Comprehensive Comprehensive Accreditation Accreditation Manual

Transcription

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:
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Updated “Accreditation Decision Rules” section to reflect 2014 decision rules.
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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.
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Added numerous standards and elements of performance to the “Standards
Applicability Process” (SAP) chapter due to the addition of the BHH chapter.
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Added numerous standards and elements of performance to the “Opioid Treatment
Programs” (OTP) chapter.
How to Use This Manual (HM)
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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
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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)
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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)
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Revised Chapter Outline
Added the following standards to the Behavioral Health Home Certification
Option
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CTS.01.01.01, EP 2
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CTS.02.01.05, EP 2
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CTS.02.02.01, EPs 6–8
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CTS.03.01.01, EPs 12, 13
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CTS.03.01.03, EPs 17–22
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CTS.04.01.01, EPs 7, 14, 15
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CTS.04.01.03, EPs 24–27
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CTS.04.01.07, EPs 1–6
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CTS.04.02.23, EPs 1–3
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CTS.04.02.25, EPs 1–5
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CTS.04.02.27, EPs 1–5
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CTS.06.01.05, EPs 1–6
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CTS.06.01.07, EPs 1–2
Changed numbering of EPs in CTS.01.01.01, EPs 3–24
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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)
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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
Added the following standard to the Behavioral Health Home Certification Option
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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)
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Option
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HR.01.04.01, EPs 25, 26
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HR.01.05.03, EP 24
Infection Prevention and Control (IC)
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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
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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)
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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)
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LD.04.04.01, EPs 24, 25
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LD.04.04.09, EPs 1–5
Life Safety (LS)
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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
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Medication Management (MM)
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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)
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Option
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PI.01.01.01, EPs 40–43
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PI.02.01.01, EP 9
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PI.03.01.01, EP 11
Record of Care, Treatment, and Services (RC)
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RC.02.01.01, EPs 28–30
Rights and Responsibilities of the Individual (RI)
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Option
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RI.01.02.01, EPs 31–33
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RI.01.04.01, EP 6
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RI.01.04.03, EPs 1–6
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RI.01.05.01, EPs 1, 4, 5, 8, 10, 11
Added note to RI.01.01.03, EP 2 regarding language interpreting options
Waived Testing (WT)
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Updated website addresses in chapter overview
The Accreditation Process (ACC)
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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
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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
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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
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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
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Changing “behavioral health care organization” to “organization” throughout
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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
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Revising CONT01 to reflect that abatement survey results help determine the
Accreditation Committee’s decision
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Revising CONT05 to include failure to successfully address all RFIs
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Added reference to CONT06 in AFS09
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Clarifying that standards compliance in a written Evidence of Standards
Compliance (ESC) is validated on site in ESC02 (On-site ESC Survey)
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Deleted reference to deemed status from the Note to Preliminary Accreditation
(PA) decision rule PA01
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Adding “Behavioral Health Home Certification” section and decision rules
BHH01 and BHH02
Updated “Review and Appeal Procedures” section, including
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Changing “First Level Review & Appeal Committee” to “Review Hearing
Panel” throughout
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Changing time frame from six to four months in “III. Contingent Accreditation” section and stating that follow-up electronic survey will replace MOS
submission
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Adding “IV. Accreditation with Follow-up Survey” section
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Replacing “IV. First Level Review & Appeal” section with “V. Review
Hearings”
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Replacing “V. Second Consideration by the Accreditation Committee” section
with “VI. Accreditation Committee Review Following Review Hearing”
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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:
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Deleted CTS.01.01.01, EP 4
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Added CTS.01.01.01, EPs 2, 3, 5, 7
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Added CTS.02.01.05, EP 2
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Added CTS.02.02.01, EPs 6–8
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Added CTS.03.01.01, EPs 12–13
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Added CTS.03.01.03, EPs 17–22
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Added CTS.04.01.01, EPs 7, 14, 15
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Added CTS.04.01.03, EPs 24–27
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Added EC.02.04.03, EP 3
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Added HR.01.04.01, EPs 25–26
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Added HR.01.05.03, EP 24
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Added IM.01.01.01, EP 6
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Added LD.04.04.01, EPs 24–25
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Added LD.04.04.09, EPs 1–5
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Added PI.01.01.01, EPs 40–43
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Added PI.02.01.01, EP 9
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Added PI.03.01.01, EP 11
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Added RC.02.01.01, EPs 28–30
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Added RI.01.02.01, EPs 31–33
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Added RI.01.04.01, EP 6
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Added RI.01.04.03, EPs 1–6
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Added RI.01.05.01, EPs 1, 4, 5, 8, 10, 11
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In the Behavioral Health Care Settings Applicability Grid:
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Added CTS.03.01.01, EPs 12–13
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Added CTS.03.01.03, EPs 17–22
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Added CTS.04.01.01, EPs 7, 14, 15
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Added CTS.04.01.03, EPs 24–27
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Added EC.02.04.03, EP 3
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Added HR.01.04.01, EPs 25–26
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Added HR.01.05.03, EP 24
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Added IM.01.01.01, EP 6
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Added LD.04.04.01, EPs 24–25
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Added LD.04.04.09, EPs 1–5
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Added PI.01.01.01, EPs 40–43
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Added PI.02.01.01, EP 9
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Added PI.03.01.01, EP 11
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Added RC.02.01.01, EPs 28–30
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Added RI.01.02.01, EPs 31–33
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Added RI.01.04.01, EP 6
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Added RI.01.04.03, EPs 1–6
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Added RI.01.05.01, EPs 1, 4, 5, 8, 10, 11
In the Behavioral Health Care Services Applicability Grid:
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Added CTS.01.01.01, EPs 2, 24
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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 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)
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Revised “Definition of Occurrences That Are Subject to Review by The Joint
Commission Under the Sentinel Event Policy” section
Required Written Documentation (RWD)
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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)
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Revised introduction regarding surveys for organizations seeking accreditation for
deemed status purposes
Added CTS.02.01.05, EPs 3, 5
Opioid Treatment Programs (OTP)
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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.02.02.01, EPs 1, 4
Deleted CTS.02.03.07, EPs 1–9
Deleted CTS.03.01.01, EPs 5, 7
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
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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.04.01.01, EPs 2–5, 7–9
Added note to MM.04.01.01, EP 16
Deleted MM.05.01.01, EP 1
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Deleted MM.05.01.09, EPs 1–5, 7–12
Deleted MM.05.01.11, EPs 1–4, 9
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.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)
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Glossary (GL)
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Revised definitions for the following terms:
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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
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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
Comprehensive
AccreditationManual
CAMBHC
for Behavioral
Health
HealthCare
Care
Effective January 1, 2014
Standards
Elements of Performance
Scoring
Accreditation Policies
The Joint Commission
Accreditation
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
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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
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◤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
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Comprehensive Comprehensive Accreditation Accreditation Manual

Transcription

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