Joint Commission – PDF Standards Store

JCR EBHCAW 2024

Sun, 20 Oct 2024 09:03:13 +0000

A straightforward, hands-on resource, the 2024 Hospital Compliance Assessment Workbook engages staff and leadership in accreditation activities with questions, templates, and tools to identify areas of noncompliance and plan to address them. The workbook includes ALL hospital standards and elements of performance (EPs), including those used for deemed status purposes and primary care medical home certification in the hospital setting. Click on “Download Sample Pages” above for an inside look at the easy-to-use and -understand workbook. A color-coded compliance matrix allows you to capture manually (in the hard copy) or digitally (in the PDF site license) your compliance level with each EP and the evidence you used to assess standards compliance. Clear questions correlated directly to each EP help your hospital assess whether you are meeting standards—a “No” or “ITL” (Immediate Threat to Life”) answer should prompt action from your accreditation team. Downloadable, adaptable tools and templates help you identify and prioritize needed improvements and maintain continuous survey readiness. For example, you’ll use the Plan of Action Follow-Up worksheets to develop and prioritize next steps to bring noncompliant EPs back into compliance. The Required Documentation worksheets help you to track how your hospital meets those EPs with Required Written Documentation icons in the E-dition®/Comprehensive Accreditation Manual for Hospitals (CAMH). Hospitals need resources when preparing for a Joint Commission survey to ensure they are compliant and ready for survey. The 2024 Hospital Compliance Assessment Workbook allows you to self-assess compliance with all hospital requirements and plan and implement corrective actions before surveyors arrive on site, focusing compliance efforts and simplifying where possible. A PDF site license allows you to download a copy to a central, secure location so your accreditation prep team can capture and share these learnings and data across the organization. The 2024 version includes all standards updates that occurred over the past year, including revising and consolidating requirements that are above and beyond the US Centers for Medicare & Medicaid Services’ Conditions of Participation, eliminating the term licensed independent practitioner, elevating health care equity accreditation standard from Leadership (LD) requirement to a new National Patient Safety Goal (NPSG), and deleting requirements related to COVID-19 vaccination. If you’re looking for a self-assessment option that takes you beyond the simplicity of E-dition®/CAMH but is more budget friendly than Tracers with AMP®, the 2024 Hospital Compliance Assessment Workbook is for you. Buy a hard copy for each member of your accreditation team or a PDF site license for all to share! Key Topics Standards assessment and compliance Application of the SAFER® Matrix Tracer methodology Compliance improvement Key Features Questions to assess each element of performance in the E-dition®/CAMH as of January 1, 2024 Downloadable, adaptable tools and templates for standards assessment and compliance Writable PDFs (site license only) Standards: All hospital standards effective January 1, 2024 Setting: Organizations accredited under the Hospital Accreditation Program, including general, acute psychiatric, pediatric, medical/surgical specialty, long-term acute care, and rehabilitation hospitals Key Audience: Accreditation managers, quality improvement managers, physician and nurse leaders, chapter leaders, and department heads

PDF Catalog

PDF Pages	PDF Title
1	Title Page
2	Copyright Page
3	Contents
5	Digital Tools
7	Part 1: How to Use This Book
9	About This Book Joint Commission Standards Purpose of This Book What’s New in This Edition Understanding the Compliance Assessment Checklist
10	How to Apply the Assessment Tools in This Book
12	Additional Compliance Assessment Support Mock Tracers
13	The SAFER® Approach Addressing Your Noncompliant Findings
14	Prioritize Noncompliant Findings Develop a Plan of Action Reassess to Maintain Compliance
15	Tools to Try
16	Required Written Documentation Log
20	Mock Tracer Form
21	Survey Analysis for Evaluating Risk® (SAFER® ) Matrix
22	Plan of Action Worksheet
24	Comprehensive Compliance Assessment Checklist
31	Part 2: Compliance Assessment Checklist

JCR EBECE 2024

Sun, 20 Oct 2024 09:03:12 +0000

Are you a facility manager or emergency management coordinator who only needs Joint Commission standards that apply to the physical environment or emergency planning—not the whole manual? Or, do you work in a health care system or as a vendor and need to accurately align compliance efforts across hospitals, ambulatory surgery centers, outpatient behavioral clinics, or other settings of care? Make standards compliance and preparing for survey easier with 2024 Environment of Care® Essentials for Health Care. This indispensable spiral-bound or PDF volume bundles the environment of care (EC), emergency management (EM), and life safety (LS) standards and elements of performance (EPs) for all settings in one convenient reference so the information you need is always right at your fingertips. Equipment management (EQ) standards, which appear only in the Comprehensive Accreditation Manual for Home Care, are also included. A recently redesigned matrix will help you streamline compliance efforts in your facility and your health care system, allowing you to quickly cross-reference EC, EM, and LS requirements across settings. You can see similarities and differences at a glance. A simple matrix included at each requirement clearly identifies (with an “x”) whether the requirement applies in each of the now nine Joint Commission accreditation programs. Bracketed wording indicates how and where wording varies slightly across programs. Conversely, if standards, EPs, or notes vary greatly, abbreviations appear in brackets after that text noting it applies only to the programs listed—for example, ambulatory care (AHC), critical access hospitals (CAH), and hospitals (HAP). Click on “Download Sample Pages” above for an inside look at the easy-to-use and -understand crosswalk. Simplify your compliance efforts by picking up your copy of EC Essentials today. Buy a soft-cover, hard-copy book for each member of your facilities team or a PDF site license for all to share! Key Topics: Essential information for complying with EC requirements with regard to safety, security, hazardous materials and waste, medical equipment and utility systems, and fire safety New and revised EM requirements for hospitals and critical access hospitals Unabridged LS management requirements aligned with the 2012 Life Safety Code®*

PDF Catalog

PDF Pages	PDF Title
3	Contents
5	Introduction
13	Chapter 1: 2023 Environment of Care Matrix
79	Chapter 2. 2020 Emergency Management Matrix
129	Chapter 3. 2020 Life Safety Matrix
187	Chapter 4. 2020 Equipment Management Matrix
197	Glossary
205	Index

JCR EBCMSX 2024

Sun, 20 Oct 2024 09:03:12 +0000

Are you a hospital using Joint Commission accreditation for deemed status with the US Centers for Medicare & Medicaid? If so, are you ready for a CMS survey—every day, at any time? According to federal policy, for 60 days after a Joint Commission survey, any organization that uses accreditation for deemed status is at risk for a validation survey from the US Centers for Medicare & Medicaid Services (CMS). In fact, CMS may elect, at any time, to conduct its own additional evaluation of a hospital with deemed status through a complaint or potential immediate jeopardy investigation. When CMS or the Department of Health arrives at your facility, you need to be prepared. The 2024 Joint Commission and CMS Crosswalk: Comparing Hospital Standards and CoPs offers easy access to the full—and current as of January 1, 2024—language of the Medicare hospital Conditions of Participation (CoPs) and demonstrates their equivalency with the Joint Commission’s hospital standards. A reverse crosswalk, listing Joint Commission requirements with equivalent CoP numbers, shows equivalencies in the opposite direction. This allows staff to easily see how the two sets of requirements relate to each other, whether they are more familiar with the Medicare CoPs or the Joint Commission standards. Regulatory staff and accreditation managers can use the crosswalks in this guide to identify how your organization’s policies, procedures, and practices support one or more Joint Commission standards and demonstrate compliance with equivalent CMS regulations—or identify gaps. Hospitals and psychiatric hospitals preparing for a deemed status survey from The Joint Commission need resources to ensure they are compliant with both sets of requirements and are ready for survey. Although accredited hospitals are able to access two of the four crosswalks in this book on E-dition®, this guide goes a step further, providing the reverse crosswalks as well as critical information about CMS and deemed status. Plus, the book’s sidebars and tables provide additional information on Joint Commission accreditation for deemed status, CMS-related updates, and how both organizations survey for compliance. Key Topics: Medicare hospital CoPs and equivalent Joint Commission standards as of January 1, 2024 Eligibility requirements for Joint Commission hospital accreditation for deemed status recognition by CMS Description of deemed status and what that means for a hospital Highlights of all the revisions to CMS regulations in the new edition Tips to maintain compliance without duplicating effort

PDF Catalog

PDF Pages	PDF Title
3	Contents
5	Introduction Purpose of this Book Overview of Contents
7	What’s New How to Use this Crosswalks
8	Potential Limitations with the Crosswalks
11	Part 1: Understanding Deemed Status
13	What is Deemed Status?
18	How Does My Hospital Achieve Joint Commission Accreditation for Deemed Status Purposes?
25	What is Intracycle Monitoring
26	How Do We Know What Requirements to Meet?
27	What is an 1135 Waiver? When Might My Organization Need an 1135 Waiver? What Are Blanket Waivers?
29	How Does My Organization Request an 1135 Waiver? What Happens If a Joint Commission Surveyor Identifies Noncompliance?
36	How Will We Learn About Our Joint Commission Survery Findings?
37	How Will CMS Be Notified of Our Joint Commission Survey Results?
41	What is a CMS Validation Survey?
45	Part 2: 2024 Joint Commission and CMS Hospital Crosswalk
47	§482.1 Basics and Scope §482.11 CoP: Compliance with Federal, State and Local Laws
50	§482.12 CoP: Governing Body
70	§482.13 CoP: Patient’s Rights
111	§482.15 CoP: Emergency Preparedness
153	§482.21 CoP: Quality Assessment and Performance Improvement Program
174	§482.22 CoP: Medical Staff
205	§482.23 CoP: Nursing Services
230	§482.24 CoP: Medical Record Services
255	§482.25 CoP: Pharmaceutical Services
265	§482.26 CoP: Radiologic Services
277	§482.27 CoP: Laboratory Services
293	§482.28 CoP: Food and Dietetic Services
301	§482.30 CoP: Utilization Review
329	§482.41 CoP: Physical Environment
387	§482.42 CoP: Infection Prevention and Control and Antibiotic Stewardship Programs
408	§482.43 CoP: Discharge Planning
416	§482.45 CoP: Organ, Tissue and Eye Procurement
420	§482.51 CoP: Surgical Services
434	§482.52 CoP: Anesthesia Services
444	§482.53 CoP: Nuclear Medicine Services
453	§482.54 CoP: Outpatient Services
461	§482.55 CoP: Emergency Services
466	§482.56 CoP: Rehabilitation Services
472	§482.57 CoP: Respiratory Care Services
479	§482.58 CoP: Special Requirements for Hospital Providers of Long-Term Care Services (“Swing-Beds”)
491	§483.5 CoP: Definitions
492	§483.10 CoP: Resident Rights
505	§483.12 CoP: Freedom from Abuse, Neglect, and Exploitation
508	§483.15 CoP: Admission, Transfer, and Discharge Rights
528	§483.21 CoP: Comprehensive Person-Centered Care Planning
533	§483.40 CoP: Behavioral Health Services §483.55 CoP: Dental Services
537	§483.65 CoP: Specialized Rehabilitative Services
541	Part 3: 2024 Joint Commission and CMS Psychiatric Hospital Crosswalk
543	§482.60 CoP: Special Provisions Applying to Psychiatric Hospitals
544	§482.61 CoP: Special Medical Record Requirements for Psychiatric Hospital
570	§482.62 CoP: Special Staff Requirements for Psychiatric Hospitals
585	Part 4: Joint Commission Hospital Standards/EPs Equivalent to CoPs
587	Environment of Care (EC)
590	Emergency Management (EM)
591	Human Resources (HR)
592	Infection Prevention and Control (IC) Information Management (IM)
593	Leadership (LD)
596	Life Safety (LS)
600	Medication Management (MM)
602	Medical Staff (MS)
604	National Patient Safety Goals (NPSG) Nursing (NR) Provision of Care, Treatment, and Services (PC)
607	Performance Improvement (PI)
608	Record of Care, Treatment, and Services (RC)
609	Rights and Responsibilities of the Individual (RI)
610	Transplant Safety (TS)
611	Part 5: Joint Commission Psychiatric Hospital Standards/EPs Equivalent to CoPs
613	Human Resources (HR) Information Management (IM) Leadership (LD)
614	Medical Staff (MS) Nursing (NR) Provision of Care, Treatment, and Services (PC)
615	Record of Care, Treatment, and Services (RC) Rights and Responsibilities of the Individual (RI)

JCR CAMNCC LS 2024

Sun, 20 Oct 2024 08:34:21 +0000

2024 Comprehensive Accreditation Manual for Nursing Care Centers (CAMNCC) - CHAPTER: Life Safety (LS)

Published By	Publication Date	Number of Pages
Joint Commission	2024	22

JCR CAMNCC EC 2024

Sun, 20 Oct 2024 08:34:18 +0000

2024 Comprehensive Accreditation Manual for Nursing Care Centers (CAMNCC) - CHAPTER: Environment of Care (EC)

Published By	Publication Date	Number of Pages
Joint Commission	2024

JCR CAMNCC IC 2024

Sun, 20 Oct 2024 08:34:18 +0000

2024 Comprehensive Accreditation Manual for Nursing Care Centers (CAMNCC) - CHAPTER: Infection Prevention and Control (IC)

Published By	Publication Date	Number of Pages
Joint Commission	2024	24

JCR CAMLAB IC 2024

Sun, 20 Oct 2024 08:34:18 +0000

2024 Comprehensive Accreditation Manual for Laboratories (CAMLAB) - CHAPTER: Infection Prevention and Control (IC)

Published By	Publication Date	Number of Pages
Joint Commission	2024	20

JCR CAMNCC EM 2024

Sun, 20 Oct 2024 08:34:18 +0000

2024 Comprehensive Accreditation Manual for Nursing Care Centers (CAMNCC) - CHAPTER: Emergency Management (EM)

Published By	Publication Date	Number of Pages
Joint Commission	2024	30

JCR CAMLAB EC 2024

Sun, 20 Oct 2024 08:34:17 +0000

2024 Comprehensive Accreditation Manual for Laboratories (CAMLAB) - CHAPTER: Environment of Care (EC)

Published By	Publication Date	Number of Pages
Joint Commission	2024	34

JCR CAMH IC 2024

Sun, 20 Oct 2024 08:34:17 +0000

2024 Comprehensive Accreditation Manual for Home Care (CAMHC) - CHAPTER: Infection Prevention and Control (IC)

Published By	Publication Date	Number of Pages
Joint Commission	2024	16