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JCR CAMBHC 2023

JCR CAMBHC 2023

$190.67

Comprehensive Accreditation Manual for Behavioral Health Care and Human Services (CAMBHC)

Published By Publication Date Number of Pages
Joint Commission 2023 990
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The PDF version of the 2023 Comprehensive Accreditation Manual for Behavioral Health Care and Human Services (CAMBHC) provides all official Joint Commission standards, elements of performance (EPs), National Patient Safety Goals®, and other accreditation requirements, including those for the optional Behavioral Health Home certification. Please note: This PDF manual is a digital version of the hard-copy Comprehensive Accreditation Manual for Behavioral Health Care and Human Services with standards effective January 1, 2023. It is published annually and is not updated. Understanding Which Standards Apply. The Joint Commission surveys many types of organizations under the behavioral health care and human services standards, including mental health services, addiction treatment, eating disorders treatment, intellectual disability/developmental disability (ID/DD) services, and social service/human service agencies serving children and families. Accredited organizations may serve people throughout the life span or specialize in an age group or a disability group. (See the section on Settings below for a longer list of services and settings.) Eligibility requirements will differ based on the services provided and survey option you select; more information is available on The Joint Commission’s website. Standards for all these settings and services appear in the 2023 CAMBHC. The “Standards Applicability Grid” chapter helps each organization determine which standards and EPs in the manual apply to its setting(s), service(s), program(s), and specific population(s). These applicability grids allow you to identify the services and settings, as you identified them in your E-App, and find standards that apply to your organization. In contrast, the E-dition® on an accredited organization’s Joint Commission Connect® extranet site provides a customized manual based on the settings and services checked on your E-App. (That is, the E-dition®only displays an organization-specific complement of standards and EPs). Key Topics: Standards requirements, including the standards, National Patient Safety Goals®, and Accreditation Participation Requirements effective January 1, 2023 Standards and EPs for optional Behavioral Health Home certification 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 Key Features: 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 behavioral health care and human services standards Setting: Organizations accredited under the Behavioral Health Care and Human Services Accreditation Program, including those that that provide mental health services, substance use treatment services, foster care services, programs or services for children and youth, child welfare, services for individuals with eating disorders, services for individuals with intellectual/developmental disabilities of various ages and in various organized service or program settings, case management services, peer-based recovery services, prevention and wellness promotion services, corrections-based services, and opioid treatment programs Key Audience: Staff working on accreditation, compliance, patient safety, or quality improvement

PDF Catalog

PDF Pages PDF Title
1 What’s New 2023 CAMBHC
9 Cover
10 Copyright
11 Contents
13 Introduction: How Joint Commission Accreditation Can Help on the Road to High Reliability (INTRO)
14 I. Introduction to Joint Commission Accreditation
The Value of Joint Commission Accreditation
16 Joint Commission Accreditation
17 Addressing Complex Behavioral Health and Human Services Accreditation-Related Issues
18 Table 1. Standards That Address Complex Care, Treatment, or Service Issues in Behavioral Health Care and Human Services Organiza
19 II. About the
20 How Is This Manual Organized?
21 Table 2. Acronyms Used in This Manual
22 Table 2.
23 Accreditation Requirements
24 Accreditation Process Information
26 Identifying Applicable Standards
29 Understanding the Organization of the Standards Chapters
32 Understanding the Icons Used in the Manual
III. Steps to Achieving and Maintaining Compliance
33 Become Familiar with the Standards
Use the Standards to Improve Care, Treatment, or Services
34 Assess Compliance with the Standards
35 Stimulate Improvement
37 Keep Current with Standards Changes via Perspectives
38 IV. Get Extra Help
39 Getting Started with Accreditation
Account Executive
Contacting The Joint Commission
40 Standards Questions
Requesting Permission to Share Content from the Manual
41 Safety Systems for Individuals Served (SSIS)
Quality and Safety in Care, Treatment, or Services
42 Sidebar 1. Key Terms
43 Goals of This Chapter
44 Becoming a Learning Organization
45 The Role of Leaders in Safety
46 Safety Culture
49 Sidebar 2. Assessing Staff Accountability
50 Sidebar 2.
Data Use and Reporting Systems
51 Effective Use of Data
52 Table 1. Defining and Comparing Analytical Tools
53 A Proactive Approach to Preventing Harm
56 Sidebar 3. Strategies for an Effective Risk Assessment
Encouraging Participation of Individuals Served
58 Beyond Accreditation: The Joint Commission Is Your Safety Partner
59 References
63 Accreditation Participation Requirements (APR)
Overview
64 Chapter Outline
65 Requirements, Rationales, and Elements of Performance
APR.01.01.01
Elements of Performance for APR.01.01.01
APR.01.02.01
66 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
67 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
Elements of Performance for APR.06.01.01
68 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
Elements of Performance for APR.09.01.01
69 APR.09.02.01
Rationale for APR.09.02.01
Elements of Performance for APR.09.02.01
APR.09.03.01
70 Elements of Performance for APR.09.03.01
APR.09.04.01
Elements of Performance for APR.09.04.01
71 Care, Treatment, and Services (CTS)
Overview
73 Chapter Outline
75 Standards, Rationales, and Elements of Performance
Standard CTS.01.01.01
Elements of Performance for CTS.01.01.01
79 Standard CTS.01.02.01
Elements of Performance for CTS.01.02.01
Standard CTS.01.03.01
Rationale for CTS.01.03.01
Elements of Performance for CTS.01.03.01
Standard CTS.01.03.03
Elements of Performance for CTS.01.03.03
80 Standard CTS.01.04.01
Rationale for CTS.01.04.01
Elements of Performance for CTS.01.04.01
81 Introduction to Standards CTS.02.01.01 Through CTS.02.04.01—Screening and Assessment
Standard CTS.02.01.01
82 Elements of Performance for CTS.02.01.01
Standard CTS.02.01.03
Elements of Performance for CTS.02.01.03
83 Standard CTS.02.01.05
Elements of Performance for CTS.02.01.05
84 Standard CTS.02.01.06
Elements of Performance for CTS.02.01.06
85 Standard CTS.02.01.07
Elements of Performance for CTS.02.01.07
87 Introduction to Standard CTS.02.01.09
88 Standard CTS.02.01.09
Elements of Performance for CTS.02.01.09
Standard CTS.02.01.11
89 Rationale for CTS.02.01.11
Elements of Performance for CTS.02.01.11
Standard CTS.02.01.13
Elements of Performance for CTS.02.01.13
90 Standard CTS.02.01.15
Elements of Performance for CTS.02.01.15
Standard CTS.02.01.17
Elements of Performance for CTS.02.01.17
Standard CTS.02.02.01
Elements of Performance for CTS.02.02.01
92 Standard CTS.02.02.05
93 Rationale for CTS.02.02.05
Elements of Performance for CTS.02.02.05
94 Standard CTS.02.02.07
Elements of Performance for CTS.02.02.07
Standard CTS.02.02.09
Elements of Performance for CTS.02.02.09
97 Standard CTS.02.03.01
Elements of Performance for CTS.02.03.01
Standard CTS.02.03.03
Elements of Performance for CTS.02.03.03
98 Standard CTS.02.03.05
Elements of Performance for CTS.02.03.05
100 Introduction to Standard CTS.02.03.07
101 Standard CTS.02.03.07
Elements of Performance for CTS.02.03.07
102 Standard CTS.02.03.09
Elements of Performance for CTS.02.03.09
Standard CTS.02.03.11
Elements of Performance for CTS.02.03.11
103 Standard CTS.02.03.13
104 Elements of Performance for CTS.02.03.13
Standard CTS.02.03.15
Elements of Performance for CTS.02.03.15
Standard CTS.02.04.01
Elements of Performance for CTS.02.04.01
106 Standard CTS.02.04.03
Elements of Performance for CTS.02.04.03
Standard CTS.02.04.05
Elements of Performance for CTS.02.04.05
107 Standard CTS.02.04.07
Elements of Performance for CTS.02.04.07
108 Standard CTS.02.04.09
Elements of Performance for CTS.02.04.09
Standard CTS.02.04.11
109 Elements of Performance for CTS.02.04.11
Standard CTS.02.04.13
Elements of Performance for CTS.02.04.13
Standard CTS.02.04.15
Elements of Performance for CTS.02.04.15
110 Standard CTS.02.04.17
Elements of Performance for CTS.02.04.17
111 Standard CTS.02.04.19
Elements of Performance for CTS.02.04.19
112 Standard CTS.02.04.21
Elements of Performance for CTS.02.04.21
Standard CTS.02.04.23
Elements of Performance for CTS.02.04.23
Standard CTS.02.04.25
113 Rationale for CTS.02.04.25
Elements of Performance for CTS.02.04.25
114 Introduction to Standards CTS.03.01.01 Through CTS.03.02.03—Planning Care, Treatment, or Services
Standard CTS.03.01.01
Elements of Performance for CTS.03.01.01
116 Standard CTS.03.01.03
Elements of Performance for CTS.03.01.03
120 Standard CTS.03.01.05
Elements of Performance for CTS.03.01.05
Standard CTS.03.01.07
Elements of Performance for CTS.03.01.07
121 Standard CTS.03.01.09
Rationale for CTS.03.01.09
Elements of Performance for CTS.03.01.09
122 Standard CTS.03.02.01
123 Elements of Performance for CTS.03.02.01
Standard CTS.03.02.03
Elements of Performance for CTS.03.02.03
126 Introduction to Standards CTS.04.01.01 and CTS.04.01.03—Providing Care, Treatment, or Services
Standard CTS.04.01.01
Rationale for CTS.04.01.01
Elements of Performance for CTS.04.01.01
129 Standard CTS.04.01.03
Elements of Performance for CTS.04.01.03
132 Standard CTS.04.01.07
Elements of Performance for CTS.04.01.07
133 Standard CTS.04.02.01
Elements of Performance for CTS.04.02.01
134 Standard CTS.04.02.03
Elements of Performance for CTS.04.02.03
135 Standard CTS.04.02.05
Elements of Performance for CTS.04.02.05
Standard CTS.04.02.06
Elements of Performance for CTS.04.02.06
Standard CTS.04.02.07
Elements of Performance for CTS.04.02.07
137 Standard CTS.04.02.08
Elements of Performance for CTS.04.02.08
138 Standard CTS.04.02.09
Elements of Performance for CTS.04.02.09
Standard CTS.04.02.11
Elements of Performance for CTS.04.02.11
139 Standard CTS.04.02.13
Rationale for CTS.04.02.13
Elements of Performance for CTS.04.02.13
Standard CTS.04.02.15
Elements of Performance for CTS.04.02.15
140 Standard CTS.04.02.16
Elements of Performance for CTS.04.02.16
141 Standard CTS.04.02.17
Elements of Performance for CTS.04.02.17
Standard CTS.04.02.18
Elements of Performance for CTS.04.02.18
Introduction to Standards CTS.04.02.19 and CTS.04.02.21
143 Standard CTS.04.02.19
Rationale for CTS.04.02.19
Elements of Performance for CTS.04.02.19
145 Standard CTS.04.02.21
Rationale for CTS.04.02.21
Elements of Performance for CTS.04.02.21
146 Standard CTS.04.02.23
Elements of Performance for CTS.04.02.23
Standard CTS.04.02.25
147 Elements of Performance for CTS.04.02.25
148 Standard CTS.04.02.27
Elements of Performance for CTS.04.02.27
149 Standard CTS.04.02.29
Elements of Performance for CTS.04.02.29
Standard CTS.04.02.31
150 Elements of Performance for CTS.04.02.31
Introduction to Standards CTS.04.03.01 Through CTS.04.03.13—Vocational Rehabilitation and Employment Assistance
Standard CTS.04.03.01
151 Rationale for CTS.04.03.01
Elements of Performance for CTS.04.03.01
Standard CTS.04.03.03
Elements of Performance for CTS.04.03.03
152 Standard CTS.04.03.05
Elements of Performance for CTS.04.03.05
153 Standard CTS.04.03.13
Elements of Performance for CTS.04.03.13
154 Standard CTS.04.03.15
155 Elements of Performance for CTS.04.03.15
Standard CTS.04.03.17
Elements of Performance for CTS.04.03.17
156 Standard CTS.04.03.19
Elements of Performance for CTS.04.03.19
Standard CTS.04.03.20
Elements of Performance for CTS.04.03.20
Standard CTS.04.03.21
Rationale for CTS.04.03.21
157 Elements of Performance for CTS.04.03.21
Introduction to Standards CTS.04.03.23 and CTS.04.03.25
158 Standard CTS.04.03.23
Elements of Performance for CTS.04.03.23
159 Standard CTS.04.03.25
Elements of Performance for CTS.04.03.25
Standard CTS.04.03.27
160 Elements of Performance for CTS.04.03.27
Standard CTS.04.03.29
Elements of Performance for CTS.04.03.29
Standard CTS.04.03.31
Rationale for CTS.04.03.31
161 Elements of Performance for CTS.04.03.31
Standard CTS.04.03.33
Elements of Performance for CTS.04.03.33
162 Standard CTS.04.03.35
Elements of Performance for CTS.04.03.35
163 Standard CTS.04.03.37
Elements of Performance for CTS.04.03.37
164 Introduction to Standards CTS.05.01.01 Through CTS.05.06.35—Special Behavioral Procedures
Standard CTS.05.01.01
Elements of Performance for CTS.05.01.01
Standard CTS.05.02.01
165 Rationale for CTS.05.02.01
Elements of Performance for CTS.05.02.01
Standard CTS.05.03.01
166 Elements of Performance for CTS.05.03.01
Introduction to Standards CTS.05.04.01 Through CTS.05.04.17—Individualized Behavioral Contingencies
167 Standard CTS.05.04.01
Elements of Performance for CTS.05.04.01
Standard CTS.05.04.03
Elements of Performance for CTS.05.04.03
168 Standard CTS.05.04.05
Elements of Performance for CTS.05.04.05
Standard CTS.05.04.07
169 Elements of Performance for CTS.05.04.07
Standard CTS.05.04.09
Elements of Performance for CTS.05.04.09
170 Standard CTS.05.04.11
Elements of Performance for CTS.05.04.11
Standard CTS.05.04.13
Elements of Performance for CTS.05.04.13
171 Standard CTS.05.04.15
Elements of Performance for CTS.05.04.15
Standard CTS.05.04.17
Elements of Performance for CTS.05.04.17
172 Introduction to Standards CTS.05.05.01 Through CTS.05.05.21—Physical Holding of Children/Youth
Applicability of the Physical Holding of Children/Youth Standards
173 Standard CTS.05.05.01
Elements of Performance for CTS.05.05.01
174 Standard CTS.05.05.03
Elements of Performance for CTS.05.05.03
Standard CTS.05.05.05
175 Elements of Performance for CTS.05.05.05
176 Standard CTS.05.05.07
Elements of Performance for CTS.05.05.07
Standard CTS.05.05.09
Elements of Performance for CTS.05.05.09
177 Standard CTS.05.05.11
Elements of Performance for CTS.05.05.11
Standard CTS.05.05.13
Elements of Performance for CTS.05.05.13
178 Standard CTS.05.05.15
Elements of Performance for CTS.05.05.15
Standard CTS.05.05.17
Elements of Performance for CTS.05.05.17
179 Standard CTS.05.05.19
Rationale for CTS.05.05.19
Elements of Performance for CTS.05.05.19
180 Standard CTS.05.05.21
Elements of Performance for CTS.05.05.21
181 Introduction to Standards CTS.05.06.01 Through CTS.05.06.35—Restraint and Seclusion
Applicability of Behavioral Health Care Restraint and Seclusion Standards
182 Standard CTS.05.06.01
183 Elements of Performance for CTS.05.06.01
Standard CTS.05.06.03
Elements of Performance for CTS.05.06.03
184 Standard CTS.05.06.05
Elements of Performance for CTS.05.06.05
186 Standard CTS.05.06.07
Elements of Performance for CTS.05.06.07
187 Standard CTS.05.06.09
Elements of Performance for CTS.05.06.09
Standard CTS.05.06.11
Elements of Performance for CTS.05.06.11
188 Standard CTS.05.06.13
Elements of Performance for CTS.05.06.13
189 Standard CTS.05.06.15
Elements of Performance for CTS.05.06.15
Standard CTS.05.06.17
Elements of Performance for CTS.05.06.17
190 Standard CTS.05.06.19
Elements of Performance for CTS.05.06.19
191 Standard CTS.05.06.21
Elements of Performance for CTS.05.06.21
192 Standard CTS.05.06.23
Elements of Performance for CTS.05.06.23
Standard CTS.05.06.25
Elements of Performance for CTS.05.06.25
193 Standard CTS.05.06.27
Elements of Performance for CTS.05.06.27
Standard CTS.05.06.29
Elements of Performance for CTS.05.06.29
194 Standard CTS.05.06.31
Elements of Performance for CTS.05.06.31
Standard CTS.05.06.33
Elements of Performance for CTS.05.06.33
195 Standard CTS.05.06.35
Elements of Performance for CTS.05.06.35
196 Standard CTS.06.01.01
Elements of Performance for CTS.06.01.01
197 Standard CTS.06.01.03
Elements of Performance for CTS.06.01.03
198 Standard CTS.06.01.05
Elements of Performance for CTS.06.01.05
200 Standard CTS.06.01.07
Elements of Performance for CTS.06.01.07
201 Introduction to Standards CTS.06.01.09 Through CTS.06.01.15—Housing Support Services
Standard CTS.06.01.09
Elements of Performance for CTS.06.01.09
203 Standard CTS.06.01.11
Elements of Performance for CTS.06.01.11
204 Standard CTS.06.01.13
Elements of Performance for CTS.06.01.13
206 Standard CTS.06.01.15
Elements of Performance for CTS.06.01.15
207 Introduction to Standards CTS.06.02.01 Through CTS.06.02.05—Transfer or Discharge
Standard CTS.06.02.01
Elements of Performance for CTS.06.02.01
209 Standard CTS.06.02.03
Elements of Performance for CTS.06.02.03
211 Standard CTS.06.02.05
Elements of Performance for CTS.06.02.05
Standard CTS.06.02.07
Elements of Performance for CTS.06.02.07
212 Standard CTS.06.03.01
Rationale for CTS.06.03.01
Elements of Performance for CTS.06.03.01
213 Introduction to Standards CTS.07.01.01 Through CTS.07.01.03
214 Standard CTS.07.01.01
Elements of Performance for CTS.07.01.01
215 Standard CTS.07.01.02
Elements of Performance for CTS.07.01.02
Standard CTS.07.01.03
Elements of Performance for CTS.07.01.03
217 Environment of Care (EC)
Overview
About This Chapter
218 Other Issues for Consideration
220 Chapter Outline
221 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
222 Standard EC.02.01.01
Rationale for EC.02.01.01
223 Elements of Performance for EC.02.01.01
Standard EC.02.01.03
Elements of Performance for EC.02.01.03
224 Standard EC.02.01.05
Elements of Performance for EC.02.01.05
225 Standard EC.02.02.01
Rationale for EC.02.02.01
Elements of Performance for EC.02.02.01
Standard EC.02.03.01
Rationale for EC.02.03.01
226 Elements of Performance for EC.02.03.01
Standard EC.02.03.03
227 Elements of Performance for EC.02.03.03
228 Standard EC.02.03.05
Elements of Performance for EC.02.03.05
230 This page is blank due to revisions through the
update.
234 This page is blank due to revisions through the
update.
236 Standard EC.02.04.03
Elements of Performance for EC.02.04.03
Standard EC.02.05.01
Elements of Performance for EC.02.05.01
237 Standard EC.02.05.03
Elements of Performance for EC.02.05.03
239 Standard EC.02.05.05
Elements of Performance for EC.02.05.05
240 Standard EC.02.05.07
Rationale for EC.02.05.07
Elements of Performance for EC.02.05.07
242 Introduction to Standard EC.02.06.01
Standard EC.02.06.01
243 Elements of Performance for EC.02.06.01
244 This page is blank due to revisions through the
update.
245 Standard EC.02.06.03
Elements of Performance for EC.02.06.03
246 Standard EC.02.06.05
Rationale for EC.02.06.05
Elements of Performance for EC.02.06.05
Standard EC.03.01.01
247 Rationale for EC.03.01.01
Elements of Performance for EC.03.01.01
Standard EC.04.01.01
Elements of Performance for EC.04.01.01
248 Standard EC.04.01.03
Elements of Performance for EC.04.01.03
Standard EC.04.01.05
Elements of Performance for EC.04.01.05
249 Emergency Management (EM)
Overview
250 About This Chapter
251 Chapter Outline
252 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
253 Standard EM.02.01.01
Rationale for EM.02.01.01
254 Elements of Performance for EM.02.01.01
255 Standard EM.02.02.01
Rationale for EM.02.02.01
Elements of Performance for EM.02.02.01
256 Standard EM.02.02.03
Rationale for EM.02.02.03
Elements of Performance for EM.02.02.03
257 Standard EM.02.02.05
Rationale for EM.02.02.05
Elements of Performance for EM.02.02.05
Standard EM.02.02.07
258 Rationale for EM.02.02.07
Elements of Performance for EM.02.02.07
Standard EM.02.02.11
Elements of Performance for EM.02.02.11
259 Standard EM.03.01.03
Elements of Performance for EM.03.01.03
261 Human Resources Management (HRM)
Overview
About This Chapter
262 Chapter Outline
263 Standards, Rationales, and Elements of Performance
Standard HRM.01.01.01
Elements of Performance for HRM.01.01.01
Standard HRM.01.01.03
Elements of Performance for HRM.01.01.03
264 Standard HRM.01.02.01
Elements of Performance for HRM.01.02.01
266 Standard HRM.01.03.01
Elements of Performance for HRM.01.03.01
268 Standard HRM.01.04.01
Elements of Performance for HRM.01.04.01
Standard HRM.01.05.01
Elements of Performance for HRM.01.05.01
270 Introduction to Standards HRM.01.06.01 Through HRM.01.07.01
271 Standard HRM.01.06.01
Elements of Performance for HRM.01.06.01
Standard HRM.01.06.03
272 Elements of Performance for HRM.01.06.03
273 Standard HRM.01.06.05
Elements of Performance for HRM.01.06.05
Standard HRM.01.06.07
Elements of Performance for HRM.01.06.07
Standard HRM.01.06.09
274 Elements of Performance for HRM.01.06.09
Standard HRM.01.06.11
Elements of Performance for HRM.01.06.11
275 Standard HRM.01.07.01
Elements of Performance for HRM.01.07.01
277 Infection Prevention and Control (IC)
Overview
About This Chapter
279 Chapter Outline
280 Standards, Rationales, and Elements of Performance
Introduction to Standards IC.01.01.01 Through IC.01.06.01 – Planning
Standard IC.01.01.01
Elements of Performance for IC.01.01.01
281 Standard IC.01.02.01
Elements of Performance for IC.01.02.01
Standard IC.01.03.01
Rationale for IC.01.03.01
Elements of Performance for IC.01.03.01
282 Standard IC.01.04.01
Elements of Performance for IC.01.04.01
Standard IC.01.05.01
283 Rationale for IC.01.05.01
Elements of Performance for IC.01.05.01
284 Standard IC.01.06.01
Rationale for IC.01.06.01
285 Elements of Performance for IC.01.06.01
Introduction to Standards IC.02.01.01 Through IC.02.03.01 – Implementation
286 Standard IC.02.01.01
Elements of Performance for IC.02.01.01
287 Standard IC.02.02.01
288 Rationale for IC.02.02.01
Elements of Performance for IC.02.02.01
289 Standard IC.02.03.01
Elements of Performance for IC.02.03.01
Introduction to Standard IC.02.04.01
290 Standard IC.02.04.01
Elements of Performance for IC.02.04.01
291 Introduction to Standard IC.03.01.01 – Evaluation and Improvement
Standard IC.03.01.01
Elements of Performance for IC.03.01.01
293 Information Management (IM)
Overview
About This Chapter
294 Chapter Outline
295 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
296 Introduction to Standard IM.01.01.03
Standard IM.01.01.03
297 Elements of Performance for IM.01.01.03
Introduction to Standard IM.02.01.01
298 Standard IM.02.01.01
Elements of Performance for IM.02.01.01
299 Introduction to Standard IM.02.01.03
Standard IM.02.01.03
Elements of Performance for IM.02.01.03
300 Standard IM.02.02.01
Rationale for IM.02.02.01
Elements of Performance for IM.02.02.01
301 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
302 Standard IM.03.01.01
Elements of Performance for IM.03.01.01
303 Leadership (LD)
Overview
304 Proactive Risk Assessment
305 About This Chapter
306 Chapter Outline
307 Standards, Rationales, and Elements of Performance
Introduction to Leadership Structure, Standards LD.01.01.01 Through LD.01.07.01
Standard LD.01.01.01
Rationale for LD.01.01.01
308 Elements of Performance for LD.01.01.01
Standard LD.01.03.01
Rationale for LD.01.03.01
Elements of Performance for LD.01.03.01
Standard LD.01.04.01
309 Elements of Performance for LD.01.04.01
Standard LD.01.06.01
Elements of Performance for LD.01.06.01
Standard LD.01.07.01
Elements of Performance for LD.01.07.01
310 Introduction to Leadership Relationships, Standards LD.02.01.01 and LD.02.03.01
Standard LD.02.01.01
Rationale for LD.02.01.01
311 Elements of Performance for LD.02.01.01
Standard LD.02.03.01
Rationale for LD.02.03.01
Elements of Performance for LD.02.03.01
312 Introduction to Organization Culture and System Performance Expectations, Standards LD.03.01.01 Through LD.03.06.01
314 Standard LD.03.01.01
Rationale for LD.03.01.01
Elements of Performance for LD.03.01.01
315 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
316 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
317 Standard LD.03.05.01
Rationale for LD.03.05.01
Elements of Performance for LD.03.05.01
Standard LD.03.06.01
Rationale for LD.03.06.01
Elements of Performance for LD.03.06.01
318 Introduction to Operations, Standards LD.03.07.01 Through LD.04.03.09
Standard LD.03.07.01
319 Elements of Performance for LD.03.07.01
Standard LD.03.08.01
320 Elements of Performance for LD.03.08.01
Introduction to Standard LD.03.09.01
Standard LD.03.09.01
321 Elements of Performance for LD.03.09.01
323 Standard LD.03.10.01
Elements of Performance for LD.03.10.01
Standard LD.04.01.01
Elements of Performance for LD.04.01.01
324 Standard LD.04.01.03
Elements of Performance for LD.04.01.03
Standard LD.04.01.05
325 Rationale for LD.04.01.05
Elements of Performance for LD.04.01.05
326 Standard LD.04.01.07
Elements of Performance for LD.04.01.07
Standard LD.04.01.08
Elements of Performance for LD.04.01.08
Standard LD.04.01.09
Elements of Performance for LD.04.01.09
328 Standard LD.04.01.11
Rationale for LD.04.01.11
Elements of Performance for LD.04.01.11
329 Standard LD.04.01.13
Elements of Performance for LD.04.01.13
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
331 Standard LD.04.02.05
Rationale for LD.04.02.05
Elements of Performance for LD.04.02.05
Standard LD.04.02.07
Elements of Performance for LD.04.02.07
Standard LD.04.03.01
Elements of Performance for LD.04.03.01
332 Standard LD.04.03.05
Elements of Performance for LD.04.03.05
334 Standard LD.04.03.07
Rationale for LD.04.03.07
Elements of Performance for LD.04.03.07
Introduction to Standard LD.04.03.08
335 Standard LD.04.03.08
Rationale for LD.04.03.08
336 Elements of Performance for LD.04.03.08
337 Introduction to Oversight of Care, Treatment, or Services Provided Through Contractual Agreement, Standard LD.04.03.09
338 Monitoring Contracted Services
339 Standard LD.04.03.09
Elements of Performance for LD.04.03.09
341 Life Safety (LS)
Overview
342 About This Chapter
344 Chapter Outline
345 Standards, Rationales, and Elements of Performance
Introduction to Standard LS.01.01.01
Standard LS.01.01.01
346 Elements of Performance for LS.01.01.01
347 Standard LS.01.02.01
Elements of Performance for LS.01.02.01
349 Standard LS.02.01.10
Rationale for LS.02.01.10
Elements of Performance for LS.02.01.10
352 This page is blank due to revisions through the
update.
353 Standard LS.02.01.20
Rationale for LS.02.01.20
Elements of Performance for LS.02.01.20
359 Standard LS.02.01.30
Rationale for LS.02.01.30
360 Elements of Performance for LS.02.01.30
364 Standard LS.02.01.34
365 Elements of Performance for LS.02.01.34
366 Standard LS.02.01.35
Elements of Performance for LS.02.01.35
368 Standard LS.02.01.40
Elements of Performance for LS.02.01.40
369 Standard LS.02.01.50
370 This page is blank due to revisions through the
update.
371 Elements of Performance for LS.02.01.50
372 Standard LS.02.01.70
Elements of Performance for LS.02.01.70
373 Standard LS.04.01.20
Rationale for LS.04.01.20
374 Elements of Performance for LS.04.01.20
375 Standard LS.04.01.30
Rationale for LS.04.01.30
376 Elements of Performance for LS.04.01.30
377 Standard LS.04.01.50
Elements of Performance for LS.04.01.50
Standard LS.04.02.20
Rationale for LS.04.02.20
378 Elements of Performance for LS.04.02.20
379 Standard LS.04.02.30
Rationale for LS.04.02.30
380 Elements of Performance for LS.04.02.30
383 Standard LS.04.02.40
Elements of Performance for LS.04.02.40
Standard LS.04.02.50
384 Elements of Performance for LS.04.02.50
Standard LS.05.01.10
Elements of Performance for LS.05.01.10
385 Standard LS.05.01.20
Elements of Performance for LS.05.01.20
386 Standard LS.05.01.30
Elements of Performance for LS.05.01.30
387 Standard LS.05.01.34
Elements of Performance for LS.05.01.34
388 Standard LS.05.01.35
Elements of Performance for LS.05.01.35
389 Medication Management (MM)
Overview
390 About This Chapter
392 Chapter Outline
393 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
394 Standard MM.01.01.03
Rationale for MM.01.01.03
Elements of Performance for MM.01.01.03
395 Standard MM.01.01.05
396 Rationale for MM.01.01.05
Elements of Performance for MM.01.01.05
Standard MM.01.02.01
Elements of Performance for MM.01.02.01
Standard MM.02.01.01
397 Elements of Performance for MM.02.01.01
398 Standard MM.03.01.01
Rationale for MM.03.01.01
Elements of Performance for MM.03.01.01
399 Standard MM.03.01.03
Rationale for MM.03.01.03
Elements of Performance for MM.03.01.03
400 Standard MM.03.01.05
Rationale for MM.03.01.05
Elements of Performance for MM.03.01.05
401 Introduction to Standard MM.04.01.01
Standard MM.04.01.01
Elements of Performance for MM.04.01.01
404 Standard MM.05.01.01
Elements of Performance for MM.05.01.01
405 Standard MM.05.01.07
Elements of Performance for MM.05.01.07
Standard MM.05.01.09
Rationale for MM.05.01.09
Elements of Performance for MM.05.01.09
406 Standard MM.05.01.11
407 Elements of Performance for MM.05.01.11
Standard MM.05.01.13
408 Elements of Performance for MM.05.01.13
Standard MM.05.01.15
Elements of Performance for MM.05.01.15
409 Standard MM.05.01.17
Elements of Performance for MM.05.01.17
Standard MM.05.01.19
Rationale for MM.05.01.19
410 Elements of Performance for MM.05.01.19
Standard MM.06.01.01
Elements of Performance for MM.06.01.01
411 Standard MM.06.01.03
412 Elements of Performance for MM.06.01.03
415 Standard MM.06.01.05
Rationale for MM.06.01.05
Elements of Performance for MM.06.01.05
Standard MM.07.01.01
416 Elements of Performance for MM.07.01.01
417 Standard MM.07.01.03
Rationale for MM.07.01.03
Elements of Performance for MM.07.01.03
418 Standard MM.08.01.01
Elements of Performance for MM.08.01.01
420 Applicability for Medication Management Type
423 National Patient Safety Goals (NPSG)
Chapter Outline
National Patient Safety Goals®
424 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
425 Goal 3
Introduction to Reconciling Medication Information
426 NPSG.03.06.01
Rationale for NPSG.03.06.01
Elements of Performance for NPSG.03.06.01
427 Goal 7
NPSG.07.01.01
428 Rationale for NPSG.07.01.01
Elements of Performance for NPSG.07.01.01
429 Goal 15
NPSG.15.01.01
Rationale for NPSG.15.01.01
Elements of Performance for NPSG.15.01.01
431 Performance Improvement (PI)
Overview
About This Chapter
433 Chapter Outline
434 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
436 Standard PI.02.01.01
437 Rationale for PI.02.01.01
Elements of Performance for PI.02.01.01
438 Introduction to Standard PI.03.01.01
Standard PI.03.01.01
Elements of Performance for PI.03.01.01
Standard PI.04.01.01
439 Rationale for PI.04.01.01
Elements of Performance for PI.04.01.01
441 Record of Care, Treatment, and Services (RC)
Overview
About This Chapter
442 Chapter Outline
443 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
444 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.01.05.01
Elements of Performance for RC.01.05.01
445 Standard RC.02.01.01
Elements of Performance for RC.02.01.01
447 Standard RC.02.01.05
Elements of Performance for RC.02.01.05
449 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
450 Standard RC.03.01.01
Elements of Performance for RC.03.01.01
451 Standard RC.03.01.03
Elements of Performance for RC.03.01.03
453 Rights and Responsibilities of the Individual (RI)
Overview
454 About This Chapter
455 Chapter Outline
456 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
458 Standard RI.01.01.03
Rationale for RI.01.01.03
459 Elements of Performance for RI.01.01.03
460 Standard RI.01.02.01
Rationale for RI.01.02.01
Elements of Performance for RI.01.02.01
462 This page is blank due to revisions through the
update.
464 Standard RI.01.03.01
Rationale for RI.01.03.01
Elements of Performance for RI.01.03.01
466 Standard RI.01.03.05
Rationale for RI.01.03.05
Elements of Performance for RI.01.03.05
467 Standard RI.01.04.01
Elements of Performance for RI.01.04.01
468 Standard RI.01.04.03
Elements of Performance for RI.01.04.03
469 Standard RI.01.05.01
Elements of Performance for RI.01.05.01
Standard RI.01.06.03
470 Elements of Performance for RI.01.06.03
Standard RI.01.06.05
Elements of Performance for RI.01.06.05
471 Standard RI.01.06.07
472 Elements of Performance for RI.01.06.07
Standard RI.01.07.01
Elements of Performance for RI.01.07.01
473 Standard RI.01.07.03
Elements of Performance for RI.01.07.03
Standard RI.01.07.07
474 Elements of Performance for RI.01.07.07
Standard RI.01.07.09
Rationale for RI.01.07.09
Elements of Performance for RI.01.07.09
Standard RI.02.01.01
475 Rationale for RI.02.01.01
Elements of Performance for RI.02.01.01
Standard RI.03.01.01
Elements of Performance for RI.03.01.01
476 Standard RI.03.01.03
Elements of Performance for RI.03.01.03
Standard RI.03.01.05
Elements of Performance for RI.03.01.05
479 Waived Testing (WT)
Overview
480 About This Chapter
482 Chapter Outline
483 Standards, Rationales, and Elements of Performance
Standard WT.01.01.01
Elements of Performance for WT.01.01.01
484 Standard WT.02.01.01
Elements of Performance for WT.02.01.01
485 Standard WT.03.01.01
Elements of Performance for WT.03.01.01
Standard WT.04.01.01
486 Elements of Performance for WT.04.01.01
Standard WT.05.01.01
Elements of Performance for WT.05.01.01
489 The Accreditation Process (ACC)
Notices
ACC Chapter Contents
491 Overview
General Eligibility Requirements
492 Scope of Accreditation Surveys
493 Accreditation Policies
Tailored Survey Policy
494 Organizational and Functional Integration
497 System Accreditation Option
Table 1. Sampling for System Surveys by Size
498 Multiorganization Option
499 Table 2. Survey Process Comparison
500 Concurrent and Sequential Survey Options
Contracted Services
Initial Surveys
502 Information Accuracy and Truthfulness Policy
503 Good Faith Participation in Accreditation/ Certification
505 Public Information Policy
Process for Responding to a Complaint
506 Early Survey Policy
Sidebar 1. Early Survey Policy
507 Sidebar 1.
509 Behavioral Health Home Certification Option
511 Before the Accreditation Survey
An Organization’s Secure Joint Commission Connect Extranet Site
512 Role of the Account Executive
Electronic Application for Accreditation (E-App)
513 Accreditation/Certification Contract and Business Associate Agreement
514 Annual and Survey Fees
515 During the Survey
516 Survey Notification
517 Table 3. Exceptions to Unannounced Surveys#
519 Initial and Full Survey Team Composition
520 Survey Agenda
524 Tracer Methodology
526 Table 4. Behavioral Health Care and Human Services Accreditation–Specific Tracer Applicability and Objectives
530 Immediate Threat to Health or Safety
534 Summary of the Accreditation Reports
535 After the Survey
The Scoring Process
540 Evidence of Standards Compliance (ESC) Process
544 Accreditation Award Display and Use
545 Between Accreditation Surveys
546 Duration of Accreditation Award
Continuous Compliance
Intracycle Monitoring (ICM)
547 Focused Standards Assessment (FSA)
548 Sidebar 2. Focused Standards Assessment (FSA) Options
549 Sidebar 2.
Sentinel Event Follow-up
550 Notifying The Joint Commission About Organization Changes
552 Accreditation Status of Organizations That Cease Services After a Disaster###
554 Accreditation Status of Organizations That Cease Services or Do Not Provide Care, Treatment, or Services to Individuals Served f
555 Reentering the Accreditation Process
Additional Surveys
557 Decision Rules for Organizations Seeking Initial Accreditation
Accredited
Behavioral Health Home Certification
558 Limited, Temporary Accreditation
Evidence of Standards Compliance (ESC)
Denial of Accreditation
559 Decision Rules for Organizations Seeking Reaccreditation
Accredited
560 Behavioral Health Home Certification
Evidence of Standards Compliance (ESC)
Accreditation with Follow-up Survey
562 Preliminary Denial of Accreditation
563 Denial of Accreditation
Process for Organizations That Meet Decision Rule PDA02 for Individuals Served Placed at Risk for Serious Adverse Outcomes Due t
565 Process for Organizations That Meet Decision Rule PDA04
566 Review and Appeal Procedures
I. Evaluation by Joint Commission Staff
568 II. Accreditation with Follow-up Survey
III. Review Hearings
570 IV. Following a Review Hearing
V. Final Review &Appeal Request
573 Standards Applicability Process (SAP)
577 Behavioral Health Care Services Applicability Grid
599 Human Services Applicability Grid
626 This page is blank due to revisions through the
update.
646 This page is blank due to revisions through the
update.
665 Behavioral Health Care and Human Services Settings Applicability Grid
666 This page is blank due to revisions through the
update.
684 This page is blank due to revisions through the
update.
702 This page is blank due to revisions through the
update.
716 This page is blank due to revisions through the
update.
723 Sentinel Event Policy (SE)
724 Goals of the Sentinel Event Policy
725 Identifying Sentinel Events
727 Sidebar 1. Key Terms
728 Sidebar 1.
730 Determining That a Sentinel Event Is Subject to Review
Relationship to the Survey Process
731 Required Organization Response to a Sentinel Event
733 Reporting a Sentinel Event to The Joint Commission
735 Conducting a Comprehensive Systematic Analysis
736 Developing a Corrective Action Plan
737 Submitting the Comprehensive Systematic Analysis and Corrective Action Plan
738 Table 1. Options for a Joint Commission Review of an Organization’s Response to a Sentinel Event
739 Table 1.
740 The Joint Commission’s Response
Review of Comprehensive Systematic Analyses and Corrective Action Plans
741 Follow-up Activities
743 Disclosable Information
Handling Sentinel Event–Related Documents
The Sentinel Event Database
744 Overseeing the Sentinel Event Policy
745 The Joint Commission Quality Report (QR)
Introduction
What Is The Joint Commission Quality Report?
746 What Will My Quality Report Contain?
What Is Quality Check?
747 Is a Quality Report Available for My Accredited Health Care Organization?
Can My Health Care Organization Comment on Its Quality Report?
748 How Does My Health Care Organization 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?
749 Guidelines for Publicizing Compliance with the National Patient Safety Goals
751 Required Written Documentation (RWD)
752 List of EPs Requiring Written Documentation for Behavioral Health Care and Human Services Organizations
Accreditation Participation Requirements (APR)
Care, Treatment, and Services (CTS)
Environment of Care (EC)
Emergency Management (EM)
753 Human Resources Management (HRM)
Infection Prevention and Control (IC)
Information Management (IM)
Leadership (LD)
Life Safety (LS)
Medication Management (MM)
754 National Patient Safety Goals (NPSG)
Performance Improvement (PI)
Record of Care, Treatment, and Services (RC)
Rights and Responsibilities of the Individual (RI)
Waived Testing (WT)
755 Early Survey Policy (ESP)
Accreditation Participation Requirements (APR)
Care, Treatment, and Services (CTS)
756 Environment of Care (EC)
Emergency Management (EM)
Human Resources Management (HRM)
Infection Prevention and Control (IC)
757 Information Management (IM)
Leadership (LD)
Life Safety (LS)
Medication Management (MM)
758 National Patient Safety Goals (NPSG)
Record of Care, Treatment, and Services (RC)
Rights and Responsibilities of the Individual (RI)
Waived Testing (WT)
759 Opioid Treatment Programs (OTP)
Overview
Standards List
766 Additional Standards, Rationales, Elements of Performance, and Scoring for Opioid Treatment Programs
Care, Treatment, and Services (CTS)
Standard CTS.01.01.01
Elements of Performance for CTS.01.01.01
769 Standard CTS.02.01.01
Elements of Performance for CTS.02.01.01
Standard CTS.02.01.03
Elements of Performance for CTS.02.01.03
770 Standard CTS.02.01.07
Elements of Performance for CTS.02.01.07
771 Standard CTS.02.01.09
Elements of Performance for CTS.02.01.09
772 Standard CTS.02.01.13
Elements of Performance for CTS.02.01.13
Standard CTS.02.01.17
Elements of Performance for CTS.02.01.17
773 Standard CTS.02.02.01
Elements of Performance for CTS.02.02.01
774 Standard CTS.02.02.05
Rationale for CTS.02.02.05
Elements of Performance for CTS.02.02.05
Standard CTS.02.02.07
775 Elements of Performance for CTS.02.02.07
Standard CTS.02.02.09
Elements of Performance for CTS.02.02.09
777 Standard CTS.02.03.03
Elements of Performance for CTS.02.03.03
778 Standard CTS.03.01.01
Elements of Performance for CTS.03.01.01
780 Standard CTS.03.01.03
Elements of Performance for CTS.03.01.03
782 Standard CTS.03.01.05
Elements of Performance for CTS.03.01.05
783 Standard CTS.03.01.07
Elements of Performance for CTS.03.01.07
784 Standard CTS.03.01.09
Rationale for CTS.03.01.09
Elements of Performance for CTS.03.01.09
785 Standard CTS.04.01.01
Rationale for CTS.04.01.01
Elements of Performance for CTS.04.01.01
786 Standard CTS.04.01.03
Elements of Performance for CTS.04.01.03
788 Standard CTS.04.03.01
789 Rationale for CTS.04.03.01
Elements of Performance for CTS.04.03.01
Standard CTS.04.03.35
Elements of Performance for CTS.04.03.35
790 Standard CTS.06.02.01
Elements of Performance for CTS.06.02.01
792 Standard CTS.06.02.03
Elements of Performance for CTS.06.02.03
Standard CTS.06.02.05
Elements of Performance for CTS.06.02.05
793 Environment of Care (EC)
Standard EC.02.01.01
Rationale for EC.02.01.01
Elements of Performance for EC.02.01.01
794 Standard EC.02.03.01
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
795 Standard EC.02.03.05
Elements of Performance for EC.02.03.05
Standard EC.02.06.01
Elements of Performance for EC.02.06.01
796 Emergency Management (EM)
Standard EM.01.01.01
Rationale for EM.01.01.01
Elements of Performance for EM.01.01.01
797 Standard EM.02.01.01
Rationale for EM.02.01.01
Elements of Performance for EM.02.01.01
798 Standard EM.02.02.01
Rationale for EM.02.02.01
Elements of Performance for EM.02.02.01
Human Resources Management (HRM)
Standard HRM.01.01.01
Elements of Performance for HRM.01.01.01
799 Standard HRM.01.01.03
Elements of Performance for HRM.01.01.03
800 Standard HRM.01.02.01
Elements of Performance for HRM.01.02.01
802 Standard HRM.01.03.01
Elements of Performance for HRM.01.03.01
Standard HRM.01.05.01
Elements of Performance for HRM.01.05.01
803 Standard HRM.01.06.01
Elements of Performance for HRM.01.06.01
Standard HRM.01.06.03
Elements of Performance for HRM.01.06.03
804 Standard HRM.01.07.01
Elements of Performance for HRM.01.07.01
Infection Prevention and Control (IC)
Standard IC.01.03.01
Rationale for IC.01.03.01
Elements of Performance for IC.01.03.01
805 Standard IC.01.05.01
Rationale for IC.01.05.01
806 Elements of Performance for IC.01.05.01
Information Management (IM)
Standard IM.01.01.03
Elements of Performance for IM.01.01.03
Standard IM.02.01.01
Elements of Performance for IM.02.01.01
807 Standard IM.02.01.03
Elements of Performance for IM.02.01.03
Standard IM.02.02.03
Rationale for IM.02.02.03
Elements of Performance for IM.02.02.03
Leadership (LD)
Standard LD.01.01.01
808 Rationale for LD.01.01.01
Elements of Performance for LD.01.01.01
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
809 Standard LD.02.01.01
Rationale for LD.02.01.01
Elements of Performance for LD.02.01.01
Standard LD.03.05.01
Rationale for LD.03.05.01
Elements of Performance for LD.03.05.01
810 Standard LD.03.06.01
Rationale for LD.03.06.01
Elements of Performance for LD.03.06.01
Standard LD.03.09.01
Elements of Performance for LD.03.09.01
811 Standard LD.04.01.01
Elements of Performance for LD.04.01.01
812 Standard LD.04.01.05
Rationale for LD.04.01.05
Elements of Performance for LD.04.01.05
813 Standard LD.04.01.09
Elements of Performance for LD.04.01.09
814 Standard LD.04.01.11
Rationale for LD.04.01.11
Elements of Performance for LD.04.01.11
Standard LD.04.02.03
Elements of Performance for LD.04.02.03
815 Standard LD.04.03.05
Elements of Performance for LD.04.03.05
816 Medication Management (MM)
Standard MM.01.01.01
Rationale for MM.01.01.01
Elements of Performance for MM.01.01.01
817 Standard MM.01.01.03
Rationale for MM.01.01.03
818 Elements of Performance for MM.01.01.03
819 Standard MM.02.01.01
Elements of Performance for MM.02.01.01
Standard MM.03.01.01
Rationale for MM.03.01.01
Elements of Performance for MM.03.01.01
821 Standard MM.03.01.03
Rationale for MM.03.01.03
Elements of Performance for MM.03.01.03
Standard MM.04.01.01
Elements of Performance for MM.04.01.01
824 Standard MM.05.01.01
Elements of Performance for MM.05.01.01
Standard MM.05.01.09
Rationale for MM.05.01.09
Elements of Performance for MM.05.01.09
825 Standard MM.05.01.11
Elements of Performance for MM.05.01.11
Standard MM.05.01.13
Elements of Performance for MM.05.01.13
826 Standard MM.06.01.01
Elements of Performance for MM.06.01.01
Standard MM.06.01.03
Elements of Performance for MM.06.01.03
829 Standard MM.06.01.05
830 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
831 Standard MM.07.01.03
832 Rationale for MM.07.01.03
Elements of Performance for MM.07.01.03
Performance Improvement (PI)
Standard PI.01.01.01
833 Elements of Performance for PI.01.01.01
Record of Care, Treatment, and Services (RC)
Standard RC.01.01.01
Elements of Performance for RC.01.01.01
834 Standard RC.01.02.01
Elements of Performance for RC.01.02.01
Standard RC.01.03.01
Elements of Performance for RC.01.03.01
835 Standard RC.01.04.01
Elements of Performance for RC.01.04.01
Standard RC.01.05.01
Elements of Performance for RC.01.05.01
Standard RC.02.01.01
Elements of Performance for RC.02.01.01
837 Standard RC.02.04.01
Elements of Performance for RC.02.04.01
Rights and Responsibilities of the Individual (RI)
Standard RI.01.01.01
Rationale for RI.01.01.01
838 Elements of Performance for RI.01.01.01
839 Standard RI.01.01.03
Rationale for RI.01.01.03
840 Elements of Performance for RI.01.01.03
Standard RI.01.02.01
Rationale for RI.01.02.01
841 Elements of Performance for RI.01.02.01
842 Standard RI.01.03.01
Rationale for RI.01.03.01
Elements of Performance for RI.01.03.01
843 Standard RI.01.03.05
Rationale for RI.01.03.05
844 Elements of Performance for RI.01.03.05
845 Standard RI.01.06.03
Elements of Performance for RI.01.06.03
Standard RI.01.07.01
Elements of Performance for RI.01.07.01
846 Standard RI.02.01.01
Rationale for RI.02.01.01
Elements of Performance for RI.02.01.01
849 Child Welfare (CW)
Overview
850 Care, Treatment, and Services (CTS)
Standard CTS.01.01.01
Elements of Performance for CTS.01.01.01
851 Standard CTS.01.03.03
Elements of Performance for CTS.01.03.03
Standard CTS.02.04.01
Elements of Performance for CTS.02.04.01
853 Standard CTS.02.04.03
Elements of Performance for CTS.02.04.03
Standard CTS.02.04.05
Elements of Performance for CTS.02.04.05
854 Standard CTS.02.04.07
Elements of Performance for CTS.02.04.07
855 Standard CTS.02.04.09
Elements of Performance for CTS.02.04.09
Standard CTS.02.04.11
Elements of Performance for CTS.02.04.11
856 Standard CTS.02.04.13
Elements of Performance for CTS.02.04.13
Standard CTS.02.04.15
Elements of Performance for CTS.02.04.15
857 Standard CTS.02.04.17
Elements of Performance for CTS.02.04.17
858 Standard CTS.02.04.19
Elements of Performance for CTS.02.04.19
Standard CTS.02.04.21
859 Elements of Performance for CTS.02.04.21
Standard CTS.02.04.25
Rationale for CTS.02.04.25
Elements of Performance for CTS.02.04.25
860 Standard CTS.03.02.03
Elements of Performance for CTS.03.02.03
863 Standard CTS.04.02.07
Elements of Performance for CTS.04.02.07
865 Standard CTS.04.02.08
Elements of Performance for CTS.04.02.08
Standard CTS.04.02.09
Elements of Performance for CTS.04.02.09
866 Standard CTS.04.02.31
Elements of Performance for CTS.04.02.31
Standard CTS.04.03.37
Elements of Performance for CTS.04.03.37
867 Standard CTS.06.02.07
Elements of Performance for CTS.06.02.07
868 Environment of Care (EC)
Standard EC.02.01.05
Elements of Performance for EC.02.01.05
869 Human Resources Management (HRM)
Standard HRM.01.05.01
Elements of Performance for HRM.01.05.01
Standard HRM.01.06.01
Elements of Performance for HRM.01.06.01
870 Leadership (LD)
Standard LD.02.01.01
Rationale for LD.02.01.01
Elements of Performance for LD.02.01.01
Standard LD.03.04.01
Rationale for LD.03.04.01
Elements of Performance for LD.03.04.01
871 Standard LD.03.06.01
Rationale for LD.03.06.01
Elements of Performance for LD.03.06.01
Standard LD.04.01.08
Elements of Performance for LD.04.01.08
872 Standard LD.04.01.09
Elements of Performance for LD.04.01.09
Standard LD.04.01.13
Elements of Performance for LD.04.01.13
873 Standard LD.04.03.01
Elements of Performance for LD.04.03.01
Standard LD.04.03.07
Rationale for LD.04.03.07
874 Elements of Performance for LD.04.03.07
Performance Improvement (PI)
Standard PI.01.01.01
Elements of Performance for PI.01.01.01
Record of Care, Treatment, and Services (RC)
Standard RC.03.01.01
875 Elements of Performance for RC.03.01.01
876 Standard RC.03.01.03
Elements of Performance for RC.03.01.03
Rights and Responsibilities of the Individual (RI)
Standard RI.01.03.01
Rationale for RI.01.03.01
Elements of Performance for RI.01.03.01
877 Standard RI.03.01.01
Elements of Performance for RI.03.01.01
Standard RI.03.01.03
Elements of Performance for RI.03.01.03
878 Standard RI.03.01.05
Elements of Performance for RI.03.01.05
879 Behavioral Health Home Certification Option (BHH)
Introduction to Behavioral Health Home Certification Option
881 Care, Treatment, and Services (CTS)
Standard CTS.01.01.01
Elements of Performance for CTS.01.01.01
882 Standard CTS.01.04.01
Elements of Performance for CTS.01.04.01
Standard CTS.02.01.05
883 Elements of Performance for CTS.02.01.05
Standard CTS.02.02.01
Elements of Performance for CTS.02.02.01
885 Standard CTS.03.01.01
Elements of Performance for CTS.03.01.01
886 Standard CTS.03.01.03
Elements of Performance for CTS.03.01.03
888 Standard CTS.03.01.05
Elements of Performance for CTS.03.01.05
Standard CTS.03.01.07
Elements of Performance for CTS.03.01.07
889 Standard CTS.04.01.01
Elements of Performance for CTS.04.01.01
890 Standard CTS.04.01.03
Elements of Performance for CTS.04.01.03
891 Standard CTS.04.01.07
Elements of Performance for CTS.04.01.07
892 Standard CTS.04.02.19
Elements of Performance for CTS.04.02.19
894 Standard CTS.04.02.21
Elements of Performance for CTS.04.02.21
895 Standard CTS.04.02.23
Elements of Performance for CTS.04.02.23
Standard CTS.04.02.25
Elements of Performance for CTS.04.02.25
896 Standard CTS.04.02.27
897 Elements of Performance for CTS.04.02.27
Standard CTS.06.01.05
898 Elements of Performance for CTS.06.01.05
899 Standard CTS.06.01.07
Elements of Performance for CTS.06.01.07
900 Human Resources Management (HRM)
Standard HRM.01.03.01
Elements of Performance for HRM.01.03.01
901 Standard HRM.01.05.01
Elements of Performance for HRM.01.05.01
902 Information Management (IM)
Standard IM.01.01.01
Elements of Performance for IM.01.01.01
Leadership (LD)
Standard LD.03.04.01
Elements of Performance for LD.03.04.01
903 Standard LD.03.07.01
Elements of Performance for LD.03.07.01
904 Standard LD.03.08.01
Elements of Performance for LD.03.08.01
Standard LD.03.09.01
Elements of Performance for LD.03.09.01
906 Standard LD.03.10.01
907 Elements of Performance for LD.03.10.01
Standard LD.04.01.11
Elements of Performance for LD.04.01.11
Performance Improvement (PI)
Standard PI.01.01.01
908 Elements of Performance for PI.01.01.01
909 Standard PI.03.01.01
Elements of Performance for PI.03.01.01
Standard PI.04.01.01
Elements of Performance for PI.04.01.01
910 Record of Care, Treatment, and Services (RC)
Standard RC.01.01.01
Elements of Performance for RC.01.01.01
911 Standard RC.02.01.01
Elements of Performance for RC.02.01.01
913 Rights and Responsibilities of the Individual (RI)
Standard RI.01.01.01
Elements of Performance for RI.01.01.01
914 Standard RI.01.01.03
Elements of Performance for RI.01.01.03
Standard RI.01.02.01
Elements of Performance for RI.01.02.01
916 Standard RI.01.03.01
Elements of Performance for RI.01.03.01
917 Standard RI.01.03.05
Elements of Performance for RI.01.03.05
918 Standard RI.01.04.01
Elements of Performance for RI.01.04.01
Standard RI.01.04.03
Elements of Performance for RI.01.04.03
919 Standard RI.01.05.01
920 Elements of Performance for RI.01.05.01
Standard RI.01.06.03
Elements of Performance for RI.01.06.03
921 Standard RI.01.06.05
Elements of Performance for RI.01.06.05
Standard RI.01.07.01
Elements of Performance for RI.01.07.01
Standard RI.01.07.03
Elements of Performance for RI.01.07.03
923 Glossary (GL)
961 Index (IX)

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