JCR CAMCAH 2022

$178.21

Comprehensive Accreditation Manual for Critical Access Hospitals (CAMCAH)

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 Critical Access Hospitals (CAMCAH) provides all 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 Primary Care Medical Home certification. The portable CAMCAH is spiral bound with color-coded tabs that allow you to find exactly what you need for standards compliance or survey readiness when you need it. It’s lean and light, making it a perfect on-the-go reference. Keep it handy in meetings, during orientation and training, and as a practical overview of the Joint Commission’s accreditation requirements for everyone in your organization, from staff to leaders. Then, get ready to power performance improvement and excellence in your organization! Please note: The CAMCAH is delivered annually. For the most up-to-date standards throughout 2022, access your E-dition® on your Joint Commission Connect® extranet site or consider purchasing the E-dition Critical Access Hospital version. Not sure if your organization is a critical access hospital? A critical access hospital is defined by CMS as hospital that offers limited services and is located more than 35 miles from a hospital or another critical access hospital, or is certified by the state as being a necessary provider of health care services to residents in the area. It maintains no more than 25 beds that could be used for inpatient care. This manual won’t apply unless you meet those criteria. Key Topics: “Gold tab” standards 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 Keys to successfully using the manual for survey preparedness Key Features: Integrated regulatory requirements for critical access hospital recognition Icons to help navigate documentation requirements as well as risk areas “What’s New” summary of changes made since the previous edition Color-coded blue and gold tabs allow you to find exactly what you need when you need it Softcover, spiral-bound book Standards: All critical access hospital standards Setting: Critical access hospitals Key Audience: Staff responsible for accreditation, patient safety, or quality improvement in critical access hospitals or the distinct part psychiatric and/or rehabilitation distinct part units within a critical access hospital.

PDF Catalog

PDF Pages	PDF Title
1	What’s New 2022 CAMCAH
2	Introduction: How Joint Commission Accreditation Can Help on the Road toHigh Reliability (INTRO) Patient Safety Systems (PS)
4	Accreditation Requirements Accreditation Participation Requirements (APR)
5	Environment of Care (EC) Emergency Management (EM)
6	Human Resources (HR) Infection Prevention and Control (IC) Information Management (IM)
7	Leadership (LD) Life Safety (LS)
8	Medication Management (MM)
9	Medical Staff (MS) National Patient Safety Goals (NPSG) Nursing (NR)
10	Provision of Care, Treatment, and Services (PC) Performance Improvement (PI)
11	Record of Care, Treatment, and Services (RC)
12	Rights and Responsibilities of the Individual (RI) Transplant Safety (TS) Waived Testing (WT) Accreditation Process Information The Accreditation Process (ACC)
13	Standards Applicability Grid (SAG)
14	Sentinel Event Policy (SE)
15	The Joint Commission Quality Report (QR)
16	Performance Measurement and the ORYX® Initiative (PM) Required Written Documentation (RWD Early Survey Policy (ESP)
17	Primary Care Medical Home (PCMH) Appendix A: Medicare Requirements for Critical Access Hospitals (AXA) Appendix B: Medicare Requirements for Critical Access Hospitals withDPUs (AXB) Glossary
18	Index (IX)
19	Cover
20	Copyright
21	Contents
23	Introduction: How Joint Commission Accreditation Can Help on the Road to High Reliability (INTRO)
24	I. Introduction to Joint Commission Accreditation The Value of Joint Commission Accreditation
26	The Joint Commission’s Critical Access Hospital Accreditation Program
27	II. About the
28	How Is This Manual Organized?
31	Accreditation Requirements
33	Accreditation Process Information
35	Identifying Applicable Standards
37	Understanding the Organization of the Standards Chapters
40	Understanding the Icons Used in the Manual
41	III. Steps to Achieving and Maintaining Compliance Become Familiar with the Standards Use the Standards to Improve Care, Treatment, and Services
42	Assess Compliance with the Standards
44	Stimulate Improvement
47	Keep Current with Standards Changes via Perspectives
48	IV. Get Extra Help Getting Started with Accreditation Account Executive
49	Contacting The Joint Commission Standards Questions Requesting Permission to Share Content from the Manual
51	Patient Safety Systems (PS) Quality and Safety in Health Care
53	Goals of This Chapter
54	Becoming a Learning Organization
55	The Role of Leaders in Patient Safety Safety Culture
58	A Fair and Just Safety Culture
60	Data Use and Reporting Systems
61	Effective Use of Data Collecting Data
62	Analyzing Data
63	Using Data to Drive Improvement
64	A Proactive Approach to Preventing Harm
65	Tools for Conducting a Proactive Risk Assessment
67	Encouraging Patient Activation
68	Beyond Accreditation: The Joint Commission Is Your Patient Safety Partner
70	References
75	Accreditation Participation Requirements (APR) Overview
76	Chapter Outline
77	Requirements, Rationales, and Elements of Performance
85	Environment of Care (EC) Overview About This Chapter
86	Other Issues for Consideration
88	Chapter Outline
89	Standards, Rationales, and Elements of Performance
127	Introduction to Standard EC.02.06.01
133	Emergency Management (EM) Overview About This Chapter
135	Chapter Outline
136	Standards, Rationales, and Elements of Performance
145	Introduction to Standard EM.02.02.05
151	Introduction to Standards EM.02.02.13 and EM.02.02.15
160	Introduction to Standard EM.04.01.01
163	Human Resources (HR) Overview About This Chapter
164	Chapter Outline
165	Standards, Rationales, and Elements of Performance
174	Introduction to Standards HR.01.06.01 and HR.01.07.01
177	Infection Prevention and Control (IC) Overview
178	About This Chapter
179	Chapter Outline
180	Standards, Rationales, and Elements of Performance Introduction to Standards IC.01.01.01 Through IC.01.06.01 – Planning
184	Introduction to Standards IC.02.01.01 Through IC.02.04.01 – Implementation
188	Introduction to Standard IC.02.04.01
191	Introduction to Standard IC.03.01.01— Evaluation and Improvement
193	Information Management (IM) Overview About This Chapter
194	Chapter Outline
195	Standards, Rationales, and Elements of Performance Introduction to Standard IM.01.01.01
196	Introduction to Standard IM.01.01.03
197	Introduction to Standard IM.02.01.01
198	Introduction to Standard IM.02.01.03
200	Introduction to Standard IM.02.02.03
205	Leadership (LD) Overview
206	Proactive Risk Assessment
207	About This Chapter
209	Chapter Outline
210	Standards, Rationales, and Elements of Performance Introduction to Leadership Structure, Standards LD.01.01.01 Through LD.01.05.01
214	Introduction to Leadership Relationships, Standards LD.02.01.01 Through LD.02.04.01
215	Introduction to Standard LD.02.04.01
217	Introduction to Critical Access Hospital Culture and System Performance Expectations, Standards LD.03.01.01 Through LD.03.06.01
223	Introduction to Operations, Standards LD.03.07.01 Through LD.04.03.11
225	Introduction to Standard LD.03.09.01
240	Introduction to Oversight of Care, Treatment, and Services Provided Through Contractual Agreement, Standard LD.04.03.09
245	Introduction to Standard LD.04.03.13
247	Life Safety (LS) Overview About This Chapter
250	Chapter Outline
251	Standards, Rationales, and Elements of Performance Introduction to Standard LS.01.01.01
303	Medication Management (MM) Overview
304	About This Chapter
306	Chapter Outline
307	Standards, Rationales, and Elements of Performance
314	Introduction to Standard MM.04.01.01
331	Medical Staff (MS) Overview
332	Medical Staff Structure
333	Chapter Outline
334	Standards, Rationales, and Elements of Performance Introduction to Standard MS.01.01.01
340	Introduction to Standard MS.03.01.01
346	Introduction to Standard MS.06.01.01
348	Introduction to Standard MS.06.01.03
352	Introduction to Standard MS.06.01.05
358	Introduction to Standard MS.08.01.01
360	Introduction to Standard MS.08.01.03
362	Introduction to Standard MS.13.01.01
367	National Patient Safety Goals (NPSG) Chapter Outline
368	Requirements, Rationales, and Elements of Performance Goal 1
369	Goal 2
370	Goal 3
373	Introduction to Reconciling Medication Information
376	Goal 6
377	Goal 7
378	Goal 15
380	Introduction to the Universal Protocol for Preventing Wrong Site, Wrong Procedure, and Wrong Person Surgery™
382	Introduction to UP.01.02.01
387	Nursing (NR) Overview
388	Chapter Outline
389	Standards, Rationales, and Elements of Performance
393	Provision of Care, Treatment, and Services (PC) Overview
394	About This Chapter
395	Chapter Outline
396	Standards, Rationales, and Elements of Performance Introduction to Standard PC.01.02.01
401	Introduction to Standard PC.01.02.07
404	Introduction to Standard PC.01.02.09
405	Introduction to Standard PC.01.02.13
409	Introduction to Standard PC.01.03.01
417	Introduction to Standard PC.02.02.01
419	Introduction to Standard PC.02.03.01
424	Introduction to Standards PC.03.01.01 Through PC.03.01.07
445	Performance Improvement (PI) Overview About This Chapter
447	Chapter Outline
448	Standards, Rationales, and Elements of Performance Introduction to Standard PI.01.01.01
451	Introduction to Standard PI.03.01.01
455	Record of Care, Treatment, and Services (RC) Overview About This Chapter
456	Chapter Outline
457	Standards, Rationales, and Elements of Performance
467	Rights and Responsibilities of the Individual (RI) Overview About This Chapter
469	Chapter Outline
470	Standards, Rationales, and Elements of Performance Introduction to Standard RI.01.01.01
472	Introduction to Standard RI.01.01.03
485	Transplant Safety (TS) Overview
486	About This Chapter
487	Chapter Outline
488	Standards, Rationales, and Elements of Performance Introduction to Standard TS.01.01.01
491	Introduction to Standards TS.03.01.01, TS.03.02.01, and TS.03.03.01
497	Waived Testing (WT) Overview
498	About This Chapter
500	Chapter Outline
501	Standards, Rationales, and Elements of Performance
507	The Accreditation Process (ACC) Notices ACC Chapter Contents
509	Overview General Eligibility Requirements
510	Initial Surveys
511	Scope of Accreditation Surveys Accreditation Policies Tailored Survey Policy
512	Complex Organization Survey Process
513	Organizational and Functional Integration
516	Inclusion of Physician Practices in Survey Multiorganization Option Concurrent Survey Option
517	Contracted Services Integrated Care Certification Option
518	Primary Care Medical Home Certification Option
519	Patient Blood Management Certification Option
520	Survey Postponement Policy Information Accuracy and Truthfulness Policy
521	Policy Requirements
522	Good Faith Participation in Accreditation/ Certification
523	Public Information Policy
524	Process for Responding to a Complaint
525	Early Survey Policy
526	Eligibility for Limited, Temporary Accreditation
528	Before the Survey An Organization’s Secure Joint Commission Connect Extranet Site EnsuringJoint Commission Connect Security
529	Role of Consultants Role of the Account Executive Electronic Application for Accreditation (E-App)
530	Accuracy of the Application Information Forfeiture of Survey Deposit
531	Accreditation/Certification Contract and Business Associate Agreement
532	Annual and Survey Fees
533	During the Survey Survey Notification
536	Initial and Full Survey Team Composition Life Safety Code Surveyor Scope of Survey Survey Agenda
541	Tracer Methodology Accreditation Program–Specific Tracer
542	Individual Tracer Activity
543	Risk Areas
544	System Tracer Activity
545	The Role of Staff in Tracer Methodology Immediate Threat to Health or Safety
549	Immediate Threat to Health or Safety During Initial Survey Summary of the Accreditation Reports
550	After the Survey The Scoring Process
551	How Accreditation Decisions Are Made
553	Accreditation Decisions for Organizations Seeking Renewal
554	Decision Outcomes for Organizations Seeking Initial Accreditation
555	Accreditation Effective Dates
556	Withdrawing or Closing After Undergoing a Resurvey Evidence of Standards Compliance (ESC) Process
557	Clarifying ESC
558	Corrective ESC
559	Accreditation Award Display and Use
561	Recommendation Letter for Critical Access Hospitals That Use Joint Commission Accreditation for Deemed Status Purposes Between Accreditation Surveys Duration of Accreditation Award
562	Continuous Compliance Intracycle Monitoring (ICM)
563	Focused Standards Assessment (FSA)
565	Plan of Action (POA) Sentinel Event Follow-up Notifying The Joint Commission About Organization Changes
566	Changes Affecting E-App Information
567	Changes to the Site of Care, Treatment, or Services Mergers, Consolidations, and Acquisitions Accreditation Status of Organizations That Cease Services After a Disaster\|\|\|\|\|\|\|\|\|\|\|\|
569	Accreditation Status of Organizations That Cease Services or Do Not Have Patients for a Period of Time
570	Reentering the Accreditation Process Additional Surveys Extension Surveys
571	For-Cause Surveys
572	Random Validation of Evidence of Standards Compliance Follow-up Survey for a Condition-level Deficiency
573	Decision Rules for Organizations Seeking Initial Accreditation Accredited
574	Primary Care Medical Home Certification Limited, Temporary Accreditation Evidence of Standards Compliance (ESC)
575	One-Month Survey Medicare Deficiency Follow-up Survey Denial of Accreditation
577	Decision Rules for Organizations Seeking Reaccreditation Accredited Primary Care Medical Home Certification
578	Evidence of Standards Compliance (ESC) One-Month Survey Medicare Deficiency Follow-up Survey Accreditation with Follow-up Survey
580	Preliminary Denial of Accreditation
581	Denial of Accreditation
582	Process for Organizations That Meet Decision Rule PDA02 for Patients Placed at Risk for Serious Adverse Outcomes Due to Signific
584	Process for Organizations That Meet Decision Rule PDA04
585	Review and Appeal Procedures I. Evaluation by Joint Commission Staff
586	II. Accreditation with Follow-up Survey
587	III. Review Hearings
588	IV. Following a Review Hearing
589	V. Final Review &Appeal Request
591	Standards Applicability Grid (SAG)
629	Sentinel Event Policy (SE)
630	Goals of the Sentinel Event Policy
631	Identifying Sentinel Events
635	Determining That a Sentinel Event Is Subject to Review
636	Relationship to the Survey Process
637	Required Organization Response to a Sentinel Event
638	Reporting a Sentinel Event to The Joint Commission
640	Conducting a Comprehensive Systematic Analysis
641	Developing a Corrective Action Plan
642	Submitting the Comprehensive Systematic Analysis and Corrective Action Plan
645	The Joint Commission’s Response Review of Comprehensive Systematic Analyses and Corrective Action Plans
646	Follow-up Activities
647	Sentinel Event Measures of Success Optional On-Site Review of a Sentinel Event
648	Disclosable Information Handling Sentinel Event–Related Documents The Sentinel Event Database
649	Overseeing the Sentinel Event Policy
651	The Joint Commission Quality Report (QR) Introduction What Is The Joint Commission Quality Report?
652	What Will My Quality Report Contain?
653	What Is Quality Check?
654	Is a Quality Report Available for My Accredited Critical Access Hospital? Can My Critical Access Hospital Comment on Its Quality Report? How Does My Critical Access Hospital Submit a Commentary? Are There Any Criteria That Must Be Met in a Commentary?
655	What Are the Marketing and Communication Guidelines for Publicizing Your Accreditation and Commitment to Quality?
656	Guidelines for Publicizing Compliance with the National Patient Safety Goals
657	Information Released by The Joint Commission Guidelines for Publication
659	Performance Measurement and the ORYX Initiative (PM) Overview The Continued Role of ORYX
660	Accelerate PI™
661	Use of Performance Measure Data Current Requirements for Critical Access Hospitals
663	Required Written Documentation (RWD)
664	List of EPs Requiring Written Documentation for Critical Access Hospitals by Service Acute
667	Inpatient Rehab Distinct Part Unit
668	Psychiatric Distinct Part Unit
670	Swing Beds
671	Early Survey Policy (ESP)
683	Primary Care Medical Home Certification Option (PCMH) Overview Primary Care Medical Home Model
684	I. Patient-Centered Care II. Comprehensive Care
685	III. Coordinated Care
686	IV. Superb Access to Care V. Systems-Based Approach to Quality and Safety
687	Standards, Rationales, Elements of Performance, and Scoring Specific to the Primary Care Medical Home Certification Option I. Patient-Centered Care Leadership (LD)
689	Provision of Care, Treatment, and Services (PC)
692	Record of Care, Treatment, and Services (RC)
693	Rights and Responsibilities of the Individual (RI)
701	II. Comprehensive Care Leadership (LD) Medical Staff (MS)
702	Provision of Care, Treatment, and Services (PC)
704	III. Coordinated Care Human Resources (HR) Medical Staff (MS) Provision of Care, Treatment, and Services (PC)
709	Record of Care, Treatment, and Services (RC)
710	IV. Superb Access to Care Provision of Care, Treatment, and Services (PC)
711	V. Systems-Based Approach to Quality and Safety Leadership (LD)
715	Medication Management (MM)
716	Provision of Care, Treatment, and Services (PC) Performance Improvement (PI)
719	Appendix A: Medicare Requirements for Critical Access Hospitals (AXA) 485.610 Condition of Participation: Status and Location
720	485.616 Condition of Participation: Agreements
723	485.627 Condition of Participation: Organizational Structure 485.635 Condition of Participation: Provision of Services
724	485.641 Condition of Participation: Periodic Evaluation and Quality Assurance Review
725	Appendix B: Medicare Requirements for Critical Access Hospitals with DPUs (AXB) Part 409 Subpart B—Inpatient Hospital Services and Inpatient Critical Access Hospital Services
726	409.17: Physical Therapy, Occupational Therapy, and Speech-Language Pathology Services
727	412.25 Excluded Hospital Units: Common Requirements
729	412.29 Excluded Rehabilitation Units: Additional Requirements
730	412.30 Exclusion of New Rehabilitation Units and Expansion of Units Already Excluded
732	482.12 Condition of Participation: Governing Body
733	482.22 Condition of Participation: Medical Staff
735	482.24 Condition of Participation: Medical Record Services
736	482.27 Condition of Participation: Laboratory Services
740	482.30 Condition of Participation: Utilization Review
743	482.51 Condition of Participation: Surgical Services
745	Glossary (GL)
787	Index (IX)