JCR CAMNCC 2022

$178.21

Comprehensive Accreditation Manual for Nursing Care Centers (CAMNCC)

Published By	Publication Date	Number of Pages
Joint Commission	2022	656

Guaranteed Safe Checkout

Category: Joint Commission

If you have any questions, feel free to reach out to our online customer service team by clicking on the bottom right corner. We’re here to assist you 24/7.
Email:[email protected]

Description

The 2022 Comprehensive Accreditation Manual for Nursing Care Centers (CAMNCC) is now offered exclusively as a PDF manual. The CAMNCC PDF manual provides you with direct digital access to 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 tihe optional Post–Acute Care Certification and Memory Care Certification options. The CAMNCC PDF manual provides everything you need to successfully achieve and maintain compliance with Joint Commission accreditation and optional specialty certification standards. Inside you’ll find descriptions of the survey and decision process, questions to prompt discussion in your organization about compliance with the standards, checklists of the elements of performance that require written documentation, and action planning worksheets to address any issues of noncompliance. Available as a single-user or site license for the whole facility, the PDF puts the content of the CAMNCC a simple search away! Please note: The CAMNCC 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 Nursing Care Center version. Key Topics: Standards, National Patient Safety Goals®, and Accreditation Participation Requirements effective January 1, 2022 Accreditation process information about Joint Commission policies and procedures and practical survey preparation information on the Early Survey Policy, documentation requirements, and more Standards and elements of performance for optional post–acute care and memory care certifications Keys to successfully using the manual for survey preparedness Key Features: Survey readiness tools including compliance prompts, documentation checklists, and action planning worksheets in every standards chapter Icons to help navigate documentation requirements as well as risk areas “What’s New” summary of changes PDF format—printable, downloadable, and accessible Standards: All standards for nursing care centers and rehabilitation centers Setting: Organizations accredited under the Nursing Care Center Accreditation Program, including those that provide specialized services to patients or residents, which may include rehabilitative care, dementia-specific memory care, and long-term nursing care Key Audience: Staff responsible for accreditation, compliance, patient safety, or quality improvement

PDF Catalog

PDF Pages	PDF Title
1	What’s New 2022 CAMNCC
13	Cover
14	Copyright
15	Contents
17	Introduction: How Joint Commission Accreditation Can Help on the Road to High Reliability (INTRO)
19	The Value of Joint Commission Accreditation
21	The Joint Commission’s Nursing Care Center Accreditation Program
22	Addressing Complex Issues in Nursing Care Centers
23	Table 1. Standards That Address Complex Care Issues in Nursing Care Centers
25	How Is This Manual Organized?
26	Table 2. Acronyms Used in This Manual
27	Table 2.
28	Accreditation Requirements
29	Accreditation Process Information
31	Identifying Applicable Standards
33	Understanding the Organization of the Standards Chapters
36	Understanding the Icons Used in the Manual
37	Become Familiar with the Standards
38	Use the Standards to Improve Care, Treatment, and Services Assess Compliance with the Standards
40	Stimulate Improvement
42	Accelerate PI™
43	Keep Current with Standards Changes via
45	Getting Started with Accreditation Account Executive
46	Contacting The Joint Commission Standards Questions Requesting Permission to Share Content from the Manual
47	Patient Safety Systems (PS) Quality and Safety in Health Care
48	Sidebar 1. Key Terms
49	Goals of This Chapter
50	Becoming a Learning Organization
51	The Role of Leaders in Patient and Resident Safety
52	Safety Culture
55	Sidebar 2. Assessing Staff Accountability
56	Sidebar 2.
57	Data Use and Reporting Systems
58	Effective Use of Data
59	Table 1. Defining and Comparing Analytical Tools
60	A Proactive Approach to Preventing Harm
62	Sidebar 3. Strategies for an Effective Risk Assessment
63	Sidebar 3. Encouraging Patient or Resident Activation
64	Beyond Accreditation: The Joint Commission Is Your Patient and Resident Safety Partner
66	References
71	Accreditation Participation Requirements (APR) Overview
72	Chapter Outline
73	Requirements, Rationales, and Elements of Performance APR.01.01.01 Elements of Performance for APR.01.01.01 APR.01.02.01
74	Rationale for APR.01.02.01 Elements of Performance for APR.01.02.01 APR.01.03.01 Elements of Performance for APR.01.03.01
75	APR.02.01.01 Elements of Performance for APR.02.01.01 APR.05.01.01 Rationale for APR.05.01.01 Elements of Performance for APR.05.01.01 APR.06.01.01
76	Elements of Performance for APR.06.01.01 APR.07.01.01 Elements of Performance for APR.07.01.01 APR.08.01.01 Elements of Performance for APR.08.01.01 APR.09.01.01
77	Elements of Performance for APR.09.01.01 APR.09.02.01 Rationale for APR.09.02.01 Elements of Performance for APR.09.02.01
78	APR.09.03.01 Elements of Performance for APR.09.03.01 APR.09.04.01 Elements of Performance for APR.09.04.01
80	Written Documentation Checklist
83	Environment of Care (EC) Overview About This Chapter
84	Other Issues for Consideration
85	Chapter Outline
86	Standards, Rationales, and Elements of Performance Standard EC.01.01.01 Rationale for EC.01.01.01 Elements of Performance for EC.01.01.01
87	Standard EC.02.01.01 Rationale for EC.02.01.01 Elements of Performance for EC.02.01.01 Standard EC.02.01.03
88	Elements of Performance for EC.02.01.03 Standard EC.02.02.01 Rationale for EC.02.02.01
89	Elements of Performance for EC.02.02.01 Standard EC.02.03.01
90	Rationale for EC.02.03.01 Elements of Performance for EC.02.03.01 Standard EC.02.03.03 Elements of Performance for EC.02.03.03
91	Standard EC.02.03.05 Elements of Performance for EC.02.03.05
93	Standard EC.02.04.01 Elements of Performance for EC.02.04.01
94	Standard EC.02.04.03 Elements of Performance for EC.02.04.03
95	Standard EC.02.05.01 Elements of Performance for EC.02.05.01
97	Standard EC.02.05.02 Elements of Performance for EC.02.05.02
98	Standard EC.02.05.03
99	Elements of Performance for EC.02.05.03
100	Standard EC.02.05.05
101	Rationale for EC.02.05.05 Elements of Performance for EC.02.05.05
102	Standard EC.02.05.07 Rationale for EC.02.05.07 Elements of Performance for EC.02.05.07
105	Standard EC.02.05.09 Rationale for EC.02.05.09 Elements of Performance for EC.02.05.09
106	Introduction to Standard EC.02.06.01
107	Standard EC.02.06.01 Elements of Performance for EC.02.06.01
109	Standard EC.02.06.03 Elements of Performance for EC.02.06.03 Standard EC.02.06.05
110	Rationale for EC.02.06.05 Elements of Performance for EC.02.06.05 Introduction to Standard EC.04.01.01
111	Standard EC.04.01.01 Elements of Performance for EC.04.01.01 Standard EC.04.01.03 Elements of Performance for EC.04.01.03 Standard EC.04.01.05
112	Elements of Performance for EC.04.01.05
116	Written Documentation Checklist
133	Emergency Management (EM) Overview
134	About This Chapter
135	Chapter Outline
136	Standards, Rationales, and Elements of Performance Standard EM.01.01.01 Rationale for EM.01.01.01 Elements of Performance for EM.01.01.01
137	Standard EM.02.01.01
138	Rationale for EM.02.01.01 Elements of Performance for EM.02.01.01
139	Standard EM.02.02.01 Rationale for EM.02.02.01 Elements of Performance for EM.02.02.01
140	Standard EM.02.02.03
141	Rationale for EM.02.02.03 Elements of Performance for EM.02.02.03
142	Introduction to Standard EM.02.02.05
143	Standard EM.02.02.05 Elements of Performance for EM.02.02.05 Standard EM.02.02.07 Rationale for EM.02.02.07
144	Elements of Performance for EM.02.02.07 Standard EM.02.02.09 Rationale for EM.02.02.09
145	Elements of Performance for EM.02.02.09 Standard EM.02.02.11
146	Rationale for EM.02.02.11 Elements of Performance for EM.02.02.11
147	Introduction to Standards EM.02.02.13 and EM.02.02.15
148	Standard EM.02.02.13 Elements of Performance for EM.02.02.13
149	Standard EM.02.02.15 Elements of Performance for EM.02.02.15
150	Standard EM.03.01.01 Rationale for EM.03.01.01 Elements of Performance for EM.03.01.01
151	Standard EM.03.01.03 Rationale for EM.03.01.03 Elements of Performance for EM.03.01.03
155	Written Documentation Checklist
163	Human Resources (HR) Overview About This Chapter
164	Chapter Outline
165	Standards, Rationales, and Elements of Performance Standard HR.01.01.01 Elements of Performance for HR.01.01.01
166	Standard HR.01.02.05 Elements of Performance for HR.01.02.05
167	Standard HR.01.02.07 Elements of Performance for HR.01.02.07 Standard HR.01.04.01
168	Elements of Performance for HR.01.04.01 Standard HR.01.05.03
169	Elements of Performance for HR.01.05.03
170	Introduction to Standards HR.01.06.01 and HR.01.07.01
171	Standard HR.01.06.01 Elements of Performance for HR.01.06.01
172	Standard HR.01.07.01 Elements of Performance for HR.01.07.01
173	Introduction to Standards HR.02.01.04, HR.02.01.05, and HR.02.01.07
174	Standard HR.02.01.04 Elements of Performance for HR.02.01.04
176	Standard HR.02.01.05 Elements of Performance for HR.02.01.05 Standard HR.02.01.07
177	Elements of Performance for HR.02.01.07 Standard HR.02.02.01 Elements of Performance for HR.02.02.01
181	Written Documentation Checklist
191	Infection Prevention and Control (IC) Overview
192	About This Chapter
193	Chapter Outline
194	Standards, Rationales, and Elements of Performance Introduction to Standards IC.01.03.01 Through IC.01.06.01 – Planning Standard IC.01.03.01 Rationale for IC.01.03.01
195	Elements of Performance for IC.01.03.01 Standard IC.01.04.01 Elements of Performance for IC.01.04.01 Standard IC.01.05.01 Elements of Performance for IC.01.05.01
196	Standard IC.01.06.01 Elements of Performance for IC.01.06.01 Introduction to Standards IC.02.01.01 Through IC.02.04.01 – Implementation
197	Standard IC.02.01.01 Elements of Performance for IC.02.01.01
199	Standard IC.02.02.01 Rationale for IC.02.02.01
200	Elements of Performance for IC.02.02.01 Standard IC.02.03.01 Elements of Performance for IC.02.03.01
201	Introduction to Standard IC.02.04.01
202	Standard IC.02.04.01 Elements of Performance for IC.02.04.01 Standard IC.02.04.03
203	Rationale for IC.02.04.03 Elements of Performance for IC.02.04.03 Standard IC.02.04.05 Elements of Performance for IC.02.04.05 Standard IC.02.05.01
204	Elements of Performance for IC.02.05.01 Introduction to Standard IC.03.01.01 – Evaluation and Improvement
205	Standard IC.03.01.01 Elements of Performance for IC.03.01.01
210	Written Documentation Checklist
215	Information Management (IM) Overview About This Chapter
216	Chapter Outline
217	Standards, Rationales, and Elements of Performance Introduction to Standard IM.01.01.01 Standard IM.01.01.01 Elements of Performance for IM.01.01.01
218	Introduction to Standard IM.01.01.03 Standard IM.01.01.03 Elements of Performance for IM.01.01.03
219	Introduction to Standard IM.02.01.01 Standard IM.02.01.01 Elements of Performance for IM.02.01.01
220	Introduction to Standard IM.02.01.03 Standard IM.02.01.03 Elements of Performance for IM.02.01.03 Standard IM.02.02.01
221	Rationale for IM.02.02.01 Elements of Performance for IM.02.02.01
222	Introduction to Standard IM.02.02.03 Standard IM.02.02.03 Rationale for IM.02.02.03 Elements of Performance for IM.02.02.03 Standard IM.03.01.01 Elements of Performance for IM.03.01.01
226	Written Documentation Checklist
229	Leadership (LD) Overview
230	Proactive Risk Assessment
231	About This Chapter
232	Chapter Outline
233	Standards, Rationales, and Elements of Performance Introduction to Leadership Structure, Standards LD.01.03.01 Through LD.01.07.01 Standard LD.01.03.01
234	Rationale for LD.01.03.01 Elements of Performance for LD.01.03.01 Standard LD.01.04.01 Elements of Performance for LD.01.04.01 Standard LD.01.06.01 Elements of Performance for LD.01.06.01
236	Standard LD.01.07.01 Elements of Performance for LD.01.07.01
237	Introduction to Leadership Relationships, Standard LD.02.03.01 Standard LD.02.03.01 Rationale for LD.02.03.01 Elements of Performance for LD.02.03.01 Introduction to Organization Culture and System Performance Expectations, Standards LD.03.01.01 Through LD.03.06.01
240	Standard LD.03.01.01 Rationale for LD.03.01.01 Elements of Performance for LD.03.01.01
241	Introduction to Standard LD.03.01.02
242	Standard LD.03.01.02 Elements of Performance for LD.03.01.02 Standard LD.03.02.01 Rationale for LD.03.02.01
243	Elements of Performance for LD.03.02.01 Standard LD.03.03.01 Rationale for LD.03.03.01 Elements of Performance for LD.03.03.01 Standard LD.03.04.01
244	Rationale for LD.03.04.01 Elements of Performance for LD.03.04.01 Standard LD.03.05.01 Rationale for LD.03.05.01 Elements of Performance for LD.03.05.01 Standard LD.03.06.01
245	Rationale for LD.03.06.01 Elements of Performance for LD.03.06.01 Introduction to Operations, Standards LD.03.07.01 Through LD.04.03.09 Standard LD.03.07.01 Elements of Performance for LD.03.07.01
246	Standard LD.03.08.01 Elements of Performance for LD.03.08.01 Introduction to Standard LD.03.09.01
247	Standard LD.03.09.01 Elements of Performance for LD.03.09.01
249	Standard LD.03.10.01 Elements of Performance for LD.03.10.01
250	Standard LD.04.01.01 Elements of Performance for LD.04.01.01 Standard LD.04.01.03 Elements of Performance for LD.04.01.03
251	Standard LD.04.01.05 Rationale for LD.04.01.05 Elements of Performance for LD.04.01.05 Standard LD.04.01.07 Elements of Performance for LD.04.01.07 Standard LD.04.01.11
252	Rationale for LD.04.01.11 Elements of Performance for LD.04.01.11 Standard LD.04.02.01 Elements of Performance for LD.04.02.01 Standard LD.04.02.03 Elements of Performance for LD.04.02.03
253	Standard LD.04.03.01 Elements of Performance for LD.04.03.01 Standard LD.04.03.07 Rationale for LD.04.03.07 Elements of Performance for LD.04.03.07
254	Introduction to Oversight of Care, Treatment, and Services Provided Through Contractual Agreement, Standard LD.04.03.09 Monitoring Contracted Services
255	Permitting Licensed Independent Practitioners to PracticeWithin the Organization Standard LD.04.03.09 Elements of Performance for LD.04.03.09
257	Introduction to Standard LD.04.03.13 Standard LD.04.03.13 Elements of Performance for LD.04.03.13
263	Written Documentation Checklist
269	Life Safety (LS) Overview Applicability of the Standards About This Chapter
271	Chapter Outline
272	Standards, Rationales, and Elements of Performance Introduction to Standard LS.01.01.01 Standard LS.01.01.01 Elements of Performance for LS.01.01.01
273	Standard LS.01.02.01
274	Elements of Performance for LS.01.02.01
276	Standard LS.02.01.10 Elements of Performance for LS.02.01.10 Standard LS.02.01.20
277	Rationale for LS.02.01.20 Elements of Performance for LS.02.01.20
279	Standard LS.02.01.30 Rationale for LS.02.01.30 Elements of Performance for LS.02.01.30
280	Standard LS.02.01.34 Elements of Performance for LS.02.01.34
281	Standard LS.02.01.35 Elements of Performance for LS.02.01.35
282	Standard LS.02.01.40 Elements of Performance for LS.02.01.40 Standard LS.02.01.50
283	Elements of Performance for LS.02.01.50 Standard LS.02.01.70 Elements of Performance for LS.02.01.70
287	Written Documentation Checklist
291	Medication Management (MM) Overview
292	About This Chapter
293	Chapter Outline
294	Standards, Rationales, and Elements of Performance Standard MM.01.01.01 Rationale for MM.01.01.01 Elements of Performance for MM.01.01.01 Standard MM.01.01.03 Rationale for MM.01.01.03
295	Elements of Performance for MM.01.01.03 Standard MM.01.01.05 Rationale for MM.01.01.05 Elements of Performance for MM.01.01.05
296	Standard MM.01.02.01 Elements of Performance for MM.01.02.01 Standard MM.03.01.01
297	Rationale for MM.03.01.01 Elements of Performance for MM.03.01.01 Standard MM.03.01.03
298	Rationale for MM.03.01.03 Elements of Performance for MM.03.01.03 Standard MM.03.01.05 Rationale for MM.03.01.05 Elements of Performance for MM.03.01.05
299	Introduction to Standard MM.04.01.01 Standard MM.04.01.01 Elements of Performance for MM.04.01.01
300	Standard MM.05.01.01
301	Elements of Performance for MM.05.01.01 Standard MM.05.01.07 Elements of Performance for MM.05.01.07 Standard MM.05.01.09
302	Rationale for MM.05.01.09 Elements of Performance for MM.05.01.09
303	Standard MM.05.01.15 Elements of Performance for MM.05.01.15 Standard MM.05.01.17 Elements of Performance for MM.05.01.17
304	Standard MM.05.01.19 Rationale for MM.05.01.19 Elements of Performance for MM.05.01.19 Standard MM.06.01.01 Elements of Performance for MM.06.01.01
305	Standard MM.06.01.03 Elements of Performance for MM.06.01.03
306	Standard MM.06.01.05 Rationale for MM.06.01.05 Elements of Performance for MM.06.01.05 Standard MM.07.01.01 Elements of Performance for MM.07.01.01
307	Standard MM.07.01.03 Rationale for MM.07.01.03 Elements of Performance for MM.07.01.03
308	Introduction to Standard MM.08.01.01 Standard MM.08.01.01 Elements of Performance for MM.08.01.01
309	Standard MM.09.01.01 Elements of Performance for MM.09.01.01
315	Written Documentation Checklist
323	National Patient Safety Goals (NPSG) Chapter Outline National Patient Safety Goals®
324	Requirements, Rationales, and Elements of Performance Goal 1 NPSG.01.01.01 Rationale for NPSG.01.01.01 Elements of Performance for NPSG.01.01.01
325	Goal 3 NPSG.03.05.01 Rationale for NPSG.03.05.01 Elements of Performance for NPSG.03.05.01
327	Introduction to Reconciling Medication Information NPSG.03.06.01
328	Rationale for NPSG.03.06.01 Elements of Performance for NPSG.03.06.01
329	Goal 7 NPSG.07.01.01 Rationale for NPSG.07.01.01
330	Elements of Performance for NPSG.07.01.01 Goal 9 NPSG.09.02.01 Rationale for NPSG.09.02.01 Elements of Performance for NPSG.09.02.01
331	Goal 14 NPSG.14.01.01 Rationale for NPSG.14.01.01 Elements of Performance for NPSG.14.01.01
335	Written Documentation Checklist
339	Provision of Care, Treatment, and Services (PC) Overview
340	About This Chapter
341	Chapter Outline
342	Standards, Rationales, and Elements of Performance Standard PC.01.01.01 Elements of Performance for PC.01.01.01 Introduction to Standard PC.01.02.01
343	Standard PC.01.02.01 Elements of Performance for PC.01.02.01
346	Standard PC.01.02.03 Elements of Performance for PC.01.02.03
348	Standard PC.01.02.05 Elements of Performance for PC.01.02.05
349	Introduction to Standard PC.01.02.07
350	Standard PC.01.02.07 Elements of Performance for PC.01.02.07
352	Introduction to Standard PC.01.02.09 Standard PC.01.02.09 Elements of Performance for PC.01.02.09
353	Standard PC.01.02.15 Elements of Performance for PC.01.02.15
354	Introduction to Standard PC.01.03.01 Standard PC.01.03.01 Elements of Performance for PC.01.03.01
356	Standard PC.02.01.01 Elements of Performance for PC.02.01.01 Standard PC.02.01.03 Elements of Performance for PC.02.01.03
357	Introduction to Standard PC.02.01.05 Standard PC.02.01.05 Rationale for PC.02.01.05
358	Elements of Performance for PC.02.01.05
359	Standard PC.02.01.07 Elements of Performance for PC.02.01.07
360	Standard PC.02.01.08 Rationale for PC.02.01.08 Elements of Performance for PC.02.01.08
361	Standard PC.02.01.09 Elements of Performance for PC.02.01.09
362	Standard PC.02.01.13 Elements of Performance for PC.02.01.13 Standard PC.02.01.15 Elements of Performance for PC.02.01.15
363	Standard PC.02.01.17 Elements of Performance for PC.02.01.17 Standard PC.02.01.19
364	Elements of Performance for PC.02.01.19 Introduction to Standard PC.02.02.01
365	Standard PC.02.02.01 Elements of Performance for PC.02.02.01
366	Standard PC.02.02.02 Rationale for PC.02.02.02 Elements of Performance for PC.02.02.02
368	Standard PC.02.02.03 Elements of Performance for PC.02.02.03
369	Standard PC.02.02.07 Rationale for PC.02.02.07 Elements of Performance for PC.02.02.07
370	Standard PC.02.02.09 Elements of Performance for PC.02.02.09
371	Standard PC.02.02.13 Elements of Performance for PC.02.02.13 Standard PC.02.03.01 Elements of Performance for PC.02.03.01
373	Introduction to Standards PC.03.02.09 and PC.03.02.13 Standard PC.03.02.09 Elements of Performance for PC.03.02.09
374	Standard PC.03.02.13 Elements of Performance for PC.03.02.13
375	Standard PC.04.01.01 Elements of Performance for PC.04.01.01
376	Standard PC.04.01.03 Elements of Performance for PC.04.01.03 Standard PC.04.01.05 Elements of Performance for PC.04.01.05
378	Standard PC.04.01.07 Elements of Performance for PC.04.01.07
379	Standard PC.04.02.01 Elements of Performance for PC.04.02.01
380	Standard PC.04.02.02 Rationale for PC.04.02.02 Elements of Performance for PC.04.02.02
383	Written Documentation Checklist
395	Performance Improvement (PI) Overview About This Chapter
397	Chapter Outline
398	Standards, Rationales, and Elements of Performance Introduction to Standard PI.01.01.01 Standard PI.01.01.01 Elements of Performance for PI.01.01.01
399	Standard PI.02.01.01
400	Rationale for PI.02.01.01 Elements of Performance for PI.02.01.01
401	Introduction to Standard PI.03.01.01 Standard PI.03.01.01 Elements of Performance for PI.03.01.01
402	Standard PI.04.01.01
403	Rationale for PI.04.01.01 Elements of Performance for PI.04.01.01
407	Written Documentation Checklist
413	Record of Care, Treatment, and Services (RC) Overview About This Chapter
414	Chapter Outline
415	Standards, Rationales, and Elements of Performance Standard RC.01.01.01 Elements of Performance for RC.01.01.01 Standard RC.01.02.01 Elements of Performance for RC.01.02.01
416	Standard RC.01.03.01 Elements of Performance for RC.01.03.01 Standard RC.01.04.01 Elements of Performance for RC.01.04.01 Standard RC.02.01.01 Elements of Performance for RC.02.01.01
417	Standard RC.02.01.05
418	Elements of Performance for RC.02.01.05 Standard RC.02.01.09 Elements of Performance for RC.02.01.09 Standard RC.02.01.11 Elements of Performance for RC.02.01.11
419	Standard RC.02.01.13 Elements of Performance for RC.02.01.13 Standard RC.02.01.15 Elements of Performance for RC.02.01.15
420	Standard RC.02.01.17 Elements of Performance for RC.02.01.17
421	Standard RC.02.01.19 Elements of Performance for RC.02.01.19 Standard RC.02.01.21 Elements of Performance for RC.02.01.21 Standard RC.02.01.25 Elements of Performance for RC.02.01.25
422	Standard RC.02.01.27 Elements of Performance for RC.02.01.27 Standard RC.02.03.07 Elements of Performance for RC.02.03.07 Standard RC.02.04.01 Elements of Performance for RC.02.04.01
426	Written Documentation Checklist
429	Rights and Responsibilities of the Individual (RI) Overview About This Chapter
431	Chapter Outline
432	Standards, Rationales, and Elements of Performance Standard RI.01.01.01 Rationale for RI.01.01.01 Elements of Performance for RI.01.01.01
433	Standard RI.01.01.03 Rationale for RI.01.01.03
434	Elements of Performance for RI.01.01.03 Standard RI.01.02.01 Rationale for RI.01.02.01 Elements of Performance for RI.01.02.01
435	Standard RI.01.03.01 Rationale for RI.01.03.01
436	Elements of Performance for RI.01.03.01 Standard RI.01.03.05 Rationale for RI.01.03.05
437	Elements of Performance for RI.01.03.05 Standard RI.01.05.01 Elements of Performance for RI.01.05.01
438	Standard RI.01.06.01 Elements of Performance for RI.01.06.01 Standard RI.01.06.03
439	Elements of Performance for RI.01.06.03 Standard RI.01.06.05 Rationale for RI.01.06.05 Elements of Performance for RI.01.06.05
440	Standard RI.01.06.07 Elements of Performance for RI.01.06.07 Standard RI.01.06.09 Elements of Performance for RI.01.06.09
441	Standard RI.01.06.11 Elements of Performance for RI.01.06.11 Standard RI.01.06.13 Elements of Performance for RI.01.06.13
442	Standard RI.01.07.01 Elements of Performance for RI.01.07.01 Standard RI.01.07.05
443	Elements of Performance for RI.01.07.05 Standard RI.01.07.07 Elements of Performance for RI.01.07.07 Standard RI.01.07.13
444	Elements of Performance for RI.01.07.13 Standard RI.02.01.01 Rationale for RI.02.01.01 Elements of Performance for RI.02.01.01
450	Written Documentation Checklist
455	Waived Testing (WT) Overview
456	About This Chapter
458	Chapter Outline
459	Standards, Rationales, and Elements of Performance Standard WT.01.01.01 Elements of Performance for WT.01.01.01 Standard WT.03.01.01 Elements of Performance for WT.03.01.01
460	Standard WT.04.01.01 Elements of Performance for WT.04.01.01 Standard WT.05.01.01 Elements of Performance for WT.05.01.01
465	Written Documentation Checklist
469	The Accreditation Process (ACC) Notices ACC Chapter Contents
471	Overview General Eligibility Requirements
472	Scope of Accreditation Surveys Accreditation Policies
473	Tailored Survey Policy
474	Organizational and Functional Integration
477	Multiorganization Option Concurrent Survey Option
478	Optional Specialty Certification for Nursing Care Centers
479	Additional Certification Options
480	Contracted Services
481	Initial Surveys
482	Information Accuracy and Truthfulness Policy
484	Good Faith Participation in Accreditation/ Certification
485	Public Information Policy Process for Responding to a Complaint
486	Early Survey Policy Sidebar 1. Early Survey Policy
487	Sidebar 1.
489	Before the Survey An Organization’s Secure Joint Commission Connect Extranet Site
490	Ensuring Joint Commission Connect Security Role of Consultants
491	Role of the Account Executive Electronic Application for Accreditation (E-App)
492	Accreditation/Certification Contract and Business Associate Agreement
493	Annual and Survey Fees
494	During the Survey
495	Survey Notification Table 1. Exceptions to Unannounced Surveys
497	Initial and Full Survey Team Composition Survey Agenda
502	Tracer Methodology
503	Table 2. Nursing Care Center–Specific Tracer Applicability and Objectives
505	Immediate Threat to Health or Safety
508	Summary of the Accreditation Reports
509	After the Survey The Scoring Process
514	Evidence of Standards Compliance (ESC) Process
518	Accreditation Award Display and Use
519	Between Accreditation Surveys
520	Duration of Accreditation Award Continuous Compliance Intracycle Monitoring (ICM)
521	Focused Standards Assessment (FSA)
522	Sidebar 2. Focused Standards Assessment (FSA) Options
523	Sidebar 2. Sentinel Event Follow-up
524	Notifying The Joint Commission About Organization Changes
525	Accreditation Status of Organizations That Cease Services After a Disaster‡‡‡
527	Accreditation Status of Organizations That Cease Services or Do Not Have Patients or Residents for a Period of Time
528	Reentering the Accreditation Process Additional Surveys
530	Decision Rules for Organizations Seeking Initial Accreditation
531	Accredited Post–Acute Care Certification Memory Care Certification
532	Limited, Temporary Accreditation Evidence of Standards Compliance (ESC) Denial of Accreditation
534	Decision Rules for Organizations Seeking Reaccreditation Accredited Post–Acute Care Certification Memory Care Certification
535	Evidence of Standards Compliance (ESC) Accreditation with Follow-up Survey
536	Preliminary Denial of Accreditation
537	Denial of Accreditation
538	Process for Organizations That Meet Decision Rule PDA02 for Patients or Residents Placed at Risk for Serious Adverse Outcomes Du
540	Process for Organizations That Meet Decision Rule PDA04
541	Review and Appeal Procedures I. Evaluation by Joint Commission Staff
542	II. Accreditation with Follow-up Survey III. Review Hearings
544	IV. Following a Review Hearing V. Final Review &Appeal Request
547	Sentinel Event Policy (SE)
548	Goals of the Sentinel Event Policy
549	Identifying Sentinel Events
551	Sidebar 1. Key Terms
552	Sidebar 1.
553	Determining That a Sentinel Event Is Subject to Review
554	Relationship to the Survey Process
555	Required Organization Response to a Sentinel Event
556	Reporting a Sentinel Event to The Joint Commission
558	Conducting a Comprehensive Systematic Analysis
559	Developing a Corrective Action Plan
560	Submitting the Comprehensive Systematic Analysis and Corrective Action Plan
561	Table 1. Options for a Joint Commission Review of an Organization’s Response to a Sentinel Event
562	Table 1.
563	The Joint Commission’s Response Review of Comprehensive Systematic Analyses and Corrective Action Plans
564	Follow-up Activities
566	Disclosable Information Handling Sentinel Event–Related Documents The Sentinel Event Database
567	Overseeing the Sentinel Event Policy
569	The Joint Commission Quality Report (QR) Introduction What Is The Joint Commission Quality Report?
570	What Will My Quality Report Contain? What Is Quality Check?
571	Is a Quality Report Available for My Accredited Nursing Care Center? Can My Nursing Care Center Comment On Its Quality Report?
572	How Does My Nursing Care Center Submit a Commentary? Are There Any Criteria That Must Be Met in a Commentary? What Are the Marketing and Communication Guidelines for Publicizing Your Accreditation and Commitment to Quality?
573	Guidelines for Publicizing Compliance with the National Patient Safety Goals
575	Required Written Documentation (RWD)
576	List of EPs Requiring Written Documentation for Nursing Care Centers Accreditation Participation Requirements (APR) Environment of Care (EC) Emergency Management (EM) Human Resources(HR)
577	Infection Prevention and Control (IC) Information Management (IM) Leadership (LD) Life Safety (LS) Medication Management (MM) National Patient Safety Goals (NPSG)
578	Provisions of Care, Treatment, and Services (PC) Performance Improvement (PI) Record of Care, Treatment, and Services (RC) Rights and Responsibilities of the Individual (RI) Waived Testing (WT)
579	Early Survey Policy (ESP) Accreditation Participation Requirements (APR) Environment of Care (EC) Emergency Management (EM)
580	Human Resources (HR) Infection Prevention and Control (IC) Information Management (IM) Leadership (LD) Life Safety (LS)
581	Medication Management (MM) National Patient Safety Goals (NPSG) Provision of Care, Treatment, and Services (PC) Performance Improvement (PI)
582	Record of Care, Treatment, and Services (RC) Rights and Responsibilities of the Individual (RI)
583	Post–Acute Care Certification (PAC) Overview
584	Human Resources (HR) Standard HR.01.02.05 Elements of Performance for HR.01.02.05 Standard HR.01.05.03 Elements of Performance for HR.01.05.03
585	Standard HR.01.06.01 Elements of Performance for HR.01.06.01 Leadership (LD) Standard LD.01.06.01 Elements of Performance for LD.01.06.01 Standard LD.03.10.01
586	Elements of Performance for LD.03.10.01
587	Provision of Care, Treatment, and Services (PC) Standard PC.01.01.01 Elements of Performance for PC.01.01.01 Standard PC.01.02.01 Elements of Performance for PC.01.02.01
588	Standard PC.01.02.03 Elements of Performance for PC.01.02.03
589	Standard PC.01.02.07 Elements of Performance for PC.01.02.07
590	Standard PC.01.02.15 Elements of Performance for PC.01.02.15
591	Standard PC.01.03.01 Elements of Performance for PC.01.03.01 Standard PC.02.01.05 Rationale for PC.02.01.05
592	Elements of Performance for PC.02.01.05
593	Standard PC.02.01.09 Elements of Performance for PC.02.01.09 Standard PC.02.01.19 Elements of Performance for PC.02.01.19
594	Standard PC.02.02.02 Rationale for PC.02.02.02 Elements of Performance for PC.02.02.02
595	Standard PC.04.01.01 Elements of Performance for PC.04.01.01
596	Standard PC.04.01.05 Elements of Performance for PC.04.01.05 Standard PC.04.02.01
597	Elements of Performance for PC.04.02.01 Standard PC.04.02.02 Rationale for PC.04.02.02 Elements of Performance for PC.04.02.02
598	Performance Improvement (PI) Standard PI.01.01.01 Elements of Performance for PI.01.01.01
601	Written Documentation Checklist
609	Memory Care Certification (MCC) Overview
610	Environment of Care (EC) Standard EC.02.06.01 Elements of Performance for EC.02.06.01
611	Human Resources (HR) Standard HR.01.05.03 Elements of Performance for HR.01.05.03 Information Management (IM) Standard IM.03.01.01
612	Elements of Performance for IM.03.01.01 Provision of Care, Treatment, and Services (PC) Standard PC.02.01.01 Elements of Performance for PC.02.01.01 Standard PC.02.02.02
613	Rationale for PC.02.02.02 Elements of Performance for PC.02.02.02
614	Standard PC.02.02.03 Elements of Performance for PC.02.02.03
615	Standard PC.02.02.09 Elements of Performance for PC.02.02.09
616	Standard PC.02.03.01 Elements of Performance for PC.02.03.01
619	Written Documentation Checklist
623	Appendix A: Reference Guide of Selected Medicare Requirements to Relevant Joint Commission Requirements (AXA)
625	Glossary (GL)