2017 ComprehensiveComprehensive Accreditation ... · q Table 1. Acronyms Used in This Manual: ... EP 1: Added new Note 1 ... ComprehensiveComprehensive Accreditation Accreditation

2017CAMHC

Update 1

ComprehensiveComprehensive AccreditationAccreditationManualManual forfor HomeHome CareCare

CAMHC Update 1, July 2017 i

What’s NewJuly 2017 ReleaseEffective as Noted

This “What’s New” section is intended to help get you up to speed regarding thesubstantive changes that have been made to the CAMHC since its previous update.Major changes to requirements, accreditation policies and procedures, and otherimportant information in this update include the following:n Reordered and streamlined “The Accreditation Process” (ACC) chapter to reduce

redundancy, improve information flow, and enrich customer understandingn Updated the decision rules for 2017 in the ACC chapter

Please refer to the table that begins on the following page for more details about thisupdate. Revisions to content within this update are highlighted using shaded text withinthe replacement pages.

E-dition July 1, 2017, Release

2017CAMHC

Update 1

ComprehensiveComprehensive AccreditationAccreditation ManualManual forforHomeHome CareCare

CAMHC Update 1, July 2017ii

TypeType ofof ChangeChange EffectiveEffectiveDateDate

Introduction:Introduction: HowHow TheThe JointJoint CommissionCommission CanCan HelpHelp YouYou MoveMove TowardToward HighHighReliabilityReliability (INTRO)(INTRO)q Addressing Complex Issues in Organizations Accredited Under the

Home Care Accreditation Program: deleted sectionq Table 1. Acronyms Used in This Manual: Updated tableq Accreditation Process Information: Added description for new

“Patient Safety Systems” (PS) chapter

EffectiveJuly 1, 2017

q Use the Standards to Improve Care, Treatment, or Services:Updated the list of challenging standards

q Stimulate Improvement: Updated guidance for standards questionsq Requesting Permission to Copy Content from the Manual:

Removed the mailing address for copy requests, but retained theemail address

q Minor editorial revisionsPatientPatient SafetySafety SystemsSystems (PS)(PS)q Added a new “Patient Safety Systems” (PS) chapter to inform and

educate home care organizations about the importance and structureof an integrated patient safety system


AccreditationAccreditation RequirementsRequirementsAccreditationAccreditation ParticipationParticipation RequirementsRequirements (APR)(APR)q APR.07.01.01, EP 1: Added new Note 1 regarding participation of

surveyor management staff in the survey processEffectiveJuly 1, 2017

EnvironmentEnvironment ofof CareCare (EC)(EC)q Overview: Updated standards referencesq EC.02.01.01: Added two new Notes for hospices that elect to use

The Joint Commission deemed status option and for moreinformation on waiver and equivalency requests

q EC.02.03.03, EP 1: Updated standards references


q EC.02.03.05, EP 19: Updated NFPA referenceq EC.02.05.03, EP 3, Note: Removed “power within 10 seconds”q EC.02.05.05, EP 7:


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n Updated NFPA referencen Spelled out HVAC as heating, ventilation, and air conditioningn Specified in Note that hospices providing inpatient care in their

own facilities and electing to use The Joint Commission deemedstatus option must meet the applicable provisions of the HealthCare Facilities Code Tentative Interim Amendments (TIAs) 12-2 and 12-3

q Standard EC.02.05.09: Added new standard and 5 elements ofperformance requiring a hospice that has medical gas and vacuumsystems to inspect, test, and maintain those systems and todocument related activities and test results

q Deleted the following EPs:n EC.02.05.07, EP 11, 12n EC.04.01.01, EP 12n EC.04.01.03, EP 1

q Minor editorial changesEmergencyEmergency ManagementManagement (EM)(EM)q Minor editorial changes Effective

July 1, 2017EquipmentEquipment ManagementManagement (EQ)(EQ)q EQ.01.03.01, new EP 9: Added new EP for hospices providing

inpatient care in their own facilities and electing to use The JointCommission deemed status option requiring the organization tomeet all other Health Care Facilities Code requirements forelectrical equipment


HumanHuman ResourcesResources (HR)(HR)q HR.01.04.01, EP 4: Updated standards referencesq Deleted the following EPs:

n HR.01.02.05, EP 6n HR.01.05.03, EP 7n HR.01.06.01, EPs 2, 15



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InfectionInfection PreventionPrevention andand ControlControl (IC)(IC)q IC.02.01.01, EPs 7 and 9: Updated standards referencesq Deleted the following EPs:

n IC.01.05.01, EPs 3, 7, 8n IC.01.06.01, EPs 1, 5, 6


InformationInformation ManagementManagement (IM)(IM)q IM.03.01.01, EP 1: Updated standards referenceq Deleted the following EPs:

n IM.01.01.01, EPs 1, 3, 4


n IM.01.01.03, EPs 5, 6n IM.02.01.01, EP 5n IM.02.01.03, EP 8n IM.02.02.01, EP 1n IM.02.02.03, EP 1n IM.04.01.01, EP 1

LeadershipLeadership (LD)(LD)q Overview: Updated standards referencesq Introduction to Leadership Structure: Updated standards range for

the introduction to LD.01.01.01 through LD.01.04.01 to reflectchanges to Leadership standards

q Introduction to Leadership Relationships: Changed applicability ofintroduction solely to Standard LD.02.01.01


q Introduction to Standard LD.04.04.05 and Standard LD.04.04.05:Clarified that the term “close call” is preferred over “near miss”

q LD.04.04.05, EP 6: Updated standards referencesq Deleted the following standards and EPs:

n LD.01.04.01, EP 2n Standard LD.01.07.01 and its EPsn Standard LD.02.03.01 and its EPsn LD.03.01.01, EPs 3, 6–10


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n LD.04.01.03, EP 5n LD.04.01.05, EP 1n LD.04.01.11, EP 2n LD.04.02.03, EPs 3, 6n LD.04.03.07, EP 2n LD.04.04.03, EPs 6, 7

LifeLife SafetySafety (LS)(LS)q LS.01.01.01, EP 2: Added Note for hospices that elect to use The

Joint Commission deemed status option to comply with the 2012Life Safety Code

q LS.01.01.01, EP 4: Replaced Note 3 with a new Note 3 for furtherinformation concerning waiver and equivalency requests


q LS.01.02.01, EP 1: Updated standards referencesq LS.01.02.01, new EP 15: Added new EP (and two Notes) allowing

the organization the use of other written interim life safety measures( ILSMs ) not addressed in EPs 2–14 new Survey-Related Plans forImprovement (SPFIs)

q LS.02.01.10, EP 5: Added a second Note for hospices providinginpatient care in their own facilities that elect to use The JointCommission deemed status option regarding applicable provisionsof the Life Safety Code Tentative Interim Amendment (TIA) 12-1

q LS.02.01.20, EP 1: Added Note for hospices providing inpatientcare in their own facilities that elect to use The Joint Commissiondeemed status option regarding TIA 12-4

q LS.02.01.30, EP 4: Added Note for hospices providing inpatientcare in their own facilities that elect to use The Joint Commissiondeemed status option regarding TIA 12-2

MedicationMedication ManagementManagement (MM)(MM)q MM.01.01.01, EP 1: Updated standards referencesq Deleted the following EPs:

n MM.03.01.05, EP 3n MM.08.01.01, EP 4



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NationalNational PatientPatient SafetySafety GoalsGoals (NPSG)(NPSG)q No changesProvisionProvision ofof Care,Care, Treatment,Treatment, andand ServicesServices (PC)(PC)q PC.01.02.01, EP 1: Clarified that patient information is collected

according to the organization’s defined requirements for the scopeand content of screening, assessment, and reassessment information

q PC.04.01.05, EP 7: Updated standards references


q Deleted the following EPs:n PC.01.02.01, EP 23n PC.01.02.09, EP 5n PC.04.01.01, EPs 3, 4n PC.04.01.05, EPs 3, 8

PerformancePerformance ImprovementImprovement (PI)(PI)q Deleted the following EPs:

n PI.01.01.01, EP 30n PI.02.01.01, EPs 1, 2, 5


RecordRecord ofof Care,Care, Treatment,Treatment, andand ServicesServices (RC)(RC)q Deleted the following EPs:

n RC.01.01.01, EPs 9, 12, 13EffectiveJuly 1, 2017

RightsRights andand ResponsibilitiesResponsibilities ofof thethe IndividualIndividual (RI)(RI)q RI.01.01.03, EP 1: Deleted standards referencesq Deleted the following EPs:

n RI.01.03.01, EP 12n RI.01.03.03, EPs 2, 6–8n RI.01.03.05, EP 1


WaivedWaived TestingTesting (WT)(WT)q Deleted the following EP:

n WT.01.01.01, EP 7EffectiveJuly 1, 2017


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AccreditationAccreditation ProcessProcess InformationInformationTheThe AccreditationAccreditation ProcessProcess (ACC)(ACC)q Removed all references to Contingent Accreditation (CONT) as this

decision rule category has been eliminatedq Notices: Moved paragraph about Joint Commission Connect™ as the

primary means of communication from the end of the chapter to thebeginning


q Eligibility for Home Care Accreditation: Added nurse practitionersto the list of home health providers and clarified that personal careand/or support services may be referred to as nonmedical services

q Eligibility Requirements for Community-Based Palliative CareCertification: Added Note recommending that program wait toapply for this certification until it has provided these services for atleast 6–12 months

q Contracted Services: Clarified that laboratory services providedunder contract are included in the evaluation of contractuallyprovided care, treatment, and services

q Information That Is Publicly Disclosed on Request: Deletedlanguage restricting the availability of an organization’s accreditationhistory to the past seven years

q Process for Responding to a Complaint: Changed time frames forresponding to complaints from calendar days to business days

q An Organization’s Secure Joint Commission Connect™ Site: Updatedto reflect that Joint Commission Connect is the primary means ofcommunication between The Joint Commission and accreditedorganizations

q Accreditation Contract and Business Associate Agreement: Deletedlanguage about contracts’ availability (via the extranet) for printing/approval and governmental organizations’ ability to enter intounique contracts with The Joint Commission

q Annual and Survey Fees: Updated to reflect that failure to payoverdue amounts will result in a loss of accreditation with noopportunity for appeal or reinstatement


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q During the Survey: Incorporated language about embeddingstandards into routine operations from the now-deleted section“The On-Site Survey”

q Survey Notification (formerly “Unannounced Surveys”): Renamed,reorganized, and revised section by adding information aboutnotifying organizations of unannounced, announced, and short-notice survey events

q Survey Agenda: Changed the web address in the footnote to connectto the 2017 Survey Activity Guide

q Immediate Threat to Health or Safety: Made the following changes:n Updated time frame within which The Joint Commission will

notify CMS of an immediate threat (in deemed status scenarios)from 24 hours to 2 business days of confirming it

n Revised to reflect that resolution of an immediate threat maychange accreditation status from Preliminary Denial ofAccreditation (PDA) to a time-limited PDA and Accreditationwith Follow-Up Survey (AFS)

q Figure 3. Process flow for Immediate Threat to Health or Safety(ITHS) situations at organizations seeking reaccreditation: Deletedreferences to Contingent Accreditation and replaced “AccreditationCommittee” with “executive leadership”

q Figure 4. Survey Analysis for Evaluating Risk (SAFER) matrix:Updated matrix to include descriptors

q How Accreditation Decisions Are Made: Made the followingchanges:n Revised to reflect that organizations recommended for a PDA02

decision are required to submit a Plan of Correction (instead ofan ESC) within 10 business days and to have a validation surveywithin 60 days

n Updated to reflect that resolution of an Immediate Threat toHealth or Safety situation may result in a change from PDA toAFS


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q The Accreditation Decision Process: Added bullet point stating thatorganizations recommended for a PDA02 decision are required tosubmit a Plan of Correction (instead of an ESC) within 10 businessdays and to have a validation survey within 60 days

q Central Office Review of Summary Reports: Deleted section toeliminate redundancy of content

q Decision Categories for Organizations Seeking AccreditationRenewal:n Streamlined description of AFSn Deleted Contingent Accreditation and noted that there are now

four possible categories for reaccreditation surveysq Figure 5. Continuum of survey activity outcomes for organizations

seeking renewal of accreditation: Deleted Contingent Accreditationq Decision Outcomes for Organizations Seeking Initial Accreditation:

Clarified that organizations found out of compliance with JointCommission requirements during their initial survey mayvoluntarily withdraw from the accreditation process with nodecision rendered if they have not yet submitted their ESC in theallotted time

q Figure 6. SAFER matrix placement and required follow-upactivities: Streamlined figure for readability

q Corrective ESC: Revised to reflect that organizations recommendedfor a PDA02 decision are required to submit a Plan of Correction(instead of an ESC) within 10 business days and to have a validationsurvey within 60 days

q The Process for Accreditation with Follow-up Survey, ContingentAccreditation, or Preliminary Denial of Accreditation: Deletedsection to eliminate obsolete and redundant content

q Figure 7. Process flow for a Preliminary Denial of Accreditation(PDA) decision: Deleted figure


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q Figure 8. Process flow for a Contingent Accreditation (CONT)decision: Deleted figure

q Focused Standards Assessment (FSA): Clarified content and updatedto reflect that the FSA tool now includes the SAFER methodology

q Clarification Validation Survey (CVS): Deleted sectionq On-site Follow-up Survey for a Condition-level Deficiency:

Clarified that these surveys occur according to CMS regulationsq Decision Rules for Organizations Seeking Initial Accreditation:

Moved section and reordered the decision rule categoriesq Decision Rules for Organizations Seeking Reaccreditation: Made the

following changes:n Moved section and reordered the decision rule categoriesn Revised decision rule AFS10 to reflect that surveyors no longer

evaluate the Plan for Improvementn Added AFS11 on Immediate Threat to Health and Safety

abatement surveys and AFS12 on fraud and abusen Eliminated Contingent Accreditation decision rule categoryn Replaced former decision rule PDA06 regarding Contingent

Accreditation with new PDA06 regarding organizations with anAFS decision that fail to resolve all RFIs after two opportunitiesto submit ESCs

n Added PDA09 for deemed-status organizations that fail theirsecond Medicare follow-up survey as a result of a one or moreConditions of Participation scored as a Condition-leveldeficiency

n Added PDA10 for organizations with patients at risk due topossible fraud or abuse


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n Removed failure to resolve Contingent Accreditation status as acause for Denial of Accreditation (DA) decision rule DA02

n Added failure to submit a Plan of Correction as a cause fordecision rule DA04

n Added DA05 regarding organizations in the sustainingimprovement program that fail to participate in JointCommission intervention

q Process for Organizations That Meet Decision Rule PDA02: Madethe following changes:n Renamed section (formerly titled “Preliminary Denial of

Accreditation Due to Patterns, Trends, or Repeat Findings”)n Relocated section (formerly included as part of “The Process for

Accreditation with Follow-up Survey, Contingent Accreditation,or Preliminary Denial of Accreditation” section)

n Revised to reflect the new process for organizations that receive aPDA02 decision (including the required submission of a Plan ofCorrection within 10 business days followed by a validationsurvey within 60 calendar days)

n Added new Figure 7. PDA02 decision process flowq Process for Organizations That Meet Decision Rule PDA04: Made

the following changes:n Renamed section (formerly titled “Preliminary Denial of

Accreditation for Organizations Without Proper License,Certificate, or Permit”)

n Relocated section (formerly included as part of “The Process forAccreditation with Follow-up Survey, Contingent Accreditation,or Preliminary Denial of Accreditation” section)

n Streamlined content and removed reference to ContingentAccreditation

q Review and Appeal Procedures: Made the following changes:n Deleted former Figure 9. Process flow for the appeal of a

Preliminary Denial of Accreditation decision


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n Deleted several sections to reflect elimination of ContingentAccreditation decision category and streamlined content toeliminate redundancies

q Minor editorial revisionsSentinelSentinel EventsEvents (SE)(SE)q Removed “near miss” throughout chapter, in deference to the more

accurate term “close call”q Clarified throughout chapter that action plans must be correctiveq Updated references to “Board of Commissioners” and

“Accreditation Committee” with “executive leadership” throughoutthe chapter to align with the current process at The JointCommission


q Definition of Sentinel Event:n Expanded footnote concerning an unintended foreign object to

define the term “after surgery”n Added language to distinguish patient safety events from sentinel

events and added a reference to the “Patient Safety Systems”(PSS) chapter

q Oversight of the Sentinel Policy: Deleted reference to aggregatingde-identified data; changed “Sentinel Event Hotline” to "Office ofQuality and Patient Safety”

q Survey Process:n Added language to clarify that surveyors are not authorized to

review root cause analysis documents and determine credibility,thoroughness, or acceptability

n Specified that surveyors can only apply the related standards andelements of performance to assess performance improvementpractices

n Added specific standards referencesq Appendix: LD.04.04.05, EP 3: Minor editorial revisionq Minor editorial revisions throughout chapter


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TheThe JointJoint CommissionCommission QualityQuality ReportReport (QR)(QR)q What Will My Quality Report Contain?: Revised the title of Figure

1 to “Legend of National Patient Safety Goal Quality IndicatorSymbols” and updated cross-references

q Minor editorial revisions


RequiredRequired WrittenWritten DocumentationDocumentation (RWD)(RWD)q Revised tables to reflect changes in the standards Effective

July 1, 2017EarlyEarly SurveySurvey PolicyPolicy (ESP)(ESP)q Revised tables to reflect changes in the standards Effective

July 1, 2017Community-BasedCommunity-Based PalliativePalliative CareCare (CBPC)(CBPC)q No changesAppendixAppendix A:A: MedicareMedicare RequirementsRequirements forfor HospiceHospiceq Updated requirements to align with the 2012 edition of the Life

Safety Code.EffectiveJuly 1, 2017

GlossaryGlossaryq Revised the following terms:

n accreditation decisionsn appeal processn Evidence of Standards Compliance (ESC) reportn Focused Standards Assessment (FSA)n Plan of Action (POA)n Review Hearing Paneln Requirement for Improvement (RFI)n SAFER matrix



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2017 ComprehensiveComprehensive Accreditation ... · q Table 1. Acronyms Used in This Manual: ... EP 1: Added new Note 1 ... ComprehensiveComprehensive Accreditation Accreditation