VIII–XI Standards Applicability Process (SAP) In the Foster Care and Shelter Services Applicability Grid: n Deleted CTS.01.01.01, EP 4 n Added CTS.01.01.01, EPs 2, 3, 5, 7 n Added CTS.02.01.05, EP 2 n Added CTS.02.02.01, EPs 6–8 n Added CTS.03.01.01, EPs 12–13 n Added CTS.03.01.03, EPs 17–22 n Added CTS.04.01.01, EPs 7, 14, 15 n Added CTS.04.01.03, EPs 24–27 n Added CTS.04.01.07, EPs 1–6 n Added CTS.04.02.23, EPs 1–3 n Added CTS.04.02.25, EPs 1–5 n Added CTS.04.02.27, EPs 1–5 n Added CTS.06.01.05, EPs 1–6 n Added CTS.06.01.07, EPs 1–2 n Added EC.02.04.03, EP 3 n Added HR.01.04.01, EPs 25–26 n Added HR.01.05.03, EP 24 n Added IM.01.01.01, EP 6 n Added LD.04.04.01, EPs 24–25 n Added LD.04.04.09, EPs 1–5 n Added PI.01.01.01, EPs 40–43 n Added PI.02.01.01, EP 9 n Added PI.03.01.01, EP 11 n Added RC.02.01.01, EPs 28–30 n Added RI.01.02.01, EPs 31–33 n Added RI.01.04.01, EP 6 n Added RI.01.04.03, EPs 1–6 n Added RI.01.05.01, EPs 1, 4, 5, 8, 10, 11 CAMBHC, January 2014 ix 2014 CAMBHC Comprehensive Accreditation Manual for Behavioral Health Care In the Behavioral Health Care Settings Applicability Grid: n Added CTS.01.01.01, EP 7 n Added CTS.02.01.05, EP 5 n Added CTS.02.02.01, EPs 6–8 n Added CTS.03.01.01, EPs 12–13 n Added CTS.03.01.03, EPs 17–22 n Added CTS.04.01.01, EPs 7, 14, 15 n Added CTS.04.01.03, EPs 24–27 n Added CTS.04.01.07, EPs 1–6 n Added CTS.04.02.23, EPs 1–3 n Added CTS.04.02.25, EPs 1–5 n Added CTS.04.02.27, EPs 1–5 n Added CTS.06.01.05, EPs 1–6 n Added CTS.06.01.07, EPs 1–2 n Added EC.02.04.03, EP 3 n Added HR.01.04.01, EPs 25–26 n Added HR.01.05.03, EP 24 n Added IM.01.01.01, EP 6 n Added LD.04.04.01, EPs 24–25 n Added LD.04.04.09, EPs 1–5 n Added PI.01.01.01, EPs 40–43 n Added PI.02.01.01, EP 9 n Added PI.03.01.01, EP 11 n Added RC.02.01.01, EPs 28–30 n Added RI.01.02.01, EPs 31–33 n Added RI.01.04.01, EP 6 n Added RI.01.04.03, EPs 1–6 n Added RI.01.05.01, EPs 1, 4, 5, 8, 10, 11 In the Behavioral Health Care Services Applicability Grid: n Deleted CTS.01.01.01, EP 7 n Added CTS.01.01.01, EPs 2, 24 n Added CTS.02.01.05, EP 2 n Added CTS.02.02.01, EPs 6–8 x CAMBHC, January 2014 2014 CAMBHC n n n n n n n n n n n n n n n n n n n n n n n n Comprehensive Accreditation Manual for Behavioral Health Care Added CTS.03.01.01, EPs 12–13 Added CTS.03.01.03, EPs 17–22 Added CTS.04.01.01, EPs 7, 14, 15 Added CTS.04.01.03, EPs 24–27 Added CTS.04.01.07, EPs 1–6 Added CTS.04.02.23, EPs 1–3 Added CTS.04.02.25, EPs 1–5 Added CTS.04.02.27, EPs 1–5 Added CTS.06.01.05, EPs 1–6 Added CTS.06.01.07, EPs 1–2 Added EC.02.04.03, EP 3 Added HR.01.04.01, EPs 25–26 Added HR.01.05.03, EP 24 Added IM.01.01.01, EP 6 Added LD.04.04.01, EPs 24–25 Added LD.04.04.09, EPs 1–5 Added PI.01.01.01, EPs 40–43 Added PI.02.01.01, EP 9 Added PI.03.01.01, EP 11 Added RC.02.01.01, EPs 28–30 Added RI.01.02.01, EPs 31–33 Added RI.01.04.01, EP 6 Added RI.01.04.03, EPs 1–6 Added RI.01.05.01, EPs 1, 4, 5, 8, 10, 11 Sentinel Events (SE) n Revised “Definition of Occurrences That Are Subject to Review by The Joint Commission Under the Sentinel Event Policy” section Required Written Documentation (RWD) n n n n Deleted CTS.01.01.01, EPs 8, 21, 23 Added CTS.01.01.01, EPs 2, 9, 22, 24 Added EC.02.04.03, EP 3 Added RI.01.05.01, EPs 1, 4 Early Survey Policy Option (ESP) CAMBHC, January 2014 xi 2014 CAMBHC n n Comprehensive Accreditation Manual for Behavioral Health Care Revised introduction regarding surveys for organizations seeking accreditation for deemed status purposes Added CTS.02.01.05, EPs 3, 5 Opioid Treatment Programs (OTP) n n n n n n n n n n n n n n n n n n n n n n n n n n n n xii Added explanation of applicability of standards and elements of performance to opioid addiction treatment programs Updated Standards List Deleted APR.09.04.01, EP 1 Changed numbering of EPs in CTS.01.01.01, EPs 8–12, 15–16, 18–21 Added note to CTS.01.01.01, EP 11 Deleted CTS.01.01.01, EPs 13–14, 22–23 Added Standard CTS.02.01.01, EP 1 Added CTS.02.01.09, EPs 1–2 Added CTS.02.02.01, EPs 1, 4 Added CTS.02.02.05, EP 2 Added CTS.02.02.07, EP 1 Added CTS.02.03.03, EPs 1–2 Deleted CTS.02.03.07, EPs 1–9 Added CTS.03.01.01, EPs 1–4 Deleted CTS.03.01.01, EPs 5, 7 Added CTS.03.01.03, EPs 1–6 Added CTS.03.01.05, EP 1 Added CTS.03.01.07, EPs 1–3 Added CTS.04.01.01, EPs 4–5 Deleted CTS.04.01.01, EP 13 Added CTS.04.03.35, EPs 1–3 Added CTS.05.01.01, EPs 2–4 Added CTS.06.02.03, EPs 3–4 Added CTS.06.02.05, EPs 1–2 Added EC.02.03.01, EPs 9–10 Added EC.02.03.03, EP 2 Added EC.02.03.05, EPs 15–16 Added EC.02.06.01, EPs 1, 20 CAMBHC, January 2014 2014 CAMBHC n n n n n n n n n n n n n n n n n n n n n n n n n n n n n n n n n n Comprehensive Accreditation Manual for Behavioral Health Care Added EM.01.01.01, EP 4 Added HR.01.02.01, EP 1 Added HR.01.02.07, EP 1 Added HR.01.05.03, EPs 1, 4–5 Added HR.01.06.01, EP 1 Deleted HR.01.06.03, EPs 1–3 Added HR.01.07.01, EP 1 Added HR.02.01.03, EP 25 Added IC.01.03.01, EPs 1–2 Added IC.01.05.01, EP 1 Deleted Rationale for IC.02.04.01 Deleted IC.02.04.01, EPs 1–9 Added IM.01.01.03, EPs 2–4 Added IM.02.01.01, EPs 1–2 Added IM.02.01.03, EPs 5–6 Added IM.02.02.03, EP 12 Added LD.01.04.01, EPs 1–3 Deleted LD.01.04.01, EP 13 Added LD.02.01.01, EP 1 Added LD.03.06.01, EP 3 Added LD.04.01.01, EPs 1–2 Deleted LD.04.01.09, EP 8 Added LD.04.01.11, EPs 2, 5 Added LD.04.02.03, EP 7 Added LD.04.04.05, EPs 5–8 Deleted MM.01.01.03, EPs 1–3, 11 Deleted MM.01.01.05, EP 1 Deleted MM.01.02.01, EPs 1–3 Deleted MM.02.01.01, EPs 1–3, 5, 7–9, 11, 13 Deleted MM.03.01.03, EPs 3, 6 Deleted MM.03.01.05, EPs 1–3 Deleted MM.04.01.01, EPs 2–5, 7–9 Added note to MM.04.01.01, EP 16 Deleted MM.05.01.01, EP 1 CAMBHC, January 2014 xiii 2014 CAMBHC n n n n n n n n n n n n n n n n n n n n n n n n n n n n n Comprehensive Accreditation Manual for Behavioral Health Care Deleted MM.05.01.07, EPs 2–3 Deleted MM.05.01.09, EPs 1–5, 7–12 Deleted MM.05.01.11, EPs 1–4, 9 Deleted MM.05.01.13, EPs 1, 7 Deleted MM.05.01.15, EPs 1–5 Deleted MM.05.01.17, EPs 1–4 Deleted MM.05.01.19, EPs 1–4 Deleted MM.06.01.01, EPs 1–5, 8, 9, 12 Deleted MM.06.01.03, EPs 1–4, 6–7, 10, 15, 17 Deleted MM.06.01.05, EPs 1, 4 Deleted MM.07.01.01, EPs 1–3 Deleted MM.07.01.03, EPs 1, 5 Deleted MM.08.01.01, EPs 1–2, 3, 5–8 Added PI.01.01.01, EP 16 Added RC.01.01.01, EPs 5–8, 11 Added RC.01.02.01, EPs 1, 3–5 Added RC.01.03.01, EPs 1, 3 Added RC.01.04.01, EP 1 Added RC.01.05.01, EP 1 Added RC.02.01.01, EPs 1, 2, 4 Added RC.02.04.01, EP 3 Added RI.01.01.01, EPs 1–2, 4, 6–7, 10, 22 Added RI.01.01.03, EPs 1–3 Added RI.01.02.01, EPs 1, 6, 8 Added RI.01.03.01, EPs 7, 11–13 Added RI.01.03.05, EPs 2–7 Added RI.01.07.01, EPs 1, 2, 4, 7 Added RI.02.01.01, EP 2 Made minor editorial changes Behavioral Health Home Certification Option (BHH) n Added the Behavioral Health Home Certification Standards (BHH) Glossary (GL) n xiv Revised definitions for the following terms: CAMBHC, January 2014 2014 CAMBHC o o o o o o o o o o o o o o o o o o o o o o o o o o o o o o o o o o Comprehensive Accreditation Manual for Behavioral Health Care accreditation decisions accreditation manual accreditation process appeal process applicant organization assessment behavioral health care child coordination of care, treatment, or services crisis stabilization criticality day treatment Early Survey Policy eating disorder Focused Standards Assessment (FSA) foster care, traditional child/youth Immediate Threat to Health or Safety in-home behavioral health care services initial survey intensive outpatient services interdisciplinary Intracycle Monitoring (ICM) licensure medical history partial hospitalization program prescriber protective services read-back residential program Review Hearing Panel safety seclusion situational decision rules surveyor CAMBHC, January 2014 xv 2014 CAMBHC o o o o n n n n xvi Comprehensive Accreditation Manual for Behavioral Health Care tabletop exercise The Joint Commission tracer methodology vocational rehabilitation services Added new terms adoption services, assistive technology, behavioral health home, evidence-based practices, facilitated referral, functional exercise, integrated care, integrated care team, self-management, and specialty physical health care, treatment, or services Deleted the terms Cooperative Accreditation Initiative, ORYX® Vendor, and performance measurement system Changed the term First Level Review & Appeal to Review Hearing Panel; no change in definition Added cross references between Focused Standards Assessment (FSA) and Intracycle Monitoring (ICM) in their respective definitions CAMBHC, January 2014 Comprehensive AccreditationManual CAMBHC for Behavioral Health HealthCare Care Effective January 1, 2014 Standards Elements of Performance Scoring Accreditation Policies The Joint Commission Accreditation Behavioral Health Care The Joint Commission Mission The mission of The Joint Commission is to continuously improve health care for the public, in collaboration with other stakeholders, by evaluating health care organizations and inspiring them to excel in providing safe and effective care of the highest quality and value. © 2014 The Joint Commission Joint Commission Resources, Inc. (JCR), a not-for-profit affiliate of The Joint Commission, has been designated by The Joint Commission to publish publications and multimedia products. JCR reproduces and distributes these materials under license from The Joint Commission. JCR educational programs and publications support, but are separate from, the accreditation activities of The Joint Commission. Attendees at JCR educational programs and purchasers of JCR publications receive no special consideration or treatment in, or confidential information about, the accreditation process. All rights reserved. No part of this publication may be reproduced in any form or by any means without written permission from the publisher. Printed in the U.S.A. 5 4 3 2 1 Requests for permission to make copies of any part of this work should be mailed to the following: Permissions Editor Department of Publications and Education Joint Commission Resources One Renaissance Boulevard Oakbrook Terrace, Illinois 60181 [email protected] ISBN: 978-1-59940-805-7 ISSN: 1089-9871 For more information about The Joint Commission, please visit http://www.jointcommission.org. Contents How to Use This Manual (HM)...........................................................HM-1 Requirements for Accreditation Accreditation Participation Requirements (APR)..................................APR-1 Care, Treatment, and Services (CTS) ...................................................CTS-1 Environment of Care (EC) .....................................................................EC-1 Emergency Management (EM) ..............................................................EM-1 Human Resources (HR).........................................................................HR-1 Infection Prevention and Control (IC) ....................................................IC-1 Information Management (IM) ..............................................................IM-1 Leadership (LD) .....................................................................................LD-1 Life Safety (LS) ........................................................................................LS-1 Medication Management (MM)...........................................................MM-1 National Patient Safety Goals (NPSG) ..............................................NPSG-1 Performance Improvement (PI)................................................................PI-1 Record of Care, Treatment, and Services (RC) .......................................RC-1 Rights and Responsibilities of the Individual (RI) ....................................RI-1 Waived Testing (WT) ...........................................................................WT-1 Policies, Procedures, and Other Information The Accreditation Process (ACC) ..................................................ACC-1 Standards Applicability Process (SAP) .........................................SAP-1 Sentinel Events (SE) ..........................................................................SE-1 The Joint Commission Quality Report (QR) ....................................QR-1 Required Written Documentation (RWD)......................................RWD-1 Early Survey Policy Option (ESP)...................................................ESP-1 Opioid Treatment Programs (OTP).................................................OTP-1 CAMBHC, January 2014 3 ◤Comprehensive Accreditation Manual for Behavioral Health Care Foster Care (FC) .................................................................................FC-1 Behavioral Health Home Certification Option (BHH)....................BHH-1 Glossary (GL) ..................................................................................... GL-1 Index (IX)............................................................................................... IX-1 4 CAMBHC, January 2014