JCR CAMNCC 2023

$190.67

Comprehensive Accreditation Manual for Nursing Care Centers (CAMNCC)

Published By	Publication Date	Number of Pages
Joint Commission	2023	680

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 2023 Comprehensive Accreditation Manual for Nursing Care Centers (CAMNCC) is offered exclusively as a PDF manual. The CAMNCC PDF manual provides the official Joint Commission standards, elements of performance (EPs), National Patient Safety Goals®, and other accreditation requirements for nursing care centers for 2023, including those for the optional Post–Acute Care 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 EPs that require written documentation, and action planning worksheets to address any issues of noncompliance. Available for single users or as a site license for the whole facility. Please note: The CAMNCC PDF manual is published annually. As such, it is not updated. The most up-to-date standards throughout 2023 are available electronically through E-dition®, found on your Joint Commission Connect® extranet site, or are available for purchase. Key Topics: Standards, EPs, National Patient Safety Goals®, and Accreditation Participation Requirements effective January 1, 2023 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 EPs 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 Catalog

PDF Pages	PDF Title
1	What’s New 2023 CAMNCC
15	Cover
16	Copyright
17	Contents
19	Introduction: How Joint Commission Accreditation Can Help on the Road to High Reliability (INTRO)
21	The Value of Joint Commission Accreditation
23	The Joint Commission’s Nursing Care Center Accreditation Program
24	Addressing Complex Issues in Nursing Care Centers
25	Table 1. Standards That Address Complex Care Issues in Nursing Care Centers
27	How Is This Manual Organized?
28	Table 2. Acronyms Used in This Manual
29	Table 2.
30	Accreditation Requirements
31	Accreditation Process Information
33	Identifying Applicable Standards
35	Understanding the Organization of the Standards Chapters
38	Understanding the Icons Used in the Manual
39	Become Familiar with the Standards
40	Use the Standards to Improve Care, Treatment, and Services Assess Compliance with the Standards
42	Stimulate Improvement
44	Accelerate PI™
45	Keep Current with Standards Changes via
47	Getting Started with Accreditation Account Executive
48	Contacting The Joint Commission Standards Questions Requesting Permission to Share Content from the Manual
49	Patient Safety Systems (PS) Quality and Safety in Health Care
50	Sidebar 1. Key Terms
51	Goals of This Chapter
52	Becoming a Learning Organization
53	The Role of Leaders in Patient and Resident Safety
54	Safety Culture
57	Sidebar 2. Assessing Staff Accountability
58	Sidebar 2.
59	Data Use and Reporting Systems
60	Effective Use of Data
61	Table 1. Defining and Comparing Analytical Tools
62	A Proactive Approach to Preventing Harm
64	Sidebar 3. Strategies for an Effective Risk Assessment
65	Sidebar 3. Encouraging Patient or Resident Activation
66	Beyond Accreditation: The Joint Commission Is Your Patient and Resident Safety Partner
68	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
88	Elements of Performance for EC.02.01.01 Standard EC.02.01.03 Elements of Performance for EC.02.01.03
89	Standard EC.02.02.01 Rationale for EC.02.02.01 Elements of Performance for EC.02.02.01
90	Standard EC.02.03.01 Rationale for EC.02.03.01 Elements of Performance for EC.02.03.01
91	Standard EC.02.03.03 Elements of Performance for EC.02.03.03
92	Standard EC.02.03.05 Elements of Performance for EC.02.03.05
94	This page is blank due to revisions through the update.
96	Standard EC.02.04.01 Elements of Performance for EC.02.04.01
97	Standard EC.02.04.03 Elements of Performance for EC.02.04.03
99	Standard EC.02.05.01 Elements of Performance for EC.02.05.01
102	This page is blank due to revisions through the update.
103	Standard EC.02.05.02 Elements of Performance for EC.02.05.02
104	Standard EC.02.05.03
105	Elements of Performance for EC.02.05.03
106	Standard EC.02.05.05
107	Rationale for EC.02.05.05 Elements of Performance for EC.02.05.05
108	Standard EC.02.05.07 Rationale for EC.02.05.07 Elements of Performance for EC.02.05.07
111	Standard EC.02.05.09 Rationale for EC.02.05.09 Elements of Performance for EC.02.05.09
112	Introduction to Standard EC.02.06.01
113	Standard EC.02.06.01 Elements of Performance for EC.02.06.01
115	Standard EC.02.06.03 Elements of Performance for EC.02.06.03 Standard EC.02.06.05
116	Rationale for EC.02.06.05 Elements of Performance for EC.02.06.05 Introduction to Standard EC.04.01.01
117	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
118	Elements of Performance for EC.04.01.05
122	Written Documentation Checklist
139	Emergency Management (EM) Overview
140	About This Chapter
141	Chapter Outline
142	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
143	Standard EM.02.01.01
144	Rationale for EM.02.01.01 Elements of Performance for EM.02.01.01
145	Standard EM.02.02.01
146	Rationale for EM.02.02.01 Elements of Performance for EM.02.02.01
147	Standard EM.02.02.03 Rationale for EM.02.02.03 Elements of Performance for EM.02.02.03
148	Introduction to Standard EM.02.02.05
149	Standard EM.02.02.05 Elements of Performance for EM.02.02.05 Standard EM.02.02.07
150	Rationale for EM.02.02.07 Elements of Performance for EM.02.02.07 Standard EM.02.02.09 Rationale for EM.02.02.09
151	Elements of Performance for EM.02.02.09
152	Standard EM.02.02.11 Rationale for EM.02.02.11 Elements of Performance for EM.02.02.11
154	This page is blank due to revisions through the update.
155	Introduction to Standards EM.02.02.13 and EM.02.02.15
156	Standard EM.02.02.13 Elements of Performance for EM.02.02.13
157	Standard EM.02.02.15 Elements of Performance for EM.02.02.15
158	Standard EM.03.01.01 Rationale for EM.03.01.01 Elements of Performance for EM.03.01.01
159	Standard EM.03.01.03 Rationale for EM.03.01.03 Elements of Performance for EM.03.01.03
163	Written Documentation Checklist
171	Human Resources (HR) Overview About This Chapter
172	Chapter Outline
173	Standards, Rationales, and Elements of Performance Standard HR.01.01.01 Elements of Performance for HR.01.01.01
174	Standard HR.01.02.05 Elements of Performance for HR.01.02.05
175	Standard HR.01.02.07 Elements of Performance for HR.01.02.07
176	Standard HR.01.04.01 Elements of Performance for HR.01.04.01
177	Standard HR.01.05.03 Elements of Performance for HR.01.05.03
178	Introduction to Standards HR.01.06.01 and HR.01.07.01
179	Standard HR.01.06.01 Elements of Performance for HR.01.06.01
180	Standard HR.01.07.01 Elements of Performance for HR.01.07.01
181	Introduction to Standards HR.02.01.04, HR.02.01.05, and HR.02.01.07
182	Standard HR.02.01.04 Elements of Performance for HR.02.01.04
184	Standard HR.02.01.05 Elements of Performance for HR.02.01.05
185	Standard HR.02.01.07 Elements of Performance for HR.02.01.07 Standard HR.02.02.01
186	Elements of Performance for HR.02.02.01
189	Written Documentation Checklist
194	This page is blank due to revisions through the update.
201	Infection Prevention and Control (IC) Overview
202	About This Chapter
203	Chapter Outline
204	Standards, Rationales, and Elements of Performance Standard IC.01.01.01 Elements of Performance for IC.01.01.01
205	Standard IC.01.02.01 Elements of Performance for IC.01.02.01 Introduction to Standards IC.01.03.01 Through IC.01.06.01 – Planning
206	Standard IC.01.03.01 Rationale for IC.01.03.01 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
207	Elements of Performance for IC.01.05.01 Standard IC.01.06.01 Elements of Performance for IC.01.06.01
208	Introduction to Standards IC.02.01.01 Through IC.02.04.01 – Implementation
209	Standard IC.02.01.01 Elements of Performance for IC.02.01.01
211	Standard IC.02.02.01 Rationale for IC.02.02.01
212	Elements of Performance for IC.02.02.01
213	Standard IC.02.03.01 Elements of Performance for IC.02.03.01 Introduction to Standard IC.02.04.01
214	Standard IC.02.04.01 Elements of Performance for IC.02.04.01
215	Standard IC.02.04.03 Elements of Performance for IC.02.04.03
216	Standard IC.02.05.01 Elements of Performance for IC.02.05.01
217	Introduction to Standard IC.03.01.01 – Evaluation and Improvement Standard IC.03.01.01 Elements of Performance for IC.03.01.01
222	Written Documentation Checklist
227	Information Management (IM) Overview About This Chapter
228	Chapter Outline
229	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
230	Introduction to Standard IM.01.01.03 Standard IM.01.01.03 Elements of Performance for IM.01.01.03
231	Introduction to Standard IM.02.01.01 Standard IM.02.01.01 Elements of Performance for IM.02.01.01
232	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
233	Rationale for IM.02.02.01 Elements of Performance for IM.02.02.01
234	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
238	Written Documentation Checklist
241	Leadership (LD) Overview
242	Proactive Risk Assessment
243	About This Chapter
244	Chapter Outline
245	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
246	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
248	Standard LD.01.07.01 Elements of Performance for LD.01.07.01
249	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
252	Standard LD.03.01.01 Rationale for LD.03.01.01 Elements of Performance for LD.03.01.01
253	Introduction to Standard LD.03.01.02
254	Standard LD.03.01.02 Elements of Performance for LD.03.01.02
255	Standard LD.03.02.01 Rationale for LD.03.02.01 Elements of Performance for LD.03.02.01 Standard LD.03.03.01 Rationale for LD.03.03.01
256	Elements of Performance for LD.03.03.01 Standard LD.03.04.01 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
257	Standard LD.03.06.01 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
258	Standard LD.03.07.01 Elements of Performance for LD.03.07.01 Standard LD.03.08.01 Elements of Performance for LD.03.08.01
259	Introduction to Standard LD.03.09.01 Standard LD.03.09.01 Elements of Performance for LD.03.09.01
261	Standard LD.03.10.01 Elements of Performance for LD.03.10.01
262	Standard LD.04.01.01 Elements of Performance for LD.04.01.01
263	Standard LD.04.01.03 Elements of Performance for LD.04.01.03 Standard LD.04.01.05 Rationale for LD.04.01.05 Elements of Performance for LD.04.01.05
264	Standard LD.04.01.07 Elements of Performance for LD.04.01.07
265	Standard LD.04.01.11 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
266	Standard LD.04.02.03 Elements of Performance for LD.04.02.03 Standard LD.04.03.01 Elements of Performance for LD.04.03.01 Standard LD.04.03.07 Rationale for LD.04.03.07
267	Elements of Performance for LD.04.03.07 Introduction to Oversight of Care, Treatment, and Services Provided Through Contractual Agreement, Standard LD.04.03.09
268	Monitoring Contracted Services
269	Permitting Licensed Independent Practitioners to PracticeWithin the Organization Standard LD.04.03.09 Elements of Performance for LD.04.03.09
270	Introduction to Standard LD.04.03.13 Standard LD.04.03.13 Elements of Performance for LD.04.03.13
277	Written Documentation Checklist
283	Life Safety (LS) Overview Applicability of the Standards About This Chapter
285	Chapter Outline
286	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
287	Standard LS.01.02.01
288	Elements of Performance for LS.01.02.01
290	Standard LS.02.01.10 Elements of Performance for LS.02.01.10 Standard LS.02.01.20
291	Rationale for LS.02.01.20 Elements of Performance for LS.02.01.20
293	Standard LS.02.01.30 Rationale for LS.02.01.30 Elements of Performance for LS.02.01.30
294	Standard LS.02.01.34 Elements of Performance for LS.02.01.34
295	Standard LS.02.01.35 Elements of Performance for LS.02.01.35
296	Standard LS.02.01.40 Elements of Performance for LS.02.01.40 Standard LS.02.01.50
297	Elements of Performance for LS.02.01.50 Standard LS.02.01.70 Elements of Performance for LS.02.01.70
301	Written Documentation Checklist
305	Medication Management (MM) Overview
306	About This Chapter
307	Chapter Outline
308	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
309	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
310	Standard MM.01.02.01 Elements of Performance for MM.01.02.01 Standard MM.03.01.01
311	Rationale for MM.03.01.01 Elements of Performance for MM.03.01.01 Standard MM.03.01.03
312	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
313	Introduction to Standard MM.04.01.01 Standard MM.04.01.01 Elements of Performance for MM.04.01.01
314	Standard MM.05.01.01
315	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
316	Rationale for MM.05.01.09 Elements of Performance for MM.05.01.09
317	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
318	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
319	Standard MM.06.01.03 Elements of Performance for MM.06.01.03
320	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
321	Standard MM.07.01.03 Rationale for MM.07.01.03 Elements of Performance for MM.07.01.03
322	Introduction to Standard MM.08.01.01 Standard MM.08.01.01
323	Elements of Performance for MM.08.01.01 Standard MM.09.01.01 Elements of Performance for MM.09.01.01
329	Written Documentation Checklist
337	National Patient Safety Goals (NPSG) Chapter Outline National Patient Safety Goals®
338	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
339	Goal 3 NPSG.03.05.01 Rationale for NPSG.03.05.01 Elements of Performance for NPSG.03.05.01
341	Introduction to Reconciling Medication Information NPSG.03.06.01
342	Rationale for NPSG.03.06.01 Elements of Performance for NPSG.03.06.01
343	Goal 7 NPSG.07.01.01 Rationale for NPSG.07.01.01
344	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
345	Goal 14 NPSG.14.01.01 Rationale for NPSG.14.01.01 Elements of Performance for NPSG.14.01.01
349	Written Documentation Checklist
353	Provision of Care, Treatment, and Services (PC) Overview
354	About This Chapter
355	Chapter Outline
356	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
357	Standard PC.01.02.01 Elements of Performance for PC.01.02.01
360	Standard PC.01.02.03 Elements of Performance for PC.01.02.03
363	Standard PC.01.02.05 Elements of Performance for PC.01.02.05
364	Introduction to Standard PC.01.02.07 Standard PC.01.02.07 Elements of Performance for PC.01.02.07
366	Introduction to Standard PC.01.02.09 Standard PC.01.02.09
367	Elements of Performance for PC.01.02.09 Standard PC.01.02.15 Elements of Performance for PC.01.02.15
368	Introduction to Standard PC.01.03.01
369	Standard PC.01.03.01 Elements of Performance for PC.01.03.01
370	Standard PC.02.01.01 Elements of Performance for PC.02.01.01
371	Standard PC.02.01.03 Elements of Performance for PC.02.01.03
372	Introduction to Standard PC.02.01.05 Standard PC.02.01.05 Rationale for PC.02.01.05 Elements of Performance for PC.02.01.05
374	Standard PC.02.01.07 Elements of Performance for PC.02.01.07 Standard PC.02.01.08 Rationale for PC.02.01.08
375	Elements of Performance for PC.02.01.08
376	Standard PC.02.01.09 Elements of Performance for PC.02.01.09 Standard PC.02.01.13 Elements of Performance for PC.02.01.13
377	Standard PC.02.01.15 Elements of Performance for PC.02.01.15
378	Standard PC.02.01.17 Elements of Performance for PC.02.01.17 Standard PC.02.01.19 Elements of Performance for PC.02.01.19
379	Introduction to Standard PC.02.02.01
380	Standard PC.02.02.01 Elements of Performance for PC.02.02.01
381	Standard PC.02.02.02 Rationale for PC.02.02.02 Elements of Performance for PC.02.02.02
383	Standard PC.02.02.03 Elements of Performance for PC.02.02.03
384	Standard PC.02.02.07 Rationale for PC.02.02.07
385	Elements of Performance for PC.02.02.07 Standard PC.02.02.09 Elements of Performance for PC.02.02.09
386	Standard PC.02.02.13 Elements of Performance for PC.02.02.13
387	Standard PC.02.03.01 Elements of Performance for PC.02.03.01
388	Introduction to Standards PC.03.02.09 and PC.03.02.13
389	Standard PC.03.02.09 Elements of Performance for PC.03.02.09
390	Standard PC.03.02.13 Elements of Performance for PC.03.02.13
391	Standard PC.04.01.01 Elements of Performance for PC.04.01.01
392	Standard PC.04.01.03 Elements of Performance for PC.04.01.03
393	Standard PC.04.01.05 Elements of Performance for PC.04.01.05
394	Standard PC.04.01.07 Elements of Performance for PC.04.01.07
395	Standard PC.04.02.01 Elements of Performance for PC.04.02.01
396	Standard PC.04.02.02 Rationale for PC.04.02.02 Elements of Performance for PC.04.02.02
401	Written Documentation Checklist
413	Performance Improvement (PI) Overview About This Chapter
415	Chapter Outline
416	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
418	Standard PI.02.01.01 Rationale for PI.02.01.01 Elements of Performance for PI.02.01.01
419	Introduction to Standard PI.03.01.01 Standard PI.03.01.01 Elements of Performance for PI.03.01.01
420	Standard PI.04.01.01
421	Rationale for PI.04.01.01 Elements of Performance for PI.04.01.01
425	Written Documentation Checklist
431	Record of Care, Treatment, and Services (RC) Overview About This Chapter
432	Chapter Outline
433	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
434	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
435	Standard RC.02.01.05
436	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
437	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
438	Standard RC.02.01.17 Elements of Performance for RC.02.01.17
439	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
440	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
444	Written Documentation Checklist
447	Rights and Responsibilities of the Individual (RI) Overview About This Chapter
449	Chapter Outline
450	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
451	Standard RI.01.01.03 Rationale for RI.01.01.03
452	Elements of Performance for RI.01.01.03 Standard RI.01.02.01 Rationale for RI.01.02.01
453	Elements of Performance for RI.01.02.01
454	Standard RI.01.03.01 Rationale for RI.01.03.01 Elements of Performance for RI.01.03.01 Standard RI.01.03.05 Rationale for RI.01.03.05
455	Elements of Performance for RI.01.03.05 Standard RI.01.05.01 Elements of Performance for RI.01.05.01
456	Standard RI.01.06.01 Elements of Performance for RI.01.06.01 Standard RI.01.06.03
457	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
458	Standard RI.01.06.07 Elements of Performance for RI.01.06.07 Standard RI.01.06.09
459	Elements of Performance for RI.01.06.09 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
460	Standard RI.01.07.01 Elements of Performance for RI.01.07.01
461	Standard RI.01.07.05 Elements of Performance for RI.01.07.05 Standard RI.01.07.07 Elements of Performance for RI.01.07.07
462	Standard RI.01.07.13 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
468	Written Documentation Checklist
473	Waived Testing (WT) Overview
474	About This Chapter
476	Chapter Outline
477	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
478	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
483	Written Documentation Checklist
487	The Accreditation Process (ACC) Notices ACC Chapter Contents
489	Overview General Eligibility Requirements
490	Scope of Accreditation Surveys Accreditation Policies
491	Tailored Survey Policy
492	Organizational and Functional Integration
495	Multiorganization Option Concurrent Survey Option
496	Optional Specialty Certification for Nursing Care Centers
497	Additional Certification Options
498	Contracted Services
499	Initial Surveys
500	Information Accuracy and Truthfulness Policy
502	Good Faith Participation in Accreditation/ Certification
503	Public Information Policy Process for Responding to a Complaint
504	Early Survey Policy Sidebar 1. Early Survey Policy
505	Sidebar 1.
507	Before the Survey An Organization’s Secure Joint Commission Connect Extranet Site
508	Ensuring Joint Commission Connect Security Role of Consultants Role of the Account Executive
509	Electronic Application for Accreditation (E-App)
510	Accreditation/Certification Contract and Business Associate Agreement
511	Annual and Survey Fees
512	During the Survey
513	Survey Notification Table 1. Exceptions to Unannounced Surveys
515	Initial and Full Survey Team Composition Survey Agenda
520	Tracer Methodology
521	Table 2. Nursing Care Center–Specific Tracer Applicability and Objectives
523	Immediate Threat to Health or Safety
526	Summary of the Accreditation Reports
527	After the Survey The Scoring Process
532	Evidence of Standards Compliance (ESC) Process
536	Accreditation Award Display and Use
537	Between Accreditation Surveys
538	Duration of Accreditation Award Continuous Compliance Intracycle Monitoring (ICM)
539	Focused Standards Assessment (FSA)
540	Sidebar 2. Focused Standards Assessment (FSA) Options
541	Sidebar 2. Sentinel Event Follow-up
542	Notifying The Joint Commission About Organization Changes
543	Accreditation Status of Organizations That Cease Services After a Disaster‡‡‡
545	Accreditation Status of Organizations That Cease Services or Do Not Have Patients or Residents for a Period of Time
546	Reentering the Accreditation Process Additional Surveys
548	Decision Rules for Organizations Seeking Initial Accreditation
549	Accredited Post–Acute Care Certification Memory Care Certification
550	Limited, Temporary Accreditation Evidence of Standards Compliance (ESC) Denial of Accreditation
552	Decision Rules for Organizations Seeking Reaccreditation Accredited Post–Acute Care Certification Memory Care Certification
553	Evidence of Standards Compliance (ESC) Accreditation with Follow-up Survey
554	Preliminary Denial of Accreditation
555	Denial of Accreditation
556	Process for Organizations That Meet Decision Rule PDA02 for Patients or Residents Placed at Risk for Serious Adverse Outcomes Du
558	Process for Organizations That Meet Decision Rule PDA04
559	Review and Appeal Procedures I. Evaluation by Joint Commission Staff
560	II. Accreditation with Follow-up Survey III. Review Hearings
562	IV. Following a Review Hearing V. Final Review &Appeal Request
565	Sentinel Event Policy (SE)
566	Goals of the Sentinel Event Policy
567	Identifying Sentinel Events
569	Sidebar 1. Key Terms
570	Sidebar 1.
572	Determining That a Sentinel Event Is Subject to Review Relationship to the Survey Process
573	Required Organization Response to a Sentinel Event
575	Reporting a Sentinel Event to The Joint Commission
577	Conducting a Comprehensive Systematic Analysis
578	Developing a Corrective Action Plan
579	Submitting the Comprehensive Systematic Analysis and Corrective Action Plan
580	Table 1. Options for a Joint Commission Review of an Organization’s Response to a Sentinel Event
581	Table 1.
582	The Joint Commission’s Response Review of Comprehensive Systematic Analyses and Corrective Action Plans
583	Follow-up Activities
585	Disclosable Information Handling Sentinel Event–Related Documents The Sentinel Event Database
586	Overseeing the Sentinel Event Policy
587	The Joint Commission Quality Report (QR) Introduction What Is The Joint Commission Quality Report?
588	What Will My Quality Report Contain? What Is Quality Check?
589	Is a Quality Report Available for My Accredited Nursing Care Center? Can My Nursing Care Center Comment On Its Quality Report?
590	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?
591	Guidelines for Publicizing Compliance with the National Patient Safety Goals
593	Required Written Documentation (RWD)
594	List of EPs Requiring Written Documentation for Nursing Care Centers Accreditation Participation Requirements (APR) Environment of Care (EC) Emergency Management (EM) Human Resources(HR)
595	Infection Prevention and Control (IC) Information Management (IM) Leadership (LD) Life Safety (LS) Medication Management (MM) National Patient Safety Goals (NPSG)
596	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)
597	Early Survey Policy (ESP) Accreditation Participation Requirements (APR) Environment of Care (EC) Emergency Management (EM)
598	Human Resources (HR) Infection Prevention and Control (IC) Information Management (IM) Leadership (LD)
599	Life Safety (LS) Medication Management (MM) National Patient Safety Goals (NPSG) Provision of Care, Treatment, and Services (PC) Performance Improvement (PI)
600	Record of Care, Treatment, and Services (RC) Rights and Responsibilities of the Individual (RI)
601	Post–Acute Care Certification (PAC) Overview
602	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
603	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
604	Standard LD.03.10.01 Elements of Performance for LD.03.10.01
605	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
606	Standard PC.01.02.03 Elements of Performance for PC.01.02.03
607	Standard PC.01.02.07 Elements of Performance for PC.01.02.07
608	Standard PC.01.02.15 Elements of Performance for PC.01.02.15
609	Standard PC.01.03.01 Elements of Performance for PC.01.03.01 Standard PC.02.01.05 Rationale for PC.02.01.05
610	Elements of Performance for PC.02.01.05
611	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
612	Standard PC.02.02.02 Rationale for PC.02.02.02 Elements of Performance for PC.02.02.02
613	Standard PC.04.01.01 Elements of Performance for PC.04.01.01
614	Standard PC.04.01.05 Elements of Performance for PC.04.01.05 Standard PC.04.02.01
615	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
616	Performance Improvement (PI) Standard PI.01.01.01 Elements of Performance for PI.01.01.01
619	Written Documentation Checklist
627	Memory Care Certification (MCC) Overview
628	Environment of Care (EC) Standard EC.02.06.01 Elements of Performance for EC.02.06.01
629	Emergency Management (EM) Standard EM.02.01.01 Rationale for EM.02.01.01
630	Elements of Performance for EM.02.01.01 Human Resources (HR) Standard HR.01.05.03 Elements of Performance for HR.01.05.03 Information Management (IM) Standard IM.03.01.01
631	Elements of Performance for IM.03.01.01 Leadership (LD) Standard LD.03.10.01 Elements of Performance for LD.03.10.01 Provision of Care, Treatment, and Services (PC) Standard PC.01.02.01
632	Elements of Performance for PC.01.02.01 Standard PC.01.02.03 Elements of Performance for PC.01.02.03 Standard PC.02.01.01 Elements of Performance for PC.02.01.01 Standard PC.02.01.15 Elements of Performance for PC.02.01.15
633	Standard PC.02.02.01 Elements of Performance for PC.02.02.01 Standard PC.02.02.02 Rationale for PC.02.02.02
634	Elements of Performance for PC.02.02.02
635	Standard PC.02.02.03 Elements of Performance for PC.02.02.03 Standard PC.02.02.09 Elements of Performance for PC.02.02.09
636	Standard PC.02.03.01 Elements of Performance for PC.02.03.01
637	Standard PC.04.01.01 Elements of Performance for PC.04.01.01
641	Written Documentation Checklist
645	Appendix A: Reference Guide of Selected Medicare Requirements to Relevant Joint Commission Requirements (AXA)
647	Glossary (GL)
664	This page is blank due to revisions through the update.