{"id":411592,"date":"2024-10-20T05:45:56","date_gmt":"2024-10-20T05:45:56","guid":{"rendered":"https:\/\/pdfstandards.shop\/product\/uncategorized\/jcr-camcah-2023\/"},"modified":"2024-10-26T10:40:09","modified_gmt":"2024-10-26T10:40:09","slug":"jcr-camcah-2023","status":"publish","type":"product","link":"https:\/\/pdfstandards.shop\/product\/publishers\/joint-commission\/jcr-camcah-2023\/","title":{"rendered":"JCR CAMCAH 2023"},"content":{"rendered":"

The 2023 Comprehensive Accreditation Manual for Critical Access Hospitals (CAMCAH) provides all the information your organization needs to understand and maintain continuous standards compliance. It features the official Joint Commission standards, elements of performance, National Patient Safety Goals\u00ae, and other accreditation requirements, including those for the optional Primary Care Medical Home certification. The CAMCAH is spiral bound with color-coded tabs that allow you to find exactly what you need. Please note: The CAMCAH is published annually. It is not updated throughout the year. The most up-to-date standards throughout 2023 are available electronically through E-dition\u00ae, found on your Joint Commission Connect\u00ae extranet site, or are available for purchase. Not sure if your organization is a critical access hospital? A critical access hospital is defined by the Centers for Medicare & Medicaid Services as a hospital that offers limited services and is located more than 35 miles from a hospital or another critical access hospital or is certified by the state as being a necessary provider of health care services to residents in the area. It maintains no more than 25 beds that could be used for inpatient care. This manual won\u2019t apply unless you meet those criteria. Key Topics: \u201cGold tab\u201d standards requirements including the standards, National Patient Safety Goals\u00ae, and Accreditation Participation Requirements effective January 1, 2023 \u201cBlue tab\u201d accreditation process information about Joint Commission policies and procedures and practical survey preparation information on the Early Survey Policy, documentation requirements, and more Keys to successfully using the manual for survey preparedness Standards: All critical access hospital standards Setting: Critical access hospitals Key Audience: Staff responsible for accreditation, patient safety, or quality improvement in critical access hospitals or the distinct part psychiatric and\/or rehabilitation distinct part units within a critical access hospital.<\/p>\n

PDF Catalog<\/h4>\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n
PDF Pages<\/th>\nPDF Title<\/th>\n<\/tr>\n
1<\/td>\nWhat\u2019s New 2023 CAMCAH <\/td>\n<\/tr>\n
15<\/td>\nCover <\/td>\n<\/tr>\n
16<\/td>\nCopyright <\/td>\n<\/tr>\n
17<\/td>\nContents <\/td>\n<\/tr>\n
19<\/td>\nIntroduction: How Joint Commission Accreditation Can Help on the Road to High Reliability (INTRO) <\/td>\n<\/tr>\n
20<\/td>\nI. Introduction to Joint Commission Accreditation
The Value of Joint Commission Accreditation <\/td>\n<\/tr>\n
22<\/td>\nThe Joint Commission\u2019s Critical Access Hospital Accreditation Program <\/td>\n<\/tr>\n
23<\/td>\nII. About the <\/td>\n<\/tr>\n
24<\/td>\nHow Is This Manual Organized?
Table 1. Acronyms Used in This Manual <\/td>\n<\/tr>\n
25<\/td>\nTable 1. <\/td>\n<\/tr>\n
27<\/td>\nAccreditation Requirements <\/td>\n<\/tr>\n
29<\/td>\nAccreditation Process Information <\/td>\n<\/tr>\n
31<\/td>\nIdentifying Applicable Standards <\/td>\n<\/tr>\n
33<\/td>\nUnderstanding the Organization of the Standards Chapters <\/td>\n<\/tr>\n
36<\/td>\nUnderstanding the Icons Used in the Manual <\/td>\n<\/tr>\n
37<\/td>\nIII. Steps to Achieving and Maintaining Compliance
Become Familiar with the Standards
Use the Standards to Improve Care, Treatment, and Services <\/td>\n<\/tr>\n
38<\/td>\nAssess Compliance with the Standards <\/td>\n<\/tr>\n
40<\/td>\nStimulate Improvement <\/td>\n<\/tr>\n
43<\/td>\nKeep Current with Standards Changes via Perspectives <\/td>\n<\/tr>\n
44<\/td>\nIV. Get Extra Help
Getting Started with Accreditation
Account Executive <\/td>\n<\/tr>\n
45<\/td>\nContacting The Joint Commission
Standards Questions
Requesting Permission to Share Content from the Manual <\/td>\n<\/tr>\n
47<\/td>\nPatient Safety Systems (PS)
Quality and Safety in Health Care
Sidebar 1. Key Terms <\/td>\n<\/tr>\n
48<\/td>\nSidebar 1. <\/td>\n<\/tr>\n
49<\/td>\nGoals of This Chapter <\/td>\n<\/tr>\n
50<\/td>\nBecoming a Learning Organization <\/td>\n<\/tr>\n
51<\/td>\nThe Role of Leaders in Patient Safety
Safety Culture <\/td>\n<\/tr>\n
55<\/td>\nSidebar 2. Assessing Staff Accountability <\/td>\n<\/tr>\n
56<\/td>\nSidebar 2.
Data Use and Reporting Systems <\/td>\n<\/tr>\n
57<\/td>\nEffective Use of Data <\/td>\n<\/tr>\n
59<\/td>\nTable 1. Defining and Comparing Analytical Tools <\/td>\n<\/tr>\n
60<\/td>\nA Proactive Approach to Preventing Harm <\/td>\n<\/tr>\n
62<\/td>\nSidebar 3. Strategies for an Effective Risk Assessment <\/td>\n<\/tr>\n
63<\/td>\nSidebar 3.
Encouraging Patient Activation <\/td>\n<\/tr>\n
64<\/td>\nBeyond Accreditation: The Joint Commission Is Your Patient Safety Partner <\/td>\n<\/tr>\n
66<\/td>\nReferences <\/td>\n<\/tr>\n
69<\/td>\nAccreditation Participation Requirements (APR)
Overview <\/td>\n<\/tr>\n
70<\/td>\nChapter Outline <\/td>\n<\/tr>\n
71<\/td>\nRequirements, Rationales, and Elements of Performance
APR.01.01.01
Elements of Performance for APR.01.01.01
APR.01.02.01 <\/td>\n<\/tr>\n
72<\/td>\nRationale 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 <\/td>\n<\/tr>\n
73<\/td>\nAPR.02.01.01
Elements of Performance for APR.02.01.01
APR.04.01.01
Elements of Performance for APR.04.01.01 <\/td>\n<\/tr>\n
74<\/td>\nAPR.05.01.01 <\/td>\n<\/tr>\n
75<\/td>\nRationale 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
APR.07.01.01
Elements of Performance for APR.07.01.01 <\/td>\n<\/tr>\n
76<\/td>\nAPR.08.01.01
Elements of Performance for APR.08.01.01
APR.09.01.01
Elements of Performance for APR.09.01.01
APR.09.02.01 <\/td>\n<\/tr>\n
77<\/td>\nRationale for APR.09.02.01
Elements of Performance for APR.09.02.01
APR.09.03.01
Elements of Performance for APR.09.03.01
APR.09.04.01 <\/td>\n<\/tr>\n
78<\/td>\nElements of Performance for APR.09.04.01 <\/td>\n<\/tr>\n
79<\/td>\nEnvironment of Care (EC)
Overview
About This Chapter <\/td>\n<\/tr>\n
80<\/td>\nOther Issues for Consideration <\/td>\n<\/tr>\n
82<\/td>\nChapter Outline <\/td>\n<\/tr>\n
83<\/td>\nStandards, Rationales, and Elements of Performance
Standard EC.01.01.01
Rationale for EC.01.01.01 <\/td>\n<\/tr>\n
84<\/td>\nElements of Performance for EC.01.01.01
Standard EC.02.01.01
Rationale for EC.02.01.01 <\/td>\n<\/tr>\n
85<\/td>\nElements of Performance for EC.02.01.01 <\/td>\n<\/tr>\n
86<\/td>\nStandard EC.02.01.03
Elements of Performance for EC.02.01.03 <\/td>\n<\/tr>\n
87<\/td>\nStandard EC.02.02.01
Elements of Performance for EC.02.02.01 <\/td>\n<\/tr>\n
89<\/td>\nStandard EC.02.03.01
Elements of Performance for EC.02.03.01 <\/td>\n<\/tr>\n
90<\/td>\nStandard EC.02.03.03
Elements of Performance for EC.02.03.03 <\/td>\n<\/tr>\n
92<\/td>\nStandard EC.02.03.05
Elements of Performance for EC.02.03.05 <\/td>\n<\/tr>\n
96<\/td>\nStandard EC.02.04.01
Elements of Performance for EC.02.04.01 <\/td>\n<\/tr>\n
98<\/td>\nStandard EC.02.04.03 <\/td>\n<\/tr>\n
99<\/td>\nElements of Performance for EC.02.04.03 <\/td>\n<\/tr>\n
105<\/td>\nStandard EC.02.05.01
Elements of Performance for EC.02.05.01 <\/td>\n<\/tr>\n
110<\/td>\nStandard EC.02.05.02 <\/td>\n<\/tr>\n
111<\/td>\nElements of Performance for EC.02.05.02 <\/td>\n<\/tr>\n
112<\/td>\nStandard EC.02.05.03
Elements of Performance for EC.02.05.03 <\/td>\n<\/tr>\n
115<\/td>\nStandard EC.02.05.05
Elements of Performance for EC.02.05.05 <\/td>\n<\/tr>\n
116<\/td>\nStandard EC.02.05.07 <\/td>\n<\/tr>\n
117<\/td>\nRationale for EC.02.05.07
Elements of Performance for EC.02.05.07 <\/td>\n<\/tr>\n
119<\/td>\nStandard EC.02.05.09
Elements of Performance for EC.02.05.09 <\/td>\n<\/tr>\n
123<\/td>\nIntroduction to Standard EC.02.06.01
Standard EC.02.06.01
Elements of Performance for EC.02.06.01 <\/td>\n<\/tr>\n
124<\/td>\nStandard EC.02.06.05
Elements of Performance for EC.02.06.05 <\/td>\n<\/tr>\n
125<\/td>\nStandard EC.03.01.01
Rationale for EC.03.01.01 <\/td>\n<\/tr>\n
126<\/td>\nElements of Performance for EC.03.01.01
Standard EC.04.01.01
Elements of Performance for EC.04.01.01 <\/td>\n<\/tr>\n
127<\/td>\nStandard 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 <\/td>\n<\/tr>\n
129<\/td>\nEmergency Management (EM)
Overview
About This Chapter <\/td>\n<\/tr>\n
131<\/td>\nChapter Outline <\/td>\n<\/tr>\n
132<\/td>\nStandards, Rationales, and Elements of Performance
Introduction to the Emergency Management Program, Standard EM.09.01.01
Standard EM.09.01.01 <\/td>\n<\/tr>\n
133<\/td>\nRationale for EM.09.01.01
Elements of Performance for EM.09.01.01 <\/td>\n<\/tr>\n
134<\/td>\nIntroduction to Leadership, Standard EM.10.01.01
Standard EM.10.01.01
Rationale for EM.10.01.01 <\/td>\n<\/tr>\n
135<\/td>\nElements of Performance for EM.10.01.01 <\/td>\n<\/tr>\n
137<\/td>\nIntroduction to Hazard Vulnerability Analysis (HVA), Standard EM.11.01.01
Standard EM.11.01.01
Rationale for EM.11.01.01 <\/td>\n<\/tr>\n
138<\/td>\nElements of Performance for EM.11.01.01 <\/td>\n<\/tr>\n
139<\/td>\nIntroduction to the Emergency Operations Plan, Standard EM.12.01.01 <\/td>\n<\/tr>\n
140<\/td>\nStandard EM.12.01.01
Rationale for EM.12.01.01
Elements of Performance for EM.12.01.01 <\/td>\n<\/tr>\n
143<\/td>\nIntroduction to Communications, Standard EM.12.02.01
Standard EM.12.02.01
Rationale for EM.12.02.01 <\/td>\n<\/tr>\n
144<\/td>\nElements of Performance for EM.12.02.01 <\/td>\n<\/tr>\n
146<\/td>\nIntroduction to Staffing, Standard EM.12.02.03
Standard EM.12.02.03 <\/td>\n<\/tr>\n
147<\/td>\nRationale for EM.12.02.03
Elements of Performance for EM.12.02.03 <\/td>\n<\/tr>\n
148<\/td>\nIntroduction to Patient Care and Clinical Support, Standard EM.12.02.05 <\/td>\n<\/tr>\n
149<\/td>\nStandard EM.12.02.05
Rationale for EM.12.02.05
Elements of Performance for EM.12.02.05
Introduction to Safety and Security, Standard EM.12.02.07 <\/td>\n<\/tr>\n
150<\/td>\nStandard EM.12.02.07
Rationale for EM.12.02.07
Elements of Performance for EM.12.02.07 <\/td>\n<\/tr>\n
151<\/td>\nIntroduction to Resources and Assets, Standard EM.12.02.09 <\/td>\n<\/tr>\n
152<\/td>\nStandard EM.12.02.09
Rationale for EM.12.02.09
Elements of Performance for EM.12.02.09 <\/td>\n<\/tr>\n
153<\/td>\nIntroduction to Utilities, Standard EM.12.02.11 <\/td>\n<\/tr>\n
154<\/td>\nStandard EM.12.02.11
Rationale for EM.12.02.11
Elements of Performance for EM.12.02.11 <\/td>\n<\/tr>\n
155<\/td>\nIntroduction to the Continuity of Operations Plan (COOP), Standard EM.13.01.01 <\/td>\n<\/tr>\n
156<\/td>\nStandard EM.13.01.01
Rationale for EM.13.01.01
Elements of Performance for EM.13.01.01 <\/td>\n<\/tr>\n
157<\/td>\nIntroduction to Disaster Recovery, Standard EM.14.01.01 <\/td>\n<\/tr>\n
158<\/td>\nStandard EM.14.01.01
Rationale for EM.14.01.01
Elements of Performance for EM.14.01.01 <\/td>\n<\/tr>\n
159<\/td>\nIntroduction to Education and Training, Standard EM.15.01.01
Standard EM.15.01.01 <\/td>\n<\/tr>\n
160<\/td>\nRationale for EM.15.01.01
Elements of Performance for EM.15.01.01 <\/td>\n<\/tr>\n
161<\/td>\nIntroduction to Exercises and Testing, Standard EM.16.01.01 <\/td>\n<\/tr>\n
162<\/td>\nStandard EM.16.01.01
Rationale for EM.16.01.01
Elements of Performance for EM.16.01.01 <\/td>\n<\/tr>\n
164<\/td>\nIntroduction to Evaluation, Standard EM.17.01.01
Standard EM.17.01.01
Rationale for EM.17.01.01
Elements of Performance for EM.17.01.01 <\/td>\n<\/tr>\n
167<\/td>\nHuman Resources (HR)
Overview
About This Chapter <\/td>\n<\/tr>\n
168<\/td>\nChapter Outline <\/td>\n<\/tr>\n
169<\/td>\nStandards, Rationales, and Elements of Performance
Standard HR.01.01.01
Elements of Performance for HR.01.01.01 <\/td>\n<\/tr>\n
172<\/td>\nStandard HR.01.02.01
Elements of Performance for HR.01.02.01
Standard HR.01.02.05 <\/td>\n<\/tr>\n
173<\/td>\nElements of Performance for HR.01.02.05 <\/td>\n<\/tr>\n
175<\/td>\nStandard HR.01.02.07
Elements of Performance for HR.01.02.07
Standard HR.01.03.01
Elements of Performance for HR.01.03.01
Standard HR.01.04.01 <\/td>\n<\/tr>\n
176<\/td>\nElements of Performance for HR.01.04.01
Standard HR.01.05.03
Elements of Performance for HR.01.05.03 <\/td>\n<\/tr>\n
178<\/td>\nIntroduction to Standards HR.01.06.01 and HR.01.07.01
Standard HR.01.06.01 <\/td>\n<\/tr>\n
179<\/td>\nElements of Performance for HR.01.06.01
Standard HR.01.07.01
Elements of Performance for HR.01.07.01 <\/td>\n<\/tr>\n
181<\/td>\nInfection Prevention and Control (IC)
Overview <\/td>\n<\/tr>\n
182<\/td>\nAbout This Chapter <\/td>\n<\/tr>\n
183<\/td>\nChapter Outline <\/td>\n<\/tr>\n
184<\/td>\nStandards, Rationales, and Elements of Performance
Introduction to Standards IC.01.01.01 Through IC.01.06.01 \u2013 Planning
Standard IC.01.01.01
Elements of Performance for IC.01.01.01 <\/td>\n<\/tr>\n
185<\/td>\nStandard IC.01.02.01 <\/td>\n<\/tr>\n
186<\/td>\nElements of Performance for IC.01.02.01
Standard IC.01.03.01
Elements of Performance for IC.01.03.01
Standard IC.01.04.01 <\/td>\n<\/tr>\n
187<\/td>\nElements of Performance for IC.01.04.01
Standard IC.01.05.01
Elements of Performance for IC.01.05.01
Standard IC.01.06.01
Elements of Performance for IC.01.06.01 <\/td>\n<\/tr>\n
188<\/td>\nIntroduction to Standards IC.02.01.01 Through IC.02.04.01 \u2013 Implementation
Standard IC.02.01.01
Elements of Performance for IC.02.01.01 <\/td>\n<\/tr>\n
190<\/td>\nStandard IC.02.02.01
Rationale for IC.02.02.01 <\/td>\n<\/tr>\n
191<\/td>\nElements of Performance for IC.02.02.01
Standard IC.02.03.01 <\/td>\n<\/tr>\n
192<\/td>\nElements of Performance for IC.02.03.01
Introduction to Standard IC.02.04.01 <\/td>\n<\/tr>\n
193<\/td>\nStandard IC.02.04.01
Elements of Performance for IC.02.04.01 <\/td>\n<\/tr>\n
194<\/td>\nStandard IC.02.04.02
Rationale for IC.02.04.02
Elements of Performance for IC.02.04.02 <\/td>\n<\/tr>\n
196<\/td>\nStandard IC.02.05.01 <\/td>\n<\/tr>\n
197<\/td>\nElements of Performance for IC.02.05.01 <\/td>\n<\/tr>\n
198<\/td>\nIntroduction to Standard IC.03.01.01\u2014 Evaluation and Improvement
Standard IC.03.01.01
Elements of Performance for IC.03.01.01 <\/td>\n<\/tr>\n
199<\/td>\nInformation Management (IM)
Overview
About This Chapter <\/td>\n<\/tr>\n
200<\/td>\nChapter Outline <\/td>\n<\/tr>\n
201<\/td>\nStandards, 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 <\/td>\n<\/tr>\n
202<\/td>\nIntroduction to Standard IM.01.01.03
Standard IM.01.01.03
Elements of Performance for IM.01.01.03 <\/td>\n<\/tr>\n
203<\/td>\nIntroduction to Standard IM.02.01.01
Standard IM.02.01.01 <\/td>\n<\/tr>\n
204<\/td>\nElements of Performance for IM.02.01.01
Introduction to Standard IM.02.01.03 <\/td>\n<\/tr>\n
205<\/td>\nStandard IM.02.01.03
Elements of Performance for IM.02.01.03
Standard IM.02.02.01
Elements of Performance for IM.02.02.01 <\/td>\n<\/tr>\n
206<\/td>\nIntroduction to Standard IM.02.02.03
Standard IM.02.02.03 <\/td>\n<\/tr>\n
207<\/td>\nElements of Performance for IM.02.02.03
Standard IM.02.02.07
Rationale for IM.02.02.07 <\/td>\n<\/tr>\n
208<\/td>\nElements of Performance for IM.02.02.07 <\/td>\n<\/tr>\n
209<\/td>\nStandard IM.03.01.01
Elements of Performance for IM.03.01.01 <\/td>\n<\/tr>\n
211<\/td>\nLeadership (LD)
Overview <\/td>\n<\/tr>\n
212<\/td>\nProactive Risk Assessment <\/td>\n<\/tr>\n
213<\/td>\nAbout This Chapter <\/td>\n<\/tr>\n
215<\/td>\nChapter Outline <\/td>\n<\/tr>\n
216<\/td>\nStandards, Rationales, and Elements of Performance
Introduction to Leadership Structure, Standards LD.01.01.01 Through LD.01.05.01 <\/td>\n<\/tr>\n
217<\/td>\nStandard LD.01.01.01
Rationale for LD.01.01.01
Elements of Performance for LD.01.01.01
Standard LD.01.02.01
Rationale for LD.01.02.01
Elements of Performance for LD.01.02.01 <\/td>\n<\/tr>\n
218<\/td>\nStandard LD.01.03.01
Rationale for LD.01.03.01
Elements of Performance for LD.01.03.01 <\/td>\n<\/tr>\n
219<\/td>\nStandard LD.01.04.01
Elements of Performance for LD.01.04.01
Standard LD.01.05.01
Elements of Performance for LD.01.05.01 <\/td>\n<\/tr>\n
220<\/td>\nIntroduction to Leadership Relationships, Standards LD.02.01.01 Through LD.02.04.01
Standard LD.02.01.01
Rationale for LD.02.01.01
Elements of Performance for LD.02.01.01 <\/td>\n<\/tr>\n
221<\/td>\nStandard LD.02.02.01
Rationale for LD.02.02.01
Elements of Performance for LD.02.02.01
Introduction to Standard LD.02.04.01 <\/td>\n<\/tr>\n
222<\/td>\nStandard LD.02.04.01
Elements of Performance for LD.02.04.01 <\/td>\n<\/tr>\n
223<\/td>\nIntroduction to Critical Access Hospital Culture and System Performance Expectations, Standards LD.03.01.01 Through LD.03.06.01 <\/td>\n<\/tr>\n
225<\/td>\nStandard LD.03.01.01
Rationale for LD.03.01.01
Elements of Performance for LD.03.01.01 <\/td>\n<\/tr>\n
226<\/td>\nStandard LD.03.02.01
Rationale for LD.03.02.01
Elements of Performance for LD.03.02.01 <\/td>\n<\/tr>\n
227<\/td>\nStandard LD.03.03.01
Rationale for LD.03.03.01
Elements of Performance for LD.03.03.01
Standard LD.03.04.01 <\/td>\n<\/tr>\n
228<\/td>\nRationale 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 <\/td>\n<\/tr>\n
229<\/td>\nStandard 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.04.03.11 <\/td>\n<\/tr>\n
230<\/td>\nStandard LD.03.07.01
Elements of Performance for LD.03.07.01
Standard LD.03.08.01 <\/td>\n<\/tr>\n
231<\/td>\nElements of Performance for LD.03.08.01
Introduction to Standard LD.03.09.01
Standard LD.03.09.01 <\/td>\n<\/tr>\n
232<\/td>\nElements of Performance for LD.03.09.01 <\/td>\n<\/tr>\n
234<\/td>\nStandard LD.03.10.01
Rationale for 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 <\/td>\n<\/tr>\n
237<\/td>\nStandard LD.04.01.03
Elements of Performance for LD.04.01.03
Standard LD.04.01.05
Rationale for LD.04.01.05 <\/td>\n<\/tr>\n
238<\/td>\nElements of Performance for LD.04.01.05 <\/td>\n<\/tr>\n
239<\/td>\nStandard LD.04.01.06
Elements of Performance for LD.04.01.06
Standard LD.04.01.07
Elements of Performance for LD.04.01.07 <\/td>\n<\/tr>\n
240<\/td>\nStandard LD.04.01.10
Elements of Performance for LD.04.01.10
Standard LD.04.01.11 <\/td>\n<\/tr>\n
241<\/td>\nRationale 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 <\/td>\n<\/tr>\n
242<\/td>\nStandard LD.04.02.03
Elements of Performance for LD.04.02.03 <\/td>\n<\/tr>\n
243<\/td>\nStandard LD.04.02.05
Rationale for LD.04.02.05
Elements of Performance for LD.04.02.05
Standard LD.04.03.01
Elements of Performance for LD.04.03.01 <\/td>\n<\/tr>\n
246<\/td>\nStandard 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 <\/td>\n<\/tr>\n
247<\/td>\nStandard LD.04.03.08
Rationale for LD.04.03.08 <\/td>\n<\/tr>\n
248<\/td>\nElements of Performance for LD.04.03.08 <\/td>\n<\/tr>\n
249<\/td>\nIntroduction to Oversight of Care, Treatment, and Services Provided Through Contractual Agreement, Standard LD.04.03.09 <\/td>\n<\/tr>\n
250<\/td>\nMonitoring Contracted Services <\/td>\n<\/tr>\n
251<\/td>\nStandard LD.04.03.09
Elements of Performance for LD.04.03.09 <\/td>\n<\/tr>\n
254<\/td>\nStandard LD.04.03.11
Rationale for LD.04.03.11
Elements of Performance for LD.04.03.11
Introduction to Standard LD.04.03.13 <\/td>\n<\/tr>\n
255<\/td>\nStandard LD.04.03.13
Elements of Performance for LD.04.03.13 <\/td>\n<\/tr>\n
257<\/td>\nLife Safety (LS)
Overview
About This Chapter <\/td>\n<\/tr>\n
260<\/td>\nChapter Outline <\/td>\n<\/tr>\n
261<\/td>\nStandards, 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 <\/td>\n<\/tr>\n
263<\/td>\nStandard LS.01.02.01
Elements of Performance for LS.01.02.01 <\/td>\n<\/tr>\n
265<\/td>\nStandard LS.02.01.10
Rationale for LS.02.01.10 <\/td>\n<\/tr>\n
266<\/td>\nElements of Performance for LS.02.01.10 <\/td>\n<\/tr>\n
268<\/td>\nStandard LS.02.01.20
Rationale for LS.02.01.20 <\/td>\n<\/tr>\n
269<\/td>\nElements of Performance for LS.02.01.20 <\/td>\n<\/tr>\n
275<\/td>\nStandard LS.02.01.30 <\/td>\n<\/tr>\n
276<\/td>\nRationale for LS.02.01.30
Elements of Performance for LS.02.01.30 <\/td>\n<\/tr>\n
282<\/td>\nStandard LS.02.01.34
Elements of Performance for LS.02.01.34 <\/td>\n<\/tr>\n
283<\/td>\nStandard LS.02.01.35
Elements of Performance for LS.02.01.35 <\/td>\n<\/tr>\n
285<\/td>\nStandard LS.02.01.40
Elements of Performance for LS.02.01.40 <\/td>\n<\/tr>\n
286<\/td>\nStandard LS.02.01.50
Elements of Performance for LS.02.01.50 <\/td>\n<\/tr>\n
288<\/td>\nStandard LS.02.01.70
Elements of Performance for LS.02.01.70 <\/td>\n<\/tr>\n
290<\/td>\nStandard LS.03.01.10
Elements of Performance for LS.03.01.10 <\/td>\n<\/tr>\n
292<\/td>\nStandard LS.03.01.20 <\/td>\n<\/tr>\n
293<\/td>\nRationale for LS.03.01.20
Elements of Performance for LS.03.01.20 <\/td>\n<\/tr>\n
295<\/td>\nStandard LS.03.01.30 <\/td>\n<\/tr>\n
296<\/td>\nElements of Performance for LS.03.01.30 <\/td>\n<\/tr>\n
299<\/td>\nStandard LS.03.01.34
Elements of Performance for LS.03.01.34 <\/td>\n<\/tr>\n
301<\/td>\nStandard LS.03.01.35
Elements of Performance for LS.03.01.35 <\/td>\n<\/tr>\n
302<\/td>\nStandard LS.03.01.40 <\/td>\n<\/tr>\n
303<\/td>\nElements of Performance for LS.03.01.40
Standard LS.03.01.50 <\/td>\n<\/tr>\n
304<\/td>\nElements of Performance for LS.03.01.50 <\/td>\n<\/tr>\n
305<\/td>\nStandard LS.03.01.70 <\/td>\n<\/tr>\n
306<\/td>\nElements of Performance for LS.03.01.70 <\/td>\n<\/tr>\n
307<\/td>\nStandard LS.05.01.10
Elements of Performance for LS.05.01.10 <\/td>\n<\/tr>\n
308<\/td>\nStandard LS.05.01.20
Elements of Performance for LS.05.01.20 <\/td>\n<\/tr>\n
309<\/td>\nStandard LS.05.01.30
Elements of Performance for LS.05.01.30 <\/td>\n<\/tr>\n
310<\/td>\nStandard LS.05.01.34
Elements of Performance for LS.05.01.34 <\/td>\n<\/tr>\n
311<\/td>\nStandard LS.05.01.35
Elements of Performance for LS.05.01.35 <\/td>\n<\/tr>\n
313<\/td>\nMedication Management (MM)
Overview <\/td>\n<\/tr>\n
314<\/td>\nAbout This Chapter <\/td>\n<\/tr>\n
316<\/td>\nChapter Outline <\/td>\n<\/tr>\n
317<\/td>\nStandards, 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 <\/td>\n<\/tr>\n
318<\/td>\nRationale for MM.01.01.03
Elements of Performance for MM.01.01.03 <\/td>\n<\/tr>\n
319<\/td>\nStandard MM.01.02.01
Elements of Performance for MM.01.02.01
Standard MM.02.01.01 <\/td>\n<\/tr>\n
320<\/td>\nElements of Performance for MM.02.01.01 <\/td>\n<\/tr>\n
321<\/td>\nStandard MM.03.01.01
Rationale for MM.03.01.01
Elements of Performance for MM.03.01.01 <\/td>\n<\/tr>\n
322<\/td>\nStandard MM.03.01.03
Rationale for MM.03.01.03 <\/td>\n<\/tr>\n
323<\/td>\nElements 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 <\/td>\n<\/tr>\n
324<\/td>\nIntroduction to Standard MM.04.01.01
Standard MM.04.01.01
Elements of Performance for MM.04.01.01 <\/td>\n<\/tr>\n
326<\/td>\nStandard MM.05.01.01
Elements of Performance for MM.05.01.01 <\/td>\n<\/tr>\n
327<\/td>\nStandard MM.05.01.07 <\/td>\n<\/tr>\n
328<\/td>\nElements 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 <\/td>\n<\/tr>\n
329<\/td>\nStandard MM.05.01.11
Elements of Performance for MM.05.01.11
Standard MM.05.01.13 <\/td>\n<\/tr>\n
330<\/td>\nRationale for MM.05.01.13
Elements of Performance for MM.05.01.13
Standard MM.05.01.15
Elements of Performance for MM.05.01.15 <\/td>\n<\/tr>\n
331<\/td>\nStandard MM.05.01.17
Elements of Performance for MM.05.01.17
Standard MM.05.01.19 <\/td>\n<\/tr>\n
332<\/td>\nRationale 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 <\/td>\n<\/tr>\n
333<\/td>\nStandard MM.06.01.03
Elements of Performance for MM.06.01.03 <\/td>\n<\/tr>\n
334<\/td>\nStandard MM.06.01.05
Rationale for MM.06.01.05
Elements of Performance for MM.06.01.05 <\/td>\n<\/tr>\n
335<\/td>\nStandard MM.07.01.01
Elements of Performance for MM.07.01.01
Standard MM.07.01.03
Rationale for MM.07.01.03
Elements of Performance for MM.07.01.03 <\/td>\n<\/tr>\n
336<\/td>\nStandard MM.08.01.01
Elements of Performance for MM.08.01.01 <\/td>\n<\/tr>\n
337<\/td>\nStandard MM.09.01.01
Elements of Performance for MM.09.01.01 <\/td>\n<\/tr>\n
341<\/td>\nMedical Staff (MS)
Overview <\/td>\n<\/tr>\n
342<\/td>\nMedical Staff Structure <\/td>\n<\/tr>\n
343<\/td>\nChapter Outline <\/td>\n<\/tr>\n
344<\/td>\nStandards, Rationales, and Elements of Performance
Introduction to Standard MS.01.01.01 <\/td>\n<\/tr>\n
345<\/td>\nStandard MS.01.01.01
Elements of Performance for MS.01.01.01 <\/td>\n<\/tr>\n
349<\/td>\nStandard MS.02.01.01
Elements of Performance for MS.02.01.01 <\/td>\n<\/tr>\n
350<\/td>\nIntroduction to Standard MS.03.01.01
Management of Patient Care, Treatment, and Services
Standard MS.03.01.01
Rationale for MS.03.01.01
Elements of Performance for MS.03.01.01 <\/td>\n<\/tr>\n
352<\/td>\nStandard MS.03.01.03
Rationale for MS.03.01.03 <\/td>\n<\/tr>\n
353<\/td>\nElements of Performance for MS.03.01.03 <\/td>\n<\/tr>\n
354<\/td>\nStandard MS.05.01.01
Rationale for MS.05.01.01
Elements of Performance for MS.05.01.01 <\/td>\n<\/tr>\n
356<\/td>\nIntroduction to Standard MS.06.01.01
Credentialing and Privileging <\/td>\n<\/tr>\n
357<\/td>\nStandard MS.06.01.01
Rationale for MS.06.01.01
Elements of Performance for MS.06.01.01 <\/td>\n<\/tr>\n
358<\/td>\nIntroduction to Standard MS.06.01.03
Credentialing <\/td>\n<\/tr>\n
360<\/td>\nStandard MS.06.01.03
Rationale for MS.06.01.03
Elements of Performance for MS.06.01.03 <\/td>\n<\/tr>\n
362<\/td>\nIntroduction to Standard MS.06.01.05
Privileging
Standard MS.06.01.05
Elements of Performance for MS.06.01.05 <\/td>\n<\/tr>\n
365<\/td>\nStandard MS.06.01.07
Elements of Performance for MS.06.01.07 <\/td>\n<\/tr>\n
366<\/td>\nStandard MS.06.01.09
Elements of Performance for MS.06.01.09
Standard MS.06.01.13
Rationale for MS.06.01.13 <\/td>\n<\/tr>\n
367<\/td>\nElements of Performance for MS.06.01.13
Standard MS.07.01.01 <\/td>\n<\/tr>\n
368<\/td>\nElements of Performance for MS.07.01.01
Introduction to Standard MS.08.01.01
Focused Professional Practice Evaluation <\/td>\n<\/tr>\n
369<\/td>\nStandard MS.08.01.01
Rationale for MS.08.01.01
Elements of Performance for MS.08.01.01 <\/td>\n<\/tr>\n
370<\/td>\nIntroduction to Standard MS.08.01.03 <\/td>\n<\/tr>\n
371<\/td>\nStandard MS.08.01.03
Elements of Performance for MS.08.01.03
Standard MS.09.01.01 <\/td>\n<\/tr>\n
372<\/td>\nRationale for MS.09.01.01
Elements of Performance for MS.09.01.01
Introduction to Standard MS.13.01.01
Telemedicine <\/td>\n<\/tr>\n
373<\/td>\nStandard MS.13.01.01
Rationale for MS.13.01.01
Elements of Performance for MS.13.01.01 <\/td>\n<\/tr>\n
377<\/td>\nNational Patient Safety Goals (NPSG)
Chapter Outline
National Patient Safety Goals\u00ae
Universal Protocol for Preventing Wrong Site, Wrong Procedure, and Wrong Person Surgery\u2122 <\/td>\n<\/tr>\n
378<\/td>\nRequirements, 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 <\/td>\n<\/tr>\n
379<\/td>\nGoal 2
NPSG.02.03.01
Rationale for NPSG.02.03.01
Elements of Performance for NPSG.02.03.01 <\/td>\n<\/tr>\n
380<\/td>\nGoal 3
NPSG.03.04.01
Rationale for NPSG.03.04.01
Elements of Performance for NPSG.03.04.01 <\/td>\n<\/tr>\n
381<\/td>\nNPSG.03.05.01 <\/td>\n<\/tr>\n
382<\/td>\nRationale for NPSG.03.05.01
Elements of Performance for NPSG.03.05.01 <\/td>\n<\/tr>\n
383<\/td>\nIntroduction to Reconciling Medication Information <\/td>\n<\/tr>\n
384<\/td>\nNPSG.03.06.01
Rationale for NPSG.03.06.01 <\/td>\n<\/tr>\n
385<\/td>\nElements of Performance for NPSG.03.06.01 <\/td>\n<\/tr>\n
386<\/td>\nGoal 6
NPSG.06.01.01
Rationale for NPSG.06.01.01
Elements of Performance for NPSG.06.01.01 <\/td>\n<\/tr>\n
387<\/td>\nGoal 7
NPSG.07.01.01 <\/td>\n<\/tr>\n
388<\/td>\nRationale for NPSG.07.01.01
Elements of Performance for NPSG.07.01.01
Goal 15
NPSG.15.01.01 <\/td>\n<\/tr>\n
389<\/td>\nElements of Performance for NPSG.15.01.01 <\/td>\n<\/tr>\n
390<\/td>\nIntroduction to the Universal Protocol for Preventing Wrong Site, Wrong Procedure, and Wrong Person Surgery\u2122 <\/td>\n<\/tr>\n
391<\/td>\nUP.01.01.01
Rationale for UP.01.01.01 <\/td>\n<\/tr>\n
392<\/td>\nElements of Performance for UP.01.01.01
Introduction to UP.01.02.01 <\/td>\n<\/tr>\n
393<\/td>\nUP.01.02.01
Elements of Performance for UP.01.02.01 <\/td>\n<\/tr>\n
394<\/td>\nUP.01.03.01 <\/td>\n<\/tr>\n
395<\/td>\nRationale for UP.01.03.01
Elements of Performance for UP.01.03.01 <\/td>\n<\/tr>\n
397<\/td>\nNursing (NR)
Overview <\/td>\n<\/tr>\n
398<\/td>\nChapter Outline <\/td>\n<\/tr>\n
399<\/td>\nStandards, Rationales, and Elements of Performance
Standard NR.01.01.01
Rationale for NR.01.01.01
Elements of Performance for NR.01.01.01 <\/td>\n<\/tr>\n
400<\/td>\nStandard NR.01.02.01
Elements of Performance for NR.01.02.01
Standard NR.02.01.01
Elements of Performance for NR.02.01.01 <\/td>\n<\/tr>\n
401<\/td>\nStandard NR.02.02.01
Elements of Performance for NR.02.02.01
Standard NR.02.03.01
Elements of Performance for NR.02.03.01 <\/td>\n<\/tr>\n
403<\/td>\nProvision of Care, Treatment, and Services (PC)
Overview <\/td>\n<\/tr>\n
404<\/td>\nAbout This Chapter <\/td>\n<\/tr>\n
405<\/td>\nChapter Outline <\/td>\n<\/tr>\n
406<\/td>\nStandards, 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 <\/td>\n<\/tr>\n
407<\/td>\nStandard PC.01.02.01
Elements of Performance for PC.01.02.01 <\/td>\n<\/tr>\n
409<\/td>\nStandard PC.01.02.03
Elements of Performance for PC.01.02.03 <\/td>\n<\/tr>\n
411<\/td>\nStandard PC.01.02.05
Elements of Performance for PC.01.02.05
Introduction to Standard PC.01.02.07 <\/td>\n<\/tr>\n
412<\/td>\nStandard PC.01.02.07
Elements of Performance for PC.01.02.07 <\/td>\n<\/tr>\n
414<\/td>\nStandard PC.01.02.08
Elements of Performance for PC.01.02.08
Introduction to Standard PC.01.02.09
Standard PC.01.02.09
Elements of Performance for PC.01.02.09 <\/td>\n<\/tr>\n
415<\/td>\nIntroduction to Standard PC.01.02.13
Standard PC.01.02.13
Elements of Performance for PC.01.02.13 <\/td>\n<\/tr>\n
417<\/td>\nStandard PC.01.02.15
Elements of Performance for PC.01.02.15 <\/td>\n<\/tr>\n
419<\/td>\nIntroduction to Standard PC.01.03.01
Standard PC.01.03.01
Elements of Performance for PC.01.03.01 <\/td>\n<\/tr>\n
421<\/td>\nStandard PC.02.01.01
Elements of Performance for PC.02.01.01 <\/td>\n<\/tr>\n
422<\/td>\nStandard PC.02.01.03
Elements of Performance for PC.02.01.03 <\/td>\n<\/tr>\n
423<\/td>\nStandard PC.02.01.05
Elements of Performance for PC.02.01.05
Standard PC.02.01.09
Elements of Performance for PC.02.01.09
Standard PC.02.01.11 <\/td>\n<\/tr>\n
424<\/td>\nElements of Performance for PC.02.01.11 <\/td>\n<\/tr>\n
425<\/td>\nStandard PC.02.01.19
Rationale for PC.02.01.19
Elements of Performance for PC.02.01.19
Standard PC.02.01.20
Elements of Performance for PC.02.01.20 <\/td>\n<\/tr>\n
426<\/td>\nStandard PC.02.01.21
Elements of Performance for PC.02.01.21 <\/td>\n<\/tr>\n
427<\/td>\nIntroduction to Standard PC.02.02.01
Standard PC.02.02.01
Elements of Performance for PC.02.02.01 <\/td>\n<\/tr>\n
428<\/td>\nStandard PC.02.02.03
Elements of Performance for PC.02.02.03 <\/td>\n<\/tr>\n
429<\/td>\nIntroduction to Standard PC.02.03.01
Standard PC.02.03.01
Elements of Performance for PC.02.03.01 <\/td>\n<\/tr>\n
430<\/td>\nStandard PC.02.04.01 <\/td>\n<\/tr>\n
431<\/td>\nElements of Performance for PC.02.04.01
Standard PC.02.04.03
Elements of Performance for PC.02.04.03 <\/td>\n<\/tr>\n
432<\/td>\nStandard PC.02.04.05
Elements of Performance for PC.02.04.05 <\/td>\n<\/tr>\n
434<\/td>\nStandard PC.02.04.06
Elements of Performance for PC.02.04.06
Introduction to Standards PC.03.01.01 Through PC.03.01.07 <\/td>\n<\/tr>\n
435<\/td>\nStandard PC.03.01.01
Elements of Performance for PC.03.01.01 <\/td>\n<\/tr>\n
437<\/td>\nStandard PC.03.01.03
Elements of Performance for PC.03.01.03 <\/td>\n<\/tr>\n
438<\/td>\nStandard PC.03.01.05
Elements of Performance for PC.03.01.05
Standard PC.03.01.07
Elements of Performance for PC.03.01.07 <\/td>\n<\/tr>\n
439<\/td>\nStandard PC.03.01.08
Elements of Performance for PC.03.01.08
Standard PC.03.05.01
Elements of Performance for PC.03.05.01 <\/td>\n<\/tr>\n
440<\/td>\nStandard PC.03.05.03
Elements of Performance for PC.03.05.03
Standard PC.03.05.05
Elements of Performance for PC.03.05.05 <\/td>\n<\/tr>\n
441<\/td>\nStandard PC.03.05.07
Elements of Performance for PC.03.05.07 <\/td>\n<\/tr>\n
442<\/td>\nStandard PC.03.05.09
Elements of Performance for PC.03.05.09 <\/td>\n<\/tr>\n
443<\/td>\nStandard PC.03.05.11
Elements of Performance for PC.03.05.11 <\/td>\n<\/tr>\n
444<\/td>\nStandard PC.03.05.13
Elements of Performance for PC.03.05.13
Standard PC.03.05.15
Elements of Performance for PC.03.05.15 <\/td>\n<\/tr>\n
445<\/td>\nStandard PC.03.05.17
Elements of Performance for PC.03.05.17 <\/td>\n<\/tr>\n
446<\/td>\nStandard PC.03.05.19
Elements of Performance for PC.03.05.19 <\/td>\n<\/tr>\n
447<\/td>\nStandard PC.04.01.01 <\/td>\n<\/tr>\n
448<\/td>\nElements of Performance for PC.04.01.01 <\/td>\n<\/tr>\n
449<\/td>\nStandard PC.04.01.03
Elements of Performance for PC.04.01.03 <\/td>\n<\/tr>\n
451<\/td>\nStandard PC.04.01.05
Elements of Performance for PC.04.01.05 <\/td>\n<\/tr>\n
452<\/td>\nStandard PC.04.01.07
Elements of Performance for PC.04.01.07 <\/td>\n<\/tr>\n
453<\/td>\nStandard PC.04.02.01
Elements of Performance for PC.04.02.01
Standard PC.05.01.09 <\/td>\n<\/tr>\n
454<\/td>\nElements of Performance for PC.05.01.09 <\/td>\n<\/tr>\n
455<\/td>\nPerformance Improvement (PI)
Overview
About This Chapter <\/td>\n<\/tr>\n
457<\/td>\nChapter Outline <\/td>\n<\/tr>\n
458<\/td>\nStandards, 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 <\/td>\n<\/tr>\n
460<\/td>\nStandard PI.02.01.01
Rationale for PI.02.01.01 <\/td>\n<\/tr>\n
461<\/td>\nElements of Performance for PI.02.01.01
Introduction to Standard PI.03.01.01 <\/td>\n<\/tr>\n
462<\/td>\nStandard PI.03.01.01
Elements of Performance for PI.03.01.01 <\/td>\n<\/tr>\n
463<\/td>\nStandard PI.04.01.01 <\/td>\n<\/tr>\n
464<\/td>\nRationale for PI.04.01.01
Elements of Performance for PI.04.01.01 <\/td>\n<\/tr>\n
465<\/td>\nRecord of Care, Treatment, and Services (RC)
Overview
About This Chapter <\/td>\n<\/tr>\n
466<\/td>\nChapter Outline <\/td>\n<\/tr>\n
467<\/td>\nStandards, 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 <\/td>\n<\/tr>\n
468<\/td>\nStandard RC.01.03.01
Elements of Performance for RC.01.03.01 <\/td>\n<\/tr>\n
469<\/td>\nStandard 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 <\/td>\n<\/tr>\n
472<\/td>\nStandard RC.02.01.03
Elements of Performance for RC.02.01.03 <\/td>\n<\/tr>\n
474<\/td>\nStandard RC.02.03.07
Elements of Performance for RC.02.03.07
Standard RC.02.04.01 <\/td>\n<\/tr>\n
475<\/td>\nElements of Performance for RC.02.04.01 <\/td>\n<\/tr>\n
477<\/td>\nRights and Responsibilities of the Individual (RI)
Overview
About This Chapter <\/td>\n<\/tr>\n
479<\/td>\nChapter Outline <\/td>\n<\/tr>\n
480<\/td>\nStandards, Rationales, and Elements of Performance
Introduction to Standard RI.01.01.01
Standard RI.01.01.01
Elements of Performance for RI.01.01.01 <\/td>\n<\/tr>\n
482<\/td>\nIntroduction to Standard RI.01.01.03 <\/td>\n<\/tr>\n
483<\/td>\nStandard RI.01.01.03
Elements of Performance for RI.01.01.03
Standard RI.01.02.01 <\/td>\n<\/tr>\n
484<\/td>\nElements of Performance for RI.01.02.01 <\/td>\n<\/tr>\n
485<\/td>\nStandard RI.01.03.01
Rationale for RI.01.03.01 <\/td>\n<\/tr>\n
486<\/td>\nElements of Performance for RI.01.03.01
Standard RI.01.03.05
Elements of Performance for RI.01.03.05 <\/td>\n<\/tr>\n
487<\/td>\nStandard RI.01.04.01
Elements of Performance for RI.01.04.01
Standard RI.01.04.03 <\/td>\n<\/tr>\n
488<\/td>\nElements of Performance for RI.01.04.03 <\/td>\n<\/tr>\n
489<\/td>\nStandard RI.01.05.01
Elements of Performance for RI.01.05.01 <\/td>\n<\/tr>\n
490<\/td>\nStandard RI.01.06.01
Elements of Performance for RI.01.06.01
Standard RI.01.06.03
Elements of Performance for RI.01.06.03 <\/td>\n<\/tr>\n
491<\/td>\nStandard RI.01.06.05
Elements of Performance for RI.01.06.05 <\/td>\n<\/tr>\n
492<\/td>\nStandard RI.01.06.09
Elements of Performance for RI.01.06.09
Standard RI.01.06.11 <\/td>\n<\/tr>\n
493<\/td>\nElements of Performance for RI.01.06.11
Standard RI.01.07.01
Rationale for RI.01.07.01
Elements of Performance for RI.01.07.01 <\/td>\n<\/tr>\n
494<\/td>\nStandard RI.01.07.05
Rationale for RI.01.07.05
Elements of Performance for RI.01.07.05 <\/td>\n<\/tr>\n
495<\/td>\nStandard RI.01.07.13
Elements of Performance for RI.01.07.13 <\/td>\n<\/tr>\n
497<\/td>\nTransplant Safety (TS)
Overview <\/td>\n<\/tr>\n
498<\/td>\nAbout This Chapter <\/td>\n<\/tr>\n
499<\/td>\nChapter Outline <\/td>\n<\/tr>\n
500<\/td>\nStandards, Rationales, and Elements of Performance
Introduction to Standard TS.01.01.01
Standard TS.01.01.01
Elements of Performance for TS.01.01.01 <\/td>\n<\/tr>\n
502<\/td>\nStandard TS.02.01.01
Elements of Performance for TS.02.01.01 <\/td>\n<\/tr>\n
503<\/td>\nIntroduction to Standards TS.03.01.01, TS.03.02.01, and TS.03.03.01
Examples of Tissue and Cell Products <\/td>\n<\/tr>\n
505<\/td>\nStandard TS.03.01.01
Elements of Performance for TS.03.01.01 <\/td>\n<\/tr>\n
507<\/td>\nStandard TS.03.02.01
Elements of Performance for TS.03.02.01 <\/td>\n<\/tr>\n
508<\/td>\nStandard TS.03.03.01
Elements of Performance for TS.03.03.01 <\/td>\n<\/tr>\n
509<\/td>\nWaived Testing (WT)
Overview <\/td>\n<\/tr>\n
510<\/td>\nAbout This Chapter <\/td>\n<\/tr>\n
512<\/td>\nChapter Outline <\/td>\n<\/tr>\n
513<\/td>\nStandards, Rationales, and Elements of Performance
Standard WT.01.01.01
Elements of Performance for WT.01.01.01 <\/td>\n<\/tr>\n
514<\/td>\nStandard WT.02.01.01
Elements of Performance for WT.02.01.01 <\/td>\n<\/tr>\n
515<\/td>\nStandard WT.03.01.01
Elements of Performance for WT.03.01.01 <\/td>\n<\/tr>\n
516<\/td>\nStandard WT.04.01.01
Elements of Performance for WT.04.01.01 <\/td>\n<\/tr>\n
517<\/td>\nStandard WT.05.01.01
Elements of Performance for WT.05.01.01 <\/td>\n<\/tr>\n
519<\/td>\nThe Accreditation Process (ACC)
Notices
ACC Chapter Contents <\/td>\n<\/tr>\n
521<\/td>\nOverview
General Eligibility Requirements <\/td>\n<\/tr>\n
522<\/td>\nInitial Surveys <\/td>\n<\/tr>\n
523<\/td>\nScope of Accreditation Surveys
Accreditation Policies
Tailored Survey Policy <\/td>\n<\/tr>\n
524<\/td>\nOrganizational and Functional Integration <\/td>\n<\/tr>\n
527<\/td>\nInclusion of Physician Practices in Survey
Multiorganization Option
Concurrent Survey Option <\/td>\n<\/tr>\n
528<\/td>\nContracted Services
Integrated Care Certification Option <\/td>\n<\/tr>\n
529<\/td>\nPrimary Care Medical Home Certification Option <\/td>\n<\/tr>\n
530<\/td>\nPatient Blood Management Certification Option <\/td>\n<\/tr>\n
531<\/td>\nSurvey Postponement Policy
Information Accuracy and Truthfulness Policy <\/td>\n<\/tr>\n
533<\/td>\nGood Faith Participation in Accreditation\/ Certification <\/td>\n<\/tr>\n
534<\/td>\nPublic Information Policy\u2021 <\/td>\n<\/tr>\n
535<\/td>\nProcess for Responding to a Complaint <\/td>\n<\/tr>\n
536<\/td>\nEarly Survey Policy
Sidebar 1. Early Survey Policy <\/td>\n<\/tr>\n
539<\/td>\nBefore the Survey
An Organization\u2019s Secure Joint Commission Connect Extranet Site <\/td>\n<\/tr>\n
540<\/td>\nRole of the Account Executive
Electronic Application for Accreditation (E-App) <\/td>\n<\/tr>\n
541<\/td>\nAccreditation\/Certification Contract and Business Associate Agreement <\/td>\n<\/tr>\n
542<\/td>\nAnnual and Survey Fees <\/td>\n<\/tr>\n
543<\/td>\nDuring the Survey <\/td>\n<\/tr>\n
544<\/td>\nSurvey Notification
Table 1. Exceptions to Unannounced Surveys|| <\/td>\n<\/tr>\n
546<\/td>\nInitial and Full Survey Team Composition <\/td>\n<\/tr>\n
547<\/td>\nSurvey Agenda <\/td>\n<\/tr>\n
552<\/td>\nTracer Methodology <\/td>\n<\/tr>\n
553<\/td>\nTable 2. Critical Access Hospital\u2013Specific Tracer Applicability and Objectives <\/td>\n<\/tr>\n
556<\/td>\nImmediate Threat to Health or Safety <\/td>\n<\/tr>\n
560<\/td>\nSummary of the Accreditation Reports <\/td>\n<\/tr>\n
561<\/td>\nAfter the Survey
The Scoring Process <\/td>\n<\/tr>\n
567<\/td>\nEvidence of Standards Compliance (ESC) Process <\/td>\n<\/tr>\n
570<\/td>\nAccreditation Award Display and Use <\/td>\n<\/tr>\n
572<\/td>\nRecommendation Letter for Critical Access Hospitals That Use Joint Commission Accreditation for Deemed Status Purposes
Between Accreditation Surveys
Duration of Accreditation Award <\/td>\n<\/tr>\n
573<\/td>\nContinuous Compliance
Intracycle Monitoring (ICM) <\/td>\n<\/tr>\n
574<\/td>\nFocused Standards Assessment (FSA) <\/td>\n<\/tr>\n
575<\/td>\nSidebar 2. Focused Standards Assessment (FSA) Options <\/td>\n<\/tr>\n
576<\/td>\nSidebar 2.
Sentinel Event Follow-up
Notifying The Joint Commission About Organization Changes <\/td>\n<\/tr>\n
578<\/td>\nAccreditation Status of Organizations That Cease Services After a Disaster <\/td>\n<\/tr>\n
580<\/td>\nAccreditation Status of Organizations That Cease Services or Do Not Have Patients for a Period of Time <\/td>\n<\/tr>\n
581<\/td>\nReentering the Accreditation Process <\/td>\n<\/tr>\n
582<\/td>\nAdditional Surveys <\/td>\n<\/tr>\n
584<\/td>\nDecision Rules for Organizations Seeking Initial Accreditation
Accredited <\/td>\n<\/tr>\n
585<\/td>\nPrimary Care Medical Home Certification
Limited, Temporary Accreditation <\/td>\n<\/tr>\n
586<\/td>\nEvidence of Standards Compliance (ESC)
One-Month Survey
Medicare Deficiency Follow-up Survey <\/td>\n<\/tr>\n
587<\/td>\nDenial of Accreditation <\/td>\n<\/tr>\n
588<\/td>\nDecision Rules for Organizations Seeking Reaccreditation
Accredited
Primary Care Medical Home Certification <\/td>\n<\/tr>\n
589<\/td>\nEvidence of Standards Compliance (ESC)
One-Month Survey
Medicare Deficiency Follow-up Survey <\/td>\n<\/tr>\n
590<\/td>\nAccreditation with Follow-up Survey <\/td>\n<\/tr>\n
591<\/td>\nPreliminary Denial of Accreditation <\/td>\n<\/tr>\n
592<\/td>\nDenial of Accreditation <\/td>\n<\/tr>\n
593<\/td>\nProcess for Organizations That Meet Decision Rule PDA02 for Patients Placed at Risk for Serious Adverse Outcomes Due to Signific <\/td>\n<\/tr>\n
595<\/td>\nProcess for Organizations That Meet Decision Rule PDA04 <\/td>\n<\/tr>\n
596<\/td>\nReview and Appeal Procedures
I. Evaluation by Joint Commission Staff <\/td>\n<\/tr>\n
597<\/td>\nII. Accreditation with Follow-up Survey <\/td>\n<\/tr>\n
598<\/td>\nIII. Review Hearings <\/td>\n<\/tr>\n
599<\/td>\nIV. Following a Review Hearing <\/td>\n<\/tr>\n
600<\/td>\nV. Final Review &Appeal Request <\/td>\n<\/tr>\n
603<\/td>\nStandards Applicability Grid (SAG) <\/td>\n<\/tr>\n
639<\/td>\nSentinel Event Policy (SE) <\/td>\n<\/tr>\n
640<\/td>\nGoals of the Sentinel Event Policy <\/td>\n<\/tr>\n
641<\/td>\nIdentifying Sentinel Events <\/td>\n<\/tr>\n
643<\/td>\nSidebar 1. Key Terms <\/td>\n<\/tr>\n
644<\/td>\nSidebar 1. <\/td>\n<\/tr>\n
646<\/td>\nDetermining That a Sentinel Event Is Subject to Review
Relationship to the Survey Process <\/td>\n<\/tr>\n
647<\/td>\nRequired Organization Response to a Sentinel Event <\/td>\n<\/tr>\n
649<\/td>\nReporting a Sentinel Event to The Joint Commission <\/td>\n<\/tr>\n
651<\/td>\nConducting a Comprehensive Systematic Analysis <\/td>\n<\/tr>\n
652<\/td>\nDeveloping a Corrective Action Plan <\/td>\n<\/tr>\n
653<\/td>\nSubmitting the Comprehensive Systematic Analysis and Corrective Action Plan <\/td>\n<\/tr>\n
654<\/td>\nTable 1. Options for a Joint Commission Review of an Organization\u2019s Response to a Sentinel Event <\/td>\n<\/tr>\n
655<\/td>\nTable 1. <\/td>\n<\/tr>\n
656<\/td>\nThe Joint Commission\u2019s Response
Review of Comprehensive Systematic Analyses and Corrective Action Plans <\/td>\n<\/tr>\n
657<\/td>\nFollow-up Activities <\/td>\n<\/tr>\n
659<\/td>\nDisclosable Information
Handling Sentinel Event\u2013Related Documents
The Sentinel Event Database <\/td>\n<\/tr>\n
660<\/td>\nOverseeing the Sentinel Event Policy <\/td>\n<\/tr>\n
661<\/td>\nThe Joint Commission Quality Report (QR)
Introduction
What Is The Joint Commission Quality Report? <\/td>\n<\/tr>\n
662<\/td>\nWhat Will My Quality Report Contain? <\/td>\n<\/tr>\n
663<\/td>\nWhat Is Quality Check? <\/td>\n<\/tr>\n
664<\/td>\nIs a Quality Report Available for My Accredited Critical Access Hospital?
Can My Critical Access Hospital Comment on Its Quality Report?
How Does My Critical Access Hospital Submit a Commentary?
Are There Any Criteria That Must Be Met in a Commentary? <\/td>\n<\/tr>\n
665<\/td>\nWhat Are the Marketing and Communication Guidelines for Publicizing Your Accreditation and Commitment to Quality? <\/td>\n<\/tr>\n
666<\/td>\nGuidelines for Publicizing Compliance with the National Patient Safety Goals <\/td>\n<\/tr>\n
667<\/td>\nInformation Released by The Joint Commission
Guidelines for Publication <\/td>\n<\/tr>\n
669<\/td>\nPerformance Measurement and the ORYX Initiative (PM)
Overview
The Continued Role of ORYX <\/td>\n<\/tr>\n
670<\/td>\nAccelerate PI\u2122 <\/td>\n<\/tr>\n
671<\/td>\nUse of Performance Measure Data
Current Requirements for Critical Access Hospitals <\/td>\n<\/tr>\n
673<\/td>\nRequired Written Documentation (RWD) <\/td>\n<\/tr>\n
674<\/td>\nList of EPs Requiring Written Documentation for Critical Access Hospitals by Service
Acute
Accreditation Participation Requirements (APR)
Environment of Care (EC)
Emergency Management (EM)
Human Resources (HR) <\/td>\n<\/tr>\n
675<\/td>\nInfection Prevention and Control (IC)
Information Management (IM)
Leadership (LD)
Life Safety (LS)
Medication Management (MM) <\/td>\n<\/tr>\n
676<\/td>\nMedical Staff (MS)
National Patient Safety Goals (NPSG) (including the Universal Protocol [UP])
Nursing (NR)
Provision of Care, Treatment, and Services (PC)
Performance Improvement (PI)
Record of Care, Treatment, and Services (RC) <\/td>\n<\/tr>\n
677<\/td>\nRights and Responsibilities of the Individual (RI)
Transplant Safety (TS)
Waived Testing (WT)
Inpatient Rehab Distinct Part Unit
Environment of Care (EC)
Leadership (LD)
Medication Management (MM) <\/td>\n<\/tr>\n
678<\/td>\nMedical Staff (MS)
National Patient Safety Goals (NPSG)
Provision of Care, Treatment, and Services (PC)
Record of Care, Treatment, and Services (RC)
Rights and Responsibilities of the Individual (RI)
Psychiatric Distinct Part Unit
Environment of Care (EC) <\/td>\n<\/tr>\n
679<\/td>\nLeadership (LD)
Medication Management (MM)
Medical Staff (MS)
National Patient Safety Goals (NPSG)
Provision of Care, Treatment, and Services (PC)
Record of Care, Treatment, and Services (RC)
Rights and Responsibilities of the Individual (RI) <\/td>\n<\/tr>\n
680<\/td>\nSwing Beds
Environment of Care (EC)
Human Resources (HR)
Leadership (LD)
Medication Management (MM)
National Patient Safety Goals (NPSG)
Provision of Care, Treatment, and Services (PC)
Rights and Responsibilities of the Individual (RI) <\/td>\n<\/tr>\n
681<\/td>\nEarly Survey Policy (ESP)
Accreditation Participation Requirements (APR)
Environment of Care (EC) <\/td>\n<\/tr>\n
682<\/td>\nEmergency Management (EM)
Human Resources (HR)
Infection Prevention and Control (IC)
Information Management (IM) <\/td>\n<\/tr>\n
683<\/td>\nLeadership (LD)
Life Safety (LS)
Medication Management (MM) <\/td>\n<\/tr>\n
684<\/td>\nMedical Staff (MS)
National Patient Safety Goals (NPSG)
Nursing (NR)
Provision of Care, Treatment, and Services (PC) <\/td>\n<\/tr>\n
685<\/td>\nPerformance Improvement (PI)
Record of Care, Treatment, and Services (RC)
Rights and Responsibilities of the Individual (RI)
Transplant Safety (TS)
Waived Testing (WT) <\/td>\n<\/tr>\n
687<\/td>\nPrimary Care Medical Home Certification Option (PCMH)
Overview
Primary Care Medical Home Model <\/td>\n<\/tr>\n
688<\/td>\nI. Patient-Centered Care
II. Comprehensive Care <\/td>\n<\/tr>\n
689<\/td>\nIII. Coordinated Care <\/td>\n<\/tr>\n
690<\/td>\nIV. Superb Access to Care
V. Systems-Based Approach to Quality and Safety <\/td>\n<\/tr>\n
691<\/td>\nStandards, Rationales, Elements of Performance, and Scoring Specific to the Primary Care Medical Home Certification Option
I. Patient-Centered Care
Leadership (LD)
Standard LD.03.04.01
Elements of Performance for LD.03.04.01 <\/td>\n<\/tr>\n
692<\/td>\nStandard 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 <\/td>\n<\/tr>\n
693<\/td>\nStandard LD.04.01.11
Elements of Performance for LD.04.01.11
Provision of Care, Treatment, and Services (PC)
Standard PC.01.03.01
Elements of Performance for PC.01.03.01
Standard PC.02.01.01
Elements of Performance for PC.02.01.01 <\/td>\n<\/tr>\n
694<\/td>\nStandard PC.02.01.21
Elements of Performance for PC.02.01.21
Standard PC.02.02.01
Elements of Performance for PC.02.02.01 <\/td>\n<\/tr>\n
695<\/td>\nStandard PC.02.03.01
Elements of Performance for PC.02.03.01 <\/td>\n<\/tr>\n
696<\/td>\nStandard PC.02.04.05
Elements of Performance for PC.02.04.05
Record of Care, Treatment, and Services (RC)
Standard RC.02.01.01
Elements of Performance for RC.02.01.01 <\/td>\n<\/tr>\n
697<\/td>\nRights and Responsibilities of the Individual (RI)
Standard RI.01.01.01
Elements of Performance for RI.01.01.01 <\/td>\n<\/tr>\n
699<\/td>\nStandard 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 <\/td>\n<\/tr>\n
701<\/td>\nStandard RI.01.03.01
Elements of Performance for RI.01.03.01 <\/td>\n<\/tr>\n
702<\/td>\nStandard 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 <\/td>\n<\/tr>\n
703<\/td>\nStandard RI.01.05.01
Elements of Performance for RI.01.05.01 <\/td>\n<\/tr>\n
704<\/td>\nStandard RI.01.07.01
Elements of Performance for RI.01.07.01 <\/td>\n<\/tr>\n
705<\/td>\nII. Comprehensive Care
Leadership (LD)
Standard LD.04.01.06
Elements of Performance for LD.04.01.06
Medical Staff (MS)
Standard MS.03.01.01
Elements of Performance for MS.03.01.01 <\/td>\n<\/tr>\n
706<\/td>\nProvision of Care, Treatment, and Services (PC)
Standard PC.02.01.05
Elements of Performance for PC.02.01.05
Standard PC.02.04.03
Elements of Performance for PC.02.04.03 <\/td>\n<\/tr>\n
707<\/td>\nStandard PC.02.04.05
Elements of Performance for PC.02.04.05 <\/td>\n<\/tr>\n
708<\/td>\nIII. Coordinated Care
Human Resources (HR)
Standard HR.01.02.07
Elements of Performance for HR.01.02.07
Medical Staff (MS)
Standard MS.03.01.01
Elements of Performance for MS.03.01.01
Provision of Care, Treatment, and Services (PC)
Standard PC.01.03.01 <\/td>\n<\/tr>\n
709<\/td>\nElements of Performance for PC.01.03.01
Standard PC.02.02.01
Elements of Performance for PC.02.02.01 <\/td>\n<\/tr>\n
710<\/td>\nStandard PC.02.04.03
Elements of Performance for PC.02.04.03
Standard PC.02.04.05
Elements of Performance for PC.02.04.05 <\/td>\n<\/tr>\n
711<\/td>\nStandard PC.04.01.01
Elements of Performance for PC.04.01.01
Standard PC.04.01.03
Elements of Performance for PC.04.01.03 <\/td>\n<\/tr>\n
712<\/td>\nStandard PC.04.01.05
Elements of Performance for PC.04.01.05
Standard PC.04.02.01
Elements of Performance for PC.04.02.01 <\/td>\n<\/tr>\n
713<\/td>\nRecord of Care, Treatment, and Services (RC)
Standard RC.01.01.01
Elements of Performance for RC.01.01.01 <\/td>\n<\/tr>\n
714<\/td>\nIV. Superb Access to Care
Provision of Care, Treatment, and Services (PC)
Standard PC.02.04.01
Elements of Performance for PC.02.04.01 <\/td>\n<\/tr>\n
715<\/td>\nV. Systems-Based Approach to Quality and Safety
Leadership (LD)
Standard LD.01.03.01
Elements of Performance for LD.01.03.01
Standard LD.03.04.01
Elements of Performance for LD.03.04.01 <\/td>\n<\/tr>\n
716<\/td>\nStandard 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
Standard LD.03.09.01
Elements of Performance for LD.03.09.01 <\/td>\n<\/tr>\n
718<\/td>\nStandard LD.03.10.01 <\/td>\n<\/tr>\n
719<\/td>\nElements of Performance for LD.03.10.01
Standard LD.04.01.11
Elements of Performance for LD.04.01.11
Medication Management (MM)
Standard MM.04.01.01
Elements of Performance for MM.04.01.01 <\/td>\n<\/tr>\n
720<\/td>\nProvision of Care, Treatment, and Services (PC)
Standard PC.01.03.01
Elements of Performance for PC.01.03.01
Performance Improvement (PI)
Standard PI.01.01.01
Elements of Performance for PI.01.01.01 <\/td>\n<\/tr>\n
721<\/td>\nStandard 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 <\/td>\n<\/tr>\n
723<\/td>\nAppendix A: Medicare Requirements for Critical Access Hospitals (AXA)
485.610 Condition of Participation: Status and Location <\/td>\n<\/tr>\n
724<\/td>\n485.616 Condition of Participation: Agreements <\/td>\n<\/tr>\n
727<\/td>\n485.627 Condition of Participation: Organizational Structure
485.635 Condition of Participation: Provision of Services <\/td>\n<\/tr>\n
728<\/td>\n485.641 Condition of Participation: Periodic Evaluation and Quality Assurance Review <\/td>\n<\/tr>\n
729<\/td>\nAppendix B: Medicare Requirements for Critical Access Hospitals with DPUs (AXB)
Part 409 Subpart B\u2014Inpatient Hospital Services and Inpatient Critical Access Hospital Services <\/td>\n<\/tr>\n
730<\/td>\n409.17: Physical Therapy, Occupational Therapy, and Speech-Language Pathology Services <\/td>\n<\/tr>\n
731<\/td>\n412.25 Excluded Hospital Units: Common Requirements <\/td>\n<\/tr>\n
733<\/td>\n412.29 Excluded Rehabilitation Units: Additional Requirements <\/td>\n<\/tr>\n
734<\/td>\n412.30 Exclusion of New Rehabilitation Units and Expansion of Units Already Excluded <\/td>\n<\/tr>\n
736<\/td>\n482.12 Condition of Participation: Governing Body <\/td>\n<\/tr>\n
737<\/td>\n482.22 Condition of Participation: Medical Staff <\/td>\n<\/tr>\n
739<\/td>\n482.24 Condition of Participation: Medical Record Services <\/td>\n<\/tr>\n
740<\/td>\n482.27 Condition of Participation: Laboratory Services <\/td>\n<\/tr>\n
744<\/td>\n482.30 Condition of Participation: Utilization Review <\/td>\n<\/tr>\n
747<\/td>\n482.51 Condition of Participation: Surgical Services <\/td>\n<\/tr>\n
749<\/td>\nGlossary (GL) <\/td>\n<\/tr>\n
791<\/td>\nIndex (IX) <\/td>\n<\/tr>\n<\/table>\n","protected":false},"excerpt":{"rendered":"

Comprehensive Accreditation Manual for Critical Access Hospitals (CAMCAH)<\/b><\/p>\n\n\n\n\n
Published By<\/td>\nPublication Date<\/td>\nNumber of Pages<\/td>\n<\/tr>\n
Joint Commission<\/b><\/a><\/td>\n2023<\/td>\n<\/td>\n<\/tr>\n<\/tbody>\n<\/table>\n","protected":false},"featured_media":411598,"template":"","meta":{"rank_math_lock_modified_date":false,"ep_exclude_from_search":false},"product_cat":[2851],"product_tag":[],"class_list":{"0":"post-411592","1":"product","2":"type-product","3":"status-publish","4":"has-post-thumbnail","6":"product_cat-joint-commission","8":"first","9":"instock","10":"sold-individually","11":"shipping-taxable","12":"purchasable","13":"product-type-simple"},"_links":{"self":[{"href":"https:\/\/pdfstandards.shop\/wp-json\/wp\/v2\/product\/411592","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/pdfstandards.shop\/wp-json\/wp\/v2\/product"}],"about":[{"href":"https:\/\/pdfstandards.shop\/wp-json\/wp\/v2\/types\/product"}],"wp:featuredmedia":[{"embeddable":true,"href":"https:\/\/pdfstandards.shop\/wp-json\/wp\/v2\/media\/411598"}],"wp:attachment":[{"href":"https:\/\/pdfstandards.shop\/wp-json\/wp\/v2\/media?parent=411592"}],"wp:term":[{"taxonomy":"product_cat","embeddable":true,"href":"https:\/\/pdfstandards.shop\/wp-json\/wp\/v2\/product_cat?post=411592"},{"taxonomy":"product_tag","embeddable":true,"href":"https:\/\/pdfstandards.shop\/wp-json\/wp\/v2\/product_tag?post=411592"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}