Focused Standards Assessment (FSA) Risk-Icon Standards Behavioral Health Care (January 2013 Standards Edition)

Transcription

1 The Focused Standards Assessment (FSA) tool uses the risk icon to identify a) National Patient Safety Goals (NPSGs), b) Standards related to Joint Commission identified risk areas, c) Selected direct and indirect impact standards, and d) Current accreditation cycle survey Requirements for Improvement (RFIs). Within the FSA tool, the standards identified with the risk icon constitute the minimum subset of standards required for a Full FSA submission. The following table lists those standards associated with the first three groupings noted above. National Patient Safety Goals National Patient Safety Goal NPSG Use at least two identifiers when providing care, treatment, or services. Note: Treatments covered by this goal include high-risk interventions and certain high risk medications (for example, methadone). In some settings, use of visual recognition as an identifier is acceptable. Such settings include those that regularly serve an individual (for example, therapy) or serve only a few individuals (for example, a group home). These are settings in which the individual stays for an extended period of time, staff and populations served are stable, and individuals receiving care are well-known to staff. National Patient Safety Goal NPSG Maintain and communicate accurate medication information for the individual served. National Patient Safety Goal NPSG Comply with either the current Centers for Disease Control and Prevention (CDC) hand hygiene guidelines or the current World Health Organization (WHO) hand hygiene guidelines. Note: This standard applies only to organizations that provide physical care. National Patient Safety Goal NPSG Identify individuals at risk for suicide. The Joint Commission Page 1 of 7

2 Joint Commission Identified Risk Areas Harmful to Self or Others Screening CTS The organization has a screening procedure for the early detection of risk of imminent harm to self or others. Screening and Assessment CTS The organization performs screenings and assessments as defined by the organization's policy. Abuse, Neglect, Exploitation and Trauma; Family/Guardian Engagement; Screening and Assessment CTS The organization collects assessment data on each individual served. Abuse, Neglect, Exploitation and Trauma CTS The organization indentifies individuals served who may have experienced trauma, abuse, neglect, or exploitation. Family/Guardian Engagement CTS For organizations providing care, treatment, or services to a child or youth: The organization facilitates and coordinates family or guardian involvement throughout the assessment process. Screening and Assessment CTS For organizations providing care, treatment, or services to individuals with addictions: The assessment includes the individual's history of addictive behaviors. Medication MM The organization plans its medication management processes. Note: This standard is applicable to organizations that engage in any of the medication management processes. Medication MM The organization safely manages high-alert medications. Note: This standard is applicable to organizations that engage in any of the medication management processes. Medication MM The organization monitors the use of psychotropic medications. Medication MM The organization addresses the safe use of look-alike/sound-alike medications. Medication MM The organization selects and procures medications. Note: This standard is applicable only to organizations that operate a pharmacy. The Joint Commission Page 2 of 7

3 Medication MM The organization safely stores medications. Note: This standard is applicable only to organizations that store medications at their sites. Medication MM The organization safely manages emergency medications and supplies. Medication MM The organization safely controls medications brought into the organization by individuals served, their families, or prescribers. Note: This standard is applicable only to organizations in which staff administer medications or self-administration of medications is allowed within the organization s facilities. Medication MM Medication orders are clear and accurate. Note: This standard is applicable only to organizations that prescribe medications. The elements of performance in this standard do not apply to prescriptions written by a prescriber who is not affiliated with the organization. Medication MM The organization reviews the appropriateness of all medication orders for medications to be dispensed in the organization. Note: This standard is applicable only to organizations that operate a pharmacy. Medication MM The organization safely prepares medications for administration. Note: This standard is applicable only to organizations that prepare medications for administration. Medication MM Medications are labeled. Note: This standard is applicable only to organizations that dispense or administer medications. Medication MM The organization safely dispenses medications. Note: This standard is applicable only to organizations that operate a pharmacy. Medication MM The organization safely obtains medications when the pharmacy is closed. Note: This standard is applicable only to organizations that operate a pharmacy. Medication MM For organizations that do not operate a pharmacy but administer medications: The organization safely obtains prescribed medications. Medication MM Organizations that operate a pharmacy or distribute sample medications follow a process to retrieve recalled or discontinued medications. The Joint Commission Page 3 of 7

4 Medication MM The organization safely manages unused, expired, or returned medications. Note: This standard is applicable only to organizations that administer medications. Medication MM The organization safely administers medications. Note: This standard is applicable only to organizations that administer medications. Medication MM Self-administered medications are administered safely and accurately. Note: The term self-administered medication(s) may refer to medications administered by a family member. Medication MM The organization safely manages investigational medications. Note 1: This standard is applicable only to organizations that use investigational medications. Note 2: Refer to the Glossary for the definition of investigational medications. Medication MM The organization monitors individuals served to determine the effects of their medication(s). Note: This standard is applicable only to organizations that prescribe or administer medications. Medication MM The organization responds to actual or potential adverse medication events, significant adverse medication reactions, and medication errors. Note 1: This standard is applicable only to organizations that prescribe or administer medications. Note 2: See the Glossary for definitions of "adverse medication event" and "significant adverse medication reaction." Medication MM The organization evaluates the effectiveness of its medication management system. Note 1: This evaluation includes reconciling medication information. (Refer to NPSG for more information) Note 2: This standard is applicable only to organizations that prescribe, dispense, or administer medications. Abuse, Neglect, Exploitation and Trauma RI The individual served has the right to be free from neglect; exploitation; and verbal, mental, physical, and sexual abuse. The Joint Commission Page 4 of 7

5 Direct / Indirect Impact Standards Direct / Indirect Impact CTS For foster and/or respite care: The agency develops criteria to match a foster or respite home to an individual. Direct / Indirect Impact CTS The organization has a plan for care, treatment, or services that reflects the assessed needs, strengths, preferences, and goals of the individual served. Direct / Indirect Impact CTS The organization coordinates the care, treatment, or services provided to an individual served as part of the plan for care, treatment, or services and in a manner consistent with the organization's scope of care, treatment, or services. Direct / Indirect Impact CTS The individual served receives education and training specific to the individual's needs and abilities consistent with the care, treatment, or services provided. Note: This standard does not apply to academic education. Direct / Indirect Impact CTS For organizations providing care, treatment, or services to individuals with intellectual and developmental disabilities: The organization provides for the health maintenance of all individuals with intellectual and developmental disabilities, including early detection and remediation of health needs. Direct / Indirect Impact CTS For respite care: The respite caregiver receives information needed to meet the needs of the individual placed in his or her care. Direct / Indirect Impact CTS For organizations that conduct outdoor/wilderness experiences: The organization safely conducts outdoor/wilderness experiences. Note: This standard refers to an activity conducted for therapeutic reasons in remote areas away from the organization s premises (for example, a wilderness experience). It does not refer to daily activities that may be conducted outside, such as going to community parks, participating in park district activities, and visiting the zoo. Direct / Indirect Impact CTS For organizations providing food services: The organization has a process for preparing and/or distributing food and nutrition products. Direct / Indirect Impact CTS For organizations that use individualized behavioral contingencies: Individuals served and, as appropriate, their families participate in selecting the individualized behavioral contingencies used for the individual. The Joint Commission Page 5 of 7

6 Direct / Indirect Impact CTS For organizations that use individualized behavioral contingencies: Each individualized behavioral contingencies plan that includes the use of aversive contingencies is reviewed and approved by both a clinical leader(s) and a person(s) external to the organization. Direct / Indirect Impact CTS For organizations that use physical holding on a child or youth: Staff are trained and competent to minimize the use of physical holding of children and youth and, when use is indicated, to use physical holding safely. Note: Requirements related to ongoing education and the continuous assessment of staff competence are addressed in the Human Resources (HR) chapter. Direct / Indirect Impact CTS For organizations that use physical holding on a child or youth: Physical holding of children and youth is used in a safe manner. Direct / Indirect Impact CTS For organizations that use physical holding on a child or youth: Physical holding is limited to emergencies in which there is an imminent risk of a child or youth physically harming himself or herself, staff, or others, and when nonphysical interventions would not be effective. Direct / Indirect Impact CTS For organizations that use restraint or seclusion: Staff are trained and competent to minimize the use of restraint and seclusion and, when use is indicated, to use restraint or seclusion safely. Direct / Indirect Impact CTS For organizations that use restraint or seclusion: A licensed independent practitioner sees and evaluates the individual in restraint or seclusion in person. Direct / Indirect Impact CTS For organizations that use restraint or seclusion: Individuals in restraint or seclusion are regularly re-evaluated. Direct / Indirect Impact CTS For organizations that use restraint or seclusion: Individuals in restraint or seclusion are monitored. Direct / Indirect Impact EC The organization manages safety and security risks. Direct / Indirect Impact EC For foster care: The agency places individuals in foster care in physically safe environments. Note: This standard applies to foster care agencies that make placement decisions. The Joint Commission Page 6 of 7

7 Direct / Indirect Impact EC The organization manages fire risks. Direct / Indirect Impact EC The organization establishes and maintains a safe, functional environment. Direct / Indirect Impact EC The organization collects information to monitor conditions in the environment. Direct / Indirect Impact EM As part of its Emergency Management Plan, the organization prepares for how it will communicate during emergencies. Direct / Indirect Impact LD The organization has an organization-wide, integrated safety program for individuals served. Direct / Indirect Impact LS The organization designs and manages the physical environment to comply with the Life Safety Code. Note: This standard applies to behavioral health care settings that provide sleeping arrangements for four or more individuals served as a required part of their care, treatment, or services. Direct / Indirect Impact LS The organization protects occupants during periods when the Life Safety Code is not met or during periods of construction. Note: This standard applies to behavioral health care settings that provide sleeping arrangements for four or more individuals served as a required part of their care, treatment, or services. Direct / Indirect Impact LS The organization maintains the integrity of the means of egress. Note: This standard applies to behavioral health care settings that provide sleeping arrangements as a required part of their care, treatment, or services and that lock doors to prohibit individuals served from leaving the building or space. Direct / Indirect Impact LS The organization maintains the integrity of the means of egress. Note 1: This standard applies to behavioral health care settings that provide sleeping arrangements for 17 or more individuals served as a required part of their care, treatment, or services. Note 2: If the organization locks doors so that individuals served are prohibited from leaving the building or space, then Standards LS through LS apply. The Joint Commission Page 7 of 7