Standard Changes Related to EP Review Phase IV
|
|
- Gyles Simmons
- 5 years ago
- Views:
Transcription
1 Issued September 5, 07 Human Resources (HR) Chapter Standard Changes Related to EP Review Phase IV Hospital (HAP) Accreditation Program Standard HR The hospital defines and verifies staff qualifications. HR The hospital defines staff qualifications specific to their job responsibilities. (See also HR , EP 9; IC.0.0.0, EP ; RI.0.0.0, EP ) Note : Qualifications for infection control may be met through ongoing education, training, experience, and/or certification (such as that offered by the Certification Board for Infection Control). Note : Qualifications for laboratory personnel are described in the Clinical Laboratory Improvement Amendments of 988 (CLIA '88), under Subpart M: Personnel for Nonwaived Testing A complete description of the requirement is located at Note : For hospitals that use Joint Commission accreditation for deemed status purposes: Qualified physical therapists, physical therapist assistants, occupational therapists, occupational therapy assistants, speech-language pathologists, or audiologists (as defined in 4 CFR 484.4) provide physical therapy, occupational therapy, speech-language pathology, or audiology services, if these services are provided by the hospital. The provision of care and staff qualifications are in accordance with national acceptable standards of practice and also meet the requirements of See Appendix A for requirements. Note 4: Qualifications for language interpreters and translators may be met through language proficiency assessment, education, training, and experience. The use of qualified interpreters and translators is supported by the Americans with Disabilities Act, Section 504 of the Rehabilitation Act of 97, and Title VI of the Civil Rights Act of 964. Revision Type: Moved and Revised HR The hospital defines staff qualifications specific to their job responsibilities. (See also HR.0.0.0, EP ; IC.0.0.0, EP ; RI.0.0.0, EP ) Note : Qualifications for infection control may be met through ongoing education, training, experience, and/or certification (such as that offered by the Certification Board for Infection Control). Note : Qualifications for laboratory personnel are described in the Clinical Laboratory Improvement Amendments of 988 (CLIA '88), under Subpart M: Personnel for Nonwaived Testing A complete description of the requirement is located at Note : For hospitals that use Joint Commission accreditation for deemed status purposes: Qualified physical therapists, physical therapist assistants, occupational therapists, occupational therapy assistants, speech-language pathologists, or audiologists (as defined in 4 CFR 484.4) provide physical therapy, occupational therapy, speech-language pathology, or audiology services, if these services are provided by the hospital. The provision of care and staff qualifications are in accordance with national acceptable standards of practice and also meet the requirements of See Appendix A for requirements. Note 4: Qualifications for language interpreters and translators may be met through language proficiency assessment, education, training, and experience. The use of qualified interpreters and translators is supported by the Americans with Disabilities Act, Section 504 of the Rehabilitation Act of 97, and Title VI of the Civil Rights Act of 964. Page of 5 Tuesday, Sep The Joint Commission
2 Hospital (HAP) Accreditation Program Issued September 5, 07 HR When law or regulation requires care providers to be currently licensed, certified, or registered to practice their professions, the hospital both verifies these credentials with the primary source and documents this verification when a provider is hired and when his or her credentials are renewed. (See also HR , EP 9; HR , EP ) Note : It is acceptable to verify current licensure, certification, or registration with the primary source via a secure electronic communication or by telephone, if this verification is documented. Note : A primary verification source may designate another agency to communicate credentials information. The designated agency can then be used as a primary source. Note : An external organization (for example, a credentials verification organization [CVO]) may be used to verify credentials information. A CVO must meet the CVO guidelines identified in the Glossary. HR The hospital verifies and documents the following: - Credentials of care providers using the primary source when licensure, certification, or registration is required by law and regulation to practice their profession. This is done at the time of hire and at the time credentials are renewed. - Credentials of care providers (primary source not required) when licensure, certification, or registration is not required by law and regulation. This is done at the time of hire and at the time credentials are renewed. Note : It is acceptable to verify current licensure, certification, or registration with the primary source via a secure electronic communication or by telephone, if this verification is documented. Note : A primary verification source may designate another agency to communicate credentials information. The designated agency can then be used as a primary source. Note : An external organization (for example, a credentials verification organization [CVO]) may be used to verify credentials information. A CVO must meet the CVO guidelines identified in the Glossary. HR When the hospital requires licensure, registration, or certification not required by law and regulation, the hospital both verifies these credentials and documents this verification at time of hire and when credentials are renewed. (See also HR , EP 9; HR , EP ) HR The hospital verifies and documents the following: - Credentials of care providers using the primary source when licensure, certification, or registration is required by law and regulation to practice their profession. This is done at the time of hire and at the time credentials are renewed. - Credentials of care providers (primary source not required) when licensure, certification, or registration is not required by law and regulation. This is done at the time of hire and at the time credentials are renewed. Note : It is acceptable to verify current licensure, certification, or registration with the primary source via a secure electronic communication or by telephone, if this verification is documented. Note : A primary verification source may designate another agency to communicate credentials information. The designated agency can then be used as a primary source. Note : An external organization (for example, a credentials verification organization [CVO]) may be used to verify credentials information. A CVO must meet the CVO guidelines identified in the Glossary. Page of 5 Tuesday, Sep The Joint Commission
3 Hospital (HAP) Accreditation Program Issued September 5, 07 HR The hospital verifies and documents that the applicant has the education and experience required by the job responsibilities. (See also HR , EP 9) Revision Type: Moved and Revised HR The hospital verifies and documents that the applicant has the education and experience required by the job responsibilities. HR The hospital obtains a criminal background check on the applicant as required by law and regulation or hospital policy. Criminal background checks are documented. 4 Revision Type: Moved HR The hospital obtains a criminal background check on the applicant as required by law and regulation or hospital policy. Criminal background checks are documented. 4 HR Staff comply with applicable health screening as required by law and regulation or hospital policy. Health screening compliance is documented. 5 Revision Type: Moved HR Staff comply with applicable health screening as required by law and regulation or hospital policy. Health screening compliance is documented. 5 HR Before providing care, treatment, and services, the hospital confirms that nonemployees who are brought into the hospital by a licensed independent practitioner to provide care, treatment, or services have the same qualifications and competencies required of employed individuals performing the same or similar services at the hospital. Note : This confirmation can be accomplished either through the hospital's regular process or with the licensed independent practitioner who brought in the individual. Note : When the care, treatment, and services provided by the nonemployee are not currently performed by anyone employed by the hospital, leadership consults the appropriate professional hospital guidelines for the required credentials and competencies. 7 Revision Type: Moved HR Before providing care, treatment, and services, the hospital confirms that nonemployees who are brought into the hospital by a licensed independent practitioner to provide care, treatment, or services have the same qualifications and competencies required of employed individuals performing the same or similar services at the hospital. Note : This confirmation can be accomplished either through the hospital's regular process or with the licensed independent practitioner who brought in the individual. Note : When the care, treatment, and services provided by the nonemployee are not currently performed by anyone employed by the hospital, leadership consults the appropriate professional hospital guidelines for the required credentials and competencies. 7 Page of 5 Tuesday, Sep The Joint Commission
4 Hospital (HAP) Accreditation Program Issued September 5, 07 HR Revision Type: Moved For hospitals that use Joint Commission accreditation for deemed status purposes and have swing beds: The activities program is directed by a professional who meets one of the following criteria: - Is a qualified therapeutic recreation specialist or an activities professional who is licensed or registered, if applicable, by the state in which he or she practices and is eligible for certification as a therapeutic recreation specialist or as an activities professional by a recognized accrediting body on or after October, Has two years of experience in a social or recreational program within the last five years, one year of which was full time in a patient activities program in a health care setting - Is a qualified occupational therapist or occupational therapy assistant - Has completed a training course approved by the state HR For hospitals that use Joint Commission accreditation for deemed status purposes and have swing beds: The activities program is directed by a professional who meets one of the following criteria: - Is a qualified therapeutic recreation specialist or an activities professional who is licensed or registered, if applicable, by the state in which he or she practices and is eligible for certification as a therapeutic recreation specialist or as an activities professional by a recognized accrediting body on or after October, Has two years of experience in a social or recreational program within the last five years, one year of which was full time in a patient activities program in a health care setting - Is a qualified occupational therapist or occupational therapy assistant - Has completed a training course approved by the state HR Revision Type: Moved For hospitals that use Joint Commission accreditation for deemed status purposes and have swing beds: The facility does not employ individuals who have been found guilty by a court of law of abusing, neglecting, or mistreating residents or who have had a finding entered into the state nurse aide registry concerning abuse, neglect, or mistreatment of residents or of misappropriation of their property. HR For hospitals that use Joint Commission accreditation for deemed status purposes and have swing beds: The facility does not employ individuals who have been found guilty by a court of law of abusing, neglecting, or mistreating residents or who have had a finding entered into the state nurse aide registry concerning abuse, neglect, or mistreatment of residents or of misappropriation of their property. HR Revision Type: Moved For psychiatric hospitals that use Joint Commission accreditation for deemed status purposes: The director of psychiatric nursing is a registered nurse who has a master s degree in psychiatric or mental health nursing, or its equivalent, from a school of nursing accredited by the National League for Nursing, or is qualified by education and experience in the care of the mentally ill. The director of psychiatric nursing demonstrates competence to participate in interdisciplinary formulation of individual treatment plans; to give skilled nursing care and therapy; and to direct, monitor, and evaluate the nursing care furnished. HR For psychiatric hospitals that use Joint Commission accreditation for deemed status purposes: The director of psychiatric nursing is a registered nurse who has a master s degree in psychiatric or mental health nursing, or its equivalent, from a school of nursing accredited by the National League for Nursing, or is qualified by education and experience in the care of the mentally ill. The director of psychiatric nursing demonstrates competence to participate in interdisciplinary formulation of individual treatment plans; to give skilled nursing care and therapy; and to direct, monitor, and evaluate the nursing care furnished. Page 4 of 5 Tuesday, Sep The Joint Commission
5 Hospital (HAP) Accreditation Program Issued September 5, 07 HR Revision Type: Moved For psychiatric hospitals that use Joint Commission accreditation for deemed status purposes: The director of the social work department or service has a master s degree from an accredited school of social work or is qualified by education and experience in the social services needs of the mentally ill. Note: If the director does not hold a master s degree in social work, at least one staff member has this qualification. HR For psychiatric hospitals that use Joint Commission accreditation for deemed status purposes: The director of the social work department or service has a master s degree from an accredited school of social work or is qualified by education and experience in the social services needs of the mentally ill. Note: If the director does not hold a master s degree in social work, at least one staff member has this qualification. HR Revision Type: Moved and Revised Technologists who perform diagnostic computed tomography (CT) exams have advanced-level certification by the American Registry of Radiologic Technologists (ARRT) or the Nuclear Medicine Technology Certification Board (NMTCB) in computed tomography or have one of the following qualifications: - State licensure that permits them to perform diagnostic CT exams and documented training on the provision of diagnostic CT exams or - Registration and certification in radiography by ARRT and documented training on the provision of diagnostic CT exams or - Certification in nuclear medicine technology by ARRT or NMTCB and documented training on the provision of diagnostic CT exams (See also HR.0.0.0, EP ; HR , EPs ; HR , EPs and ) Note : This element of performance does not apply to CT exams performed for therapeutic radiation treatment planning or delivery, or for calculating attenuation coefficients for nuclear medicine studies. Note : This element of performance does not apply to dental cone beam CT radiographic imaging studies performed for diagnosis of conditions affecting the maxillofacial region or to obtain guidance for the treatment of such conditions. HR Technologists who perform diagnostic computed tomography (CT) exams have advanced-level certification by the American Registry of Radiologic Technologists (ARRT) or the Nuclear Medicine Technology Certification Board (NMTCB) in computed tomography or have one of the following qualifications: - State licensure that permits them to perform diagnostic CT exams and documented training on the provision of diagnostic CT exams or - Registration and certification in radiography by ARRT and documented training on the provision of diagnostic CT exams or - Certification in nuclear medicine technology by ARRT or NMTCB and documented training on the provision of diagnostic CT exams (See also HR.0.0.0, EP ; HR , EPs and ) Note : This element of performance does not apply to CT exams performed for therapeutic radiation treatment planning or delivery, or for calculating attenuation coefficients for nuclear medicine studies. Note : This element of performance does not apply to dental cone beam CT radiographic imaging studies performed for diagnosis of conditions affecting the maxillofacial region or to obtain guidance for the treatment of such conditions. Page 5 of 5 Tuesday, Sep The Joint Commission
6 Hospital (HAP) Accreditation Program Issued September 5, 07 HR Revision Type: Moved The hospital verifies and documents that diagnostic medical physicists who support computed tomography (CT) services have board certification in diagnostic radiologic physics or radiologic physics by the American Board of Radiology, or in Diagnostic Imaging Physics by the American Board of Medical Physics, or in Diagnostic Radiological Physics by the Canadian College of Physicists in Medicine, or meet all of the following requirements: - A graduate degree in physics, medical physics, biophysics, radiologic physics, medical health physics, or a closely related science or engineering discipline from an accredited college or university - College coursework in the biological sciences with at least one course in biology or radiation biology and one course in anatomy, physiology, or a similar topic related to the practice of medical physics - Documented experience in a clinical CT environment conducting at least 0 CT performance evaluations under the direct supervision of a board-certified medical physicist Note: This element of performance does not apply to dental cone beam CT radiographic imaging studies performed for diagnosis of conditions affecting the maxillofacial region or to obtain guidance for the treatment of such conditions. HR The hospital verifies and documents that diagnostic medical physicists who support computed tomography (CT) services have board certification in diagnostic radiologic physics or radiologic physics by the American Board of Radiology, or in Diagnostic Imaging Physics by the American Board of Medical Physics, or in Diagnostic Radiological Physics by the Canadian College of Physicists in Medicine, or meet all of the following requirements: - A graduate degree in physics, medical physics, biophysics, radiologic physics, medical health physics, or a closely related science or engineering discipline from an accredited college or university - College coursework in the biological sciences with at least one course in biology or radiation biology and one course in anatomy, physiology, or a similar topic related to the practice of medical physics - Documented experience in a clinical CT environment conducting at least 0 CT performance evaluations under the direct supervision of a board-certified medical physicist Note: This element of performance does not apply to dental cone beam CT radiographic imaging studies performed for diagnosis of conditions affecting the maxillofacial region or to obtain guidance for the treatment of such conditions. Standard HR Physician assistants and advanced practice registered nurses who practice within the hospital are credentialed, privileged, and reprivileged through the medical staff process or an equivalent process. Note: Advanced practice registered nurses who are licensed independent practitioners are credentialed and privileged only through the medical staff credentialing and privileging process. (See the "Medical Staff" [MS] chapter) HR Revision Type: Moved The equivalent process for credentialing and privileging physician assistants and advanced practice registered nurses who practice within the hospital is approved by the governing body. HR The equivalent process for credentialing and privileging physician assistants and advanced practice registered nurses who practice within the hospital is approved by the governing body. Page 6 of 5 Tuesday, Sep The Joint Commission
7 Hospital (HAP) Accreditation Program Issued September 5, 07 HR The equivalent process for credentialing and privileging physician assistants and advanced practice registered nurses who practice within the hospital includes the following: An evaluation of the applicant s credentials. The evaluation is documented. HR The equivalent process for credentialing and privileging physician assistants and advanced practice registered nurses who practice within the hospital includes the following: - A documented evaluation of the applicant s credentials. - An evaluation of the applicant s current competence. Documented peer recommendations. - Input from individuals and committees, including the medical staff, in order to make an informed decision regarding requests for privileges. HR The equivalent process for credentialing and privileging physician assistants and advanced practice registered nurses who practice within the hospital includes the following: An evaluation of the applicant s current competence. The evaluation is documented. HR The equivalent process for credentialing and privileging physician assistants and advanced practice registered nurses who practice within the hospital includes the following: - A documented evaluation of the applicant s credentials. - An evaluation of the applicant s current competence. Documented peer recommendations. - Input from individuals and committees, including the medical staff, in order to make an informed decision regarding requests for privileges. HR The equivalent process for credentialing and privileging physician assistants and advanced practice registered nurses who practice within the hospital includes the following: Peer recommendations. The peer recommendations are documented. HR The equivalent process for credentialing and privileging physician assistants and advanced practice registered nurses who practice within the hospital includes the following: - A documented evaluation of the applicant s credentials. - An evaluation of the applicant s current competence. Documented peer recommendations. - Input from individuals and committees, including the medical staff, in order to make an informed decision regarding requests for privileges. Page 7 of 5 Tuesday, Sep The Joint Commission
8 Hospital (HAP) Accreditation Program Issued September 5, 07 HR The equivalent process for credentialing and privileging physician assistants and advanced practice registered nurses who practice within the hospital includes the following: Input from individuals and committees, including the medical staff executive committee, in order to make an informed decision regarding requests for privileges. HR The equivalent process for credentialing and privileging physician assistants and advanced practice registered nurses who practice within the hospital includes the following: - A documented evaluation of the applicant s credentials. - An evaluation of the applicant s current competence. Documented peer recommendations. - Input from individuals and committees, including the medical staff, in order to make an informed decision regarding requests for privileges. Standard HR The hospital has the necessary staff to support the care, treatment, and services it provides. HR For hospitals that use Joint Commission accreditation for deemed status purposes: The hospital has a qualified dietician on a full-time, part-time, or consultative basis. Revision Type: Moved HR For hospitals that use Joint Commission accreditation for deemed status purposes: The hospital has a qualified dietician on a full-time, part-time, or consultative basis. HR Revision Type: Deleted Physician assistants and advanced practice registered nurses who practice within the hospital are credentialed, privileged, and re-privileged through the medical staff process or an equivalent process. Note: Advanced practice registered nurses who are licensed independent practitioners are credentialed and privileged only through the medical staff credentialing and privileging process. (See the "Medical Staff" [MS] chapter) Page 8 of 5 Tuesday, Sep The Joint Commission
9 Hospital (HAP) Accreditation Program Issued September 5, 07 HR Revision Type: Moved For hospitals that use Joint Commission accreditation for deemed status purposes: A full-time, part-time, or consulting pharmacist develops, supervises, and coordinates all the activities of the pharmacy department or pharmacy services. HR For hospitals that use Joint Commission accreditation for deemed status purposes: A full-time, part-time, or consulting pharmacist develops, supervises, and coordinates all the activities of the pharmacy department or pharmacy services. Standard HR The hospital determines how staff function within the organization. HR All staff who provide patient care, treatment, and services possess a current license, certification, or registration, in accordance with law and regulation. (See also HR , EP 9) Revision Type: Revised HR All staff who provide patient care, treatment, and services possess a current license, certification, or registration, in accordance with law and regulation. (See also HR.0.0.0, EP ) HR Staff oversee the supervision of students when they provide patient care, treatment, and services as part of their training. 5 Revision Type: Revised HR Staff supervise students when they provide patient care, treatment, and services as part of their training. 5 Standard HR The hospital provides orientation to staff. HR The hospital determines the key safety content of orientation provided to staff. (See also EC.0.0.0, EP ) Note: Key safety content may include specific processes and procedures related to the provision of care, treatment, and services; the environment of care; and infection control. HR The hospital orients its staff to the key safety content it identifies before staff provides care, treatment, and services. Completion of this orientation is documented. Note: Key safety content may include specific processes and procedures related to the provision of care, treatment, or services; the environment of care; and infection control. Page 9 of 5 Tuesday, Sep The Joint Commission
10 Hospital (HAP) Accreditation Program Issued September 5, 07 HR The hospital orients its staff to the key safety content before staff provides care, treatment, and services. Completion of this orientation is documented. (See also IC , EP 6) HR The hospital orients its staff to the key safety content it identifies before staff provides care, treatment, and services. Completion of this orientation is documented. Note: Key safety content may include specific processes and procedures related to the provision of care, treatment, or services; the environment of care; and infection control. HR The hospital orients staff on the following: Relevant hospitalwide and unitspecific policies and procedures. Completion of this orientation is documented. HR The hospital orients staff on the following: - Relevant hospitalwide and unit-specific policies and procedures. - Their specific job duties, including those related to infection prevention and control and assessing and managing pain. - Sensitivity to cultural diversity based on their job duties and responsibilities. - Patient rights, including ethical aspects of care, treatment, or services and the process used to address ethical issues based on their job duties and responsibilities. Completion of this orientation is documented. HR The hospital orients staff on the following: Their specific job duties, including those related to infection prevention and control and assessing and managing pain. Completion of this orientation is documented. (See also IC , EP 6; IC.0.0.0, EP 7; IC , EP ; RI.0.0.0, EP 8) 4 HR The hospital orients staff on the following: - Relevant hospitalwide and unit-specific policies and procedures. - Their specific job duties, including those related to infection prevention and control and assessing and managing pain. - Sensitivity to cultural diversity based on their job duties and responsibilities. - Patient rights, including ethical aspects of care, treatment, or services and the process used to address ethical issues based on their job duties and responsibilities. Completion of this orientation is documented. Page 0 of 5 Tuesday, Sep The Joint Commission
11 Hospital (HAP) Accreditation Program Issued September 5, 07 HR The hospital orients staff on the following: Sensitivity to cultural diversity based on their job duties and responsibilities. Completion of this orientation is documented. 5 HR The hospital orients staff on the following: - Relevant hospitalwide and unit-specific policies and procedures. - Their specific job duties, including those related to infection prevention and control and assessing and managing pain. - Sensitivity to cultural diversity based on their job duties and responsibilities. - Patient rights, including ethical aspects of care, treatment, or services and the process used to address ethical issues based on their job duties and responsibilities. Completion of this orientation is documented. HR The hospital orients staff on the following: Patient rights, including ethical aspects of care, treatment, and services and the process used to address ethical issues based on their job duties and responsibilities. Completion of this orientation is documented. 6 HR The hospital orients staff on the following: - Relevant hospitalwide and unit-specific policies and procedures. - Their specific job duties, including those related to infection prevention and control and assessing and managing pain. - Sensitivity to cultural diversity based on their job duties and responsibilities. - Patient rights, including ethical aspects of care, treatment, or services and the process used to address ethical issues based on their job duties and responsibilities. Completion of this orientation is documented. Standard HR Staff participate in ongoing education and training. HR Staff participate in ongoing education and training to maintain or increase their competency. Staff participation is documented. HR Staff participate in ongoing education and training to maintain or increase their competency, and as needed whenever staff responsibilities change. Staff participation is documented. Page of 5 Tuesday, Sep The Joint Commission
12 Hospital (HAP) Accreditation Program Issued September 5, 07 HR Staff participate in ongoing education and training whenever staff responsibilities change. Staff participation is documented. 4 HR Staff participate in ongoing education and training to maintain or increase their competency, and as needed whenever staff responsibilities change. Staff participation is documented. Infection Prevention and Control (IC) Chapter Standard IC The hospital identifies the individual(s) responsible for the infection prevention and control program. IC The hospital assigns responsibility for the daily management of infection prevention and control activities. (See also HR.0.0.0, EP ; LD , EP ) Note: Number and skill mix of the individual(s) assigned should be determined by the goals and objectives of the infection prevention and control program. Revision Type: Revised IC The hospital assigns responsibility for the daily management of infection prevention and control activities. (See also HR.0.0.0, EP ; LD , EP ) Note: Number and skill mix of the individual(s) assigned should be determined by the goals and objectives of the infection prevention and control program. Standard IC The hospital identifies risks for acquiring and transmitting infections. IC The hospital identifies risks for acquiring and transmitting infections based on the following: Its geographic location, community, and population served. (See also NPSG , EP ) IC The hospital identifies risks for acquiring and transmitting infections based on the following: - Its geographic location, community, and population served. - The care, treatment, and services it provides. - The analysis of surveillance activities and other infection control data. (See also NPSG , EP ) Page of 5 Tuesday, Sep The Joint Commission
13 Hospital (HAP) Accreditation Program Issued September 5, 07 IC The hospital identifies risks for acquiring and transmitting infections based on the following: The care, treatment, and services it provides. (See also NPSG , EP ) IC The hospital identifies risks for acquiring and transmitting infections based on the following: - Its geographic location, community, and population served. - The care, treatment, and services it provides. - The analysis of surveillance activities and other infection control data. (See also NPSG , EP ) IC The hospital identifies risks for acquiring and transmitting infections based on the following: The analysis of surveillance activities and other infection control data. (See also NPSG , EP ; TS.0.0.0, EP ) IC The hospital identifies risks for acquiring and transmitting infections based on the following: - Its geographic location, community, and population served. - The care, treatment, and services it provides. - The analysis of surveillance activities and other infection control data. (See also NPSG , EP ) IC The hospital reviews and identifies its risks at least annually and whenever significant changes occur with input from, at a minimum, infection control personnel, medical staff, nursing, and leadership. (See also NPSG , EP ) 4 Revision Type: Moved IC The hospital reviews and identifies its risks at least annually and whenever significant changes occur with input from, at a minimum, infection control personnel, medical staff, nursing, and leadership. (See also NPSG , EP ) IC The hospital prioritizes the identified risks for acquiring and transmitting infections. These prioritized risks are documented. (See also NPSG , EP ) 5 Revision Type: Moved IC The hospital prioritizes the identified risks for acquiring and transmitting infections. These prioritized risks are documented. (See also NPSG , EP ) Page of 5 Tuesday, Sep The Joint Commission
14 Hospital (HAP) Accreditation Program Issued September 5, 07 Standard IC Based on the identified risks, the hospital sets goals to minimize the possibility of transmitting infections. Note: See NPSG for hand hygiene guidelines. IC The hospital's written infection prevention and control goals include the following: Addressing its prioritized risks. IC The hospital's written infection prevention and control goals include the following: - Addressing its prioritized risks. - Limiting unprotected exposure to pathogens. - Limiting the transmission of infections associated with procedures. - Limiting the transmission of infections associated with the use of medical equipment, devices, and supplies. - Improving compliance with hand hygiene guidelines. (See also NPSG , EP ) IC The hospital's written infection prevention and control goals include the following: Limiting unprotected exposure to pathogens. IC The hospital's written infection prevention and control goals include the following: - Addressing its prioritized risks. - Limiting unprotected exposure to pathogens. - Limiting the transmission of infections associated with procedures. - Limiting the transmission of infections associated with the use of medical equipment, devices, and supplies. - Improving compliance with hand hygiene guidelines. (See also NPSG , EP ) Page 4 of 5 Tuesday, Sep The Joint Commission
15 Hospital (HAP) Accreditation Program Issued September 5, 07 IC The hospital's written infection prevention and control goals include the following: Limiting the transmission of infections associated with procedures. IC The hospital's written infection prevention and control goals include the following: - Addressing its prioritized risks. - Limiting unprotected exposure to pathogens. - Limiting the transmission of infections associated with procedures. - Limiting the transmission of infections associated with the use of medical equipment, devices, and supplies. - Improving compliance with hand hygiene guidelines. (See also NPSG , EP ) IC The hospital's written infection prevention and control goals include the following: Limiting the transmission of infections associated with the use of medical equipment, devices, and supplies. 4 IC The hospital's written infection prevention and control goals include the following: - Addressing its prioritized risks. - Limiting unprotected exposure to pathogens. - Limiting the transmission of infections associated with procedures. - Limiting the transmission of infections associated with the use of medical equipment, devices, and supplies. - Improving compliance with hand hygiene guidelines. (See also NPSG , EP ) IC The hospital's written infection prevention and control goals include the following: Improving compliance with hand hygiene guidelines. (See also NPSG , EP ) 5 IC The hospital's written infection prevention and control goals include the following: - Addressing its prioritized risks. - Limiting unprotected exposure to pathogens. - Limiting the transmission of infections associated with procedures. - Limiting the transmission of infections associated with the use of medical equipment, devices, and supplies. - Improving compliance with hand hygiene guidelines. (See also NPSG , EP ) Page 5 of 5 Tuesday, Sep The Joint Commission
16 Hospital (HAP) Accreditation Program Issued September 5, 07 Standard IC The hospital works to prevent the transmission of infectious disease among patients, licensed independent practitioners, and staff. IC When licensed independent practitioners or staff have, or are suspected of having, an infectious disease that puts others at risk, the hospital provides them with or refers them for assessment and potential testing, prophylaxis/treatment, or counseling. IC When licensed independent practitioners or staff have, are suspected of having, or have been occupationally exposed to an infectious disease that puts others at risk, the hospital provides them with or refers them for assessment and potential testing, prophylaxis/treatment, or counseling. IC When licensed independent practitioners or staff have been occupationally exposed to an infectious disease, the hospital provides them with or refers them for assessment and potential testing, prophylaxis/treatment, or counseling. IC When licensed independent practitioners or staff have, are suspected of having, or have been occupationally exposed to an infectious disease that puts others at risk, the hospital provides them with or refers them for assessment and potential testing, prophylaxis/treatment, or counseling. Standard IC The hospital evaluates the effectiveness of its infection prevention and control plan. IC The hospital evaluates the effectiveness of its infection prevention and control plan annually and whenever risks significantly change. IC The hospital evaluates the effectiveness of its infection prevention and control plan annually and whenever risks significantly change. The evaluation includes a review of the following: - The infection prevention and control plan's prioritized risks - The infection prevention and control plan's goals. (See also NPSG , EP ) - Implementation of the infection prevention and control plan s activities. Page 6 of 5 Tuesday, Sep The Joint Commission
17 Hospital (HAP) Accreditation Program Issued September 5, 07 IC The evaluation includes a review of the following: The infection prevention and control plan's prioritized risks. IC The hospital evaluates the effectiveness of its infection prevention and control plan annually and whenever risks significantly change. The evaluation includes a review of the following: - The infection prevention and control plan's prioritized risks - The infection prevention and control plan's goals. (See also NPSG , EP ) - Implementation of the infection prevention and control plan s activities. IC The evaluation includes a review of the following: The infection prevention and control plan's goals. (See also NPSG , EP ) IC The hospital evaluates the effectiveness of its infection prevention and control plan annually and whenever risks significantly change. The evaluation includes a review of the following: - The infection prevention and control plan's prioritized risks - The infection prevention and control plan's goals. (See also NPSG , EP ) - Implementation of the infection prevention and control plan s activities. IC The evaluation includes a review of the following: Implementation of the infection prevention and control plan s activities. 4 IC The hospital evaluates the effectiveness of its infection prevention and control plan annually and whenever risks significantly change. The evaluation includes a review of the following: - The infection prevention and control plan's prioritized risks - The infection prevention and control plan's goals. (See also NPSG , EP ) - Implementation of the infection prevention and control plan s activities. Page 7 of 5 Tuesday, Sep The Joint Commission
18 Rights and Responsibilities of the Individual (RI) Chapter Hospital (HAP) Accreditation Program Issued September 5, 07 Standard RI The hospital respects, protects, and promotes patient rights. RI The hospital respects the patient s right to pain management. (See also HR , EP 4; PC , EP ; MS.0.0.0, EP ) 8 Revision Type: Revised RI The hospital respects the patient s right to pain management. (See also LD.04.0., EP ) 8 Standard RI The hospital respects the patient's right to receive information in a manner he or she understands. RI The hospital provides language interpreting and translation services. (See also HR.0.0.0, EP ; PC.0.0., EP ; RI.0.0.0, EPs and 5) Note: Language interpreting options may include hospital-employed language interpreters, contract interpreting services, or trained bilingual staff. These options may be provided in person or via telephone or video. The hospital determines which translated documents and languages are needed based on its patient population. Revision Type: Revised RI The hospital provides language interpreting and translation services. (See also HR.0.0.0, EP ; PC.0.0., EP ; RI.0.0.0, EPs and 5) Note: Language interpreting options may include hospital-employed language interpreters, contract interpreting services, or trained bilingual staff. These options may be provided in person or via telephone or video. The hospital determines which translated documents and languages are needed based on its patient population. Page 8 of 5 Tuesday, Sep The Joint Commission
19 Hospital (HAP) Accreditation Program Issued September 5, 07 Standard RI The hospital respects the patient's right to participate in decisions about his or her care, treatment, and services. Note: For hospitals that use Joint Commission accreditation for deemed status purposes: This right is not to be construed as a mechanism to demand the provision of treatment or services deemed medically unnecessary or inappropriate. RI When a patient is unable to make decisions about his or her care, treatment, and services, the hospital involves a surrogate decision-maker in making these decisions. (See also RI.0.0.0, EP 6) 6 Revision Type: Moved and Revised RI When a patient is unable to make decisions about his or her care, treatment, and services, the hospital involves a surrogate decision-maker in making these decisions. (See also PC , EP 5; RI.0.0.0, EP ) RI The hospital provides the patient with written information about the right to refuse care, treatment, and services. RI The hospital provides the patient or surrogate decision-maker with written information about the right to refuse care, treatment, and services. (See also PC , EP 5) RI When a surrogate decision-maker is responsible for making care, treatment, and services decisions, the hospital respects the surrogate decision-maker s right to refuse care, treatment, and services on the patient s behalf, in accordance with law and regulation. 7 Revision Type: Split RI The hospital provides the patient or surrogate decision-maker with written information about the right to refuse care, treatment, and services. (See also PC , EP 5) RI The hospital respects the patient s right to refuse care, treatment, and services, in accordance with law and regulation. RI The hospital respects the patient s or surrogate decision-maker's right to refuse care, treatment, and services, in accordance with law and regulation. (See also PC , EP 5) 4 Page 9 of 5 Tuesday, Sep The Joint Commission
20 Hospital (HAP) Accreditation Program Issued September 5, 07 RI When a surrogate decision-maker is responsible for making care, treatment, and services decisions, the hospital respects the surrogate decision-maker s right to refuse care, treatment, and services on the patient s behalf, in accordance with law and regulation. 7 Revision Type: Split RI The hospital respects the patient s or surrogate decision-maker's right to refuse care, treatment, and services, in accordance with law and regulation. (See also PC , EP 5) 4 RI The hospital involves the patient s family in care, treatment, and services decisions to the extent permitted by the patient or surrogate decision-maker, in accordance with law and regulation. 8 Revision Type: Revised RI The hospital involves the patient s family in care, treatment, and services decisions to the extent permitted by the patient or surrogate decision-maker, in accordance with law and regulation. (See also PC , EP 5) 8 RI The hospital provides the patient or surrogate decision-maker with the information about the outcomes of care, treatment, and services that the patient needs in order to participate in current and future health care decisions. RI The hospital provides the patient or surrogate decision-maker with the information about the following: - Outcomes of care, treatment, and services that the patient needs in order to participate in current and future health care decisions. - Unanticipated outcomes of the patient s care, treatment, and services that are sentinel events as defined by The Joint Commission. This information is provided by the licensed independent practitioner responsible for managing the patient's care, treatment, and services, or his or her designee. (Refer to the Glossary for a definition of sentinel event. Note: In settings where there is no licensed independent practitioner, the staff member responsible for managing the care of the patient is responsible for sharing information about such outcomes. Page 0 of 5 Tuesday, Sep The Joint Commission
21 Hospital (HAP) Accreditation Program Issued September 5, 07 RI The hospital informs the patient or surrogate decision-maker about unanticipated outcomes of care, treatment, and services that relate to sentinel events as defined by The Joint Commission. (Refer to the Glossary for a definition of sentinel event.) RI The hospital provides the patient or surrogate decision-maker with the information about the following: - Outcomes of care, treatment, and services that the patient needs in order to participate in current and future health care decisions. - Unanticipated outcomes of the patient s care, treatment, and services that are sentinel events as defined by The Joint Commission. This information is provided by the licensed independent practitioner responsible for managing the patient's care, treatment, and services, or his or her designee. (Refer to the Glossary for a definition of sentinel event. Note: In settings where there is no licensed independent practitioner, the staff member responsible for managing the care of the patient is responsible for sharing information about such outcomes. RI The licensed independent practitioner responsible for managing the patient's care, treatment, and services, or his or her designee, informs the patient about unanticipated outcomes of care, treatment, and services related to sentinel events when the patient is not already aware of the occurrence or when further discussion is needed. Note: In settings where there is no licensed independent practitioner, the staff member responsible for managing the care of the patient is responsible for sharing information about such outcomes. RI The hospital provides the patient or surrogate decision-maker with the information about the following: - Outcomes of care, treatment, and services that the patient needs in order to participate in current and future health care decisions. - Unanticipated outcomes of the patient s care, treatment, and services that are sentinel events as defined by The Joint Commission. This information is provided by the licensed independent practitioner responsible for managing the patient's care, treatment, and services, or his or her designee. (Refer to the Glossary for a definition of sentinel event. Note: In settings where there is no licensed independent practitioner, the staff member responsible for managing the care of the patient is responsible for sharing information about such outcomes. Page of 5 Tuesday, Sep The Joint Commission
Accreditation Program: Hospital
ccreditation Program: Hospital Infection Prevention and ontrol 2008 The Joint ommission on ccreditation of Healthcare Organizations ccreditation Program: Hospital hapter: Infection Prevention and ontrol
More informationHuman Resources & Nursing
2017 Hospital Breakfast Briefings Web-conference Series Human Resources & Nursing November 2, 2017 Faculty: Kathy Eichner, RN, MSN, CJCP Principal Consultant, Joint Commission Resources 1 Disclosure Statement
More informationHospital Crosswalk. Medicare Hospital Requirements to 2012 Joint Commission Hospital Standards & EPs
Hospital Crosswalk CFR Number Standards and Elements of Performance 482.11 TAG: A-0020 482.11 Condition of Participation: Compliance with Federal, State and Local Laws 482.11(a) TAG: A-0021 LD.04.01.01
More informationHospital Crosswalk. Medicare Hospital Requirements to 2017 Joint Commission Hospital Standards & EPs. Joint Commission Equivalent Number EP 2 EP 1
Hospital Crosswalk CFR Number 482.11 TAG: A-0020 482.11 Condition of Participation: Compliance with Federal, State and Local Laws 482.11(a) TAG: A-0021 LD.04.01.01 The hospital complies with law and regulation.
More informationProposed Standards Revisions Related to Pain Assessment and Management
Leadership (LD) Chapter LD.0001 Proposed Standards Revisions Related to Pain Assessment and Management 1 2 Leaders establish priorities for performance improvement. (Refer to the "Performance Improvement"
More informationPrepublication Requirements
Prepublication Requirements Standards Revisions for Swing Bed Final Rule in Critical Access Hospitals The Joint Commission has approved the following revisions for prepublication. While revised requirements
More informationRadiologic technologists take x rays and administer nonradioactive materials into patients bloodstreams for diagnostic purposes.
http://www.bls.gov/oco/ocos105.htm Radiologic Technologists and Technicians Nature of the Work Training, Other Qualifications, and Advancement Employment Job Outlook Projections Data Earnings OES Data
More informationPsychological Specialist
Job Code: 067 Psychological Specialist Overtime Pay: Ineligible This is work performing psychological assessments or counseling students. Administers intelligence and personality tests. Provides consultation
More informationhttp://www.bls.gov/oco/ocos299.htm Radiation Therapists Nature of the Work Training, Other Qualifications, and Advancement Employment Job Outlook Projections Data Earnings OES Data Related Occupations
More informationTITLE 114 MEDICAL IMAGING and RADIATION THERAPY BOARD ARTICLE GENERAL ADMINISTRATION CHAPTER ORGANIZATION OF THE BOARD
TITLE 114 MEDICAL IMAGING and RADIATION THERAPY BOARD Chapter 114-01-01 Organization of Board 114-01-02 Definitions 114-01-03 Fees ARTICLE 114-01 GENERAL ADMINISTRATION CHAPTER 114-01-01 ORGANIZATION OF
More informationPrepublication Requirements
Issued Prepublication Requirements The Joint Commission has approved the following revisions for prepublication. While revised requirements are published in the semiannual updates to the print manuals
More informationHOSPICE CONTRACTING CHECKLIST FOR INPATIENT SERVICES, RESPITE CARE AND VENDOR AGREEMENTS
HOSPICE CONTRACTING CHECKLIST FOR INPATIENT SERVICES, RESPITE CARE AND VENDOR AGREEMENTS The following checklist can be used to verify that the regulatory requirements are addressed in hospice contracts
More informationComparison of the current and final revisions to the Home Health Conditions of Participation
Comparison of the current and final revisions to the Home Health Conditions of Participation Significant changes are designated by ** underlined, and bolded. Where the condition or standard is ** and underlined,
More informationThe Practice Standards for Medical Imaging and Radiation Therapy. Limited X-Ray Machine Operator Practice Standards
The Practice Standards for Medical Imaging and Radiation Therapy Limited X-Ray Machine Operator Practice Standards 2017 American Society of Radiologic Technologists. All rights reserved. Reprinting all
More informationAPEx Program Standards
APEx Program Standards The following standards are the basis of the APEx program. Level 1 standards are indicated in bold. Standard 1: Patient Evaluation, Care Coordination and Follow-up The radiation
More informationNDAC TITLE 114 ND MEDICAL IMAGING and RADIATION THERAPY BOARD OF EXAMINERS ARTICLE GENERAL ADMINISTRATION
NDAC TITLE 114 ND MEDICAL IMAGING and RADIATION THERAPY BOARD OF EXAMINERS Chapter 114-01-01 Organization of Board 114-01-02 Definitions 114-01-03 Fees ARTICLE 114-01 GENERAL ADMINISTRATION CHAPTER 114-01-01
More informationThe Practice Standards for Medical Imaging and Radiation Therapy. Quality Management Practice Standards
The Practice Standards for Medical Imaging and Radiation Therapy Quality Management Practice Standards 2017 American Society of Radiologic Technologists. All rights reserved. Reprinting all or part of
More informationDepartment of Veterans Affairs VA HANDBOOK 5005/42. September 28, 2010 STAFFING
Department of Veterans Affairs VA HANDBOOK 5005/42 Washington, DC 20420 Transmittal Sheet September 28, 2010 STAFFING 1. REASON FOR ISSUE: To establish a Department of Veterans Affairs (VA) qualification
More informationIX. PERSONNEL STANDARDS A. POLICIES
IX. PERSONNEL STANDARDS A. POLICIES 1. The Lead Agency (DMHMRSAS) ensures that Virginia's Personnel Standards include policies and procedures relating to the establishment and maintenance of standards
More informationThe Practice Standards for Medical Imaging and Radiation Therapy. Cardiac Interventional and Vascular Interventional Technology. Practice Standards
The Practice Standards for Medical Imaging and Radiation Therapy Cardiac Interventional and Vascular Interventional Technology Practice Standards 2017 American Society of Radiologic Technologists. All
More informationCAMH February 2005 Update HIGHLIGHTS
CAMH February 2005 Update HIGHLIGHTS STANDARD UP 1. How to Use Manual Multiple changes to scoring, category changes and Measure of Success (MOS) designation removed 2. Accreditation Policies & Procedures
More informationCMS-3819-F Condition of participation: Reporting OASIS information. (a) Standard: Encoding and transmitting OASIS data. An HHA must encode
CMS-3819-F 319 OASIS information to the public. 484.45 Condition of participation: Reporting OASIS information. HHAs must electronically report all OASIS data collected in accordance with 484.55. (a) Standard:
More informationCHAPTER MEDICAL IMAGING AND RADIATION THERAPY
CHAPTER 43-62 MEDICAL IMAGING AND RADIATION THERAPY 43-62-01. Definitions. 1. "Board" means the North Dakota medical imaging and radiation therapy board of examiners. 2. "Certification organization" means
More informationThe Practice Standards for Medical Imaging and Radiation Therapy. Radiography Practice Standards
The Practice Standards for Medical Imaging and Radiation Therapy Radiography Practice Standards 2017 American Society of Radiologic Technologists. All rights reserved. Reprinting all or part of this document
More informationThe Practice Standards for Medical Imaging and Radiation Therapy. Computed Tomography Practice Standards
The Practice Standards for Medical Imaging and Radiation Therapy Computed Tomography Practice Standards 2011 American Society of Radiologic Technologists. All rights reserved. Reprinting all or part of
More informationMedication Administration Through Existing Vascular Access
Medication Administration Through Existing Vascular Access After a study of evidentiary documentation such as current literature, curricula, position statements, scopes of practice, laws, federal and state
More informationMISSISSIPPI LEGISLATURE REGULAR SESSION 2013
MISSISSIPPI LEGISLATURE REGULAR SESSION 2013 By: Representative Formby To: Public Health and Human Services HOUSE BILL NO. 69 1 AN ACT TO AMEND SECTIONS 41-58-1, 41-58-3 AND 41-58-5, 2 MISSISSIPPI CODE
More informationMassachusetts Society of Radiologic Technologists
Massachusetts Society of Radiologic Technologists P.O. Box 2821 Duxbury, MA 02331-2821 Phone: 781.422.3962 info@msrt-ma.org www.msrt-ma.org This testimony is submitted by the Massachusetts Society of Radiologic
More informationMichigan Department of Licensing and Regulatory Affairs Part 15 Computed Tomography Installations Guidance for CT Rules
Table of Contents R 325.5701 Purpose and scope...1 R 325.5703 Definitions...2 R 325.5705 CT operators...3 R 325.5707 Medical physicist...4 R 325.5709 Equipment requirements...6 R 325.5711 Enclosures...7
More informationChapter 4732 Modifications Summary SEPTEMBER 30, 2016
Chapter 4732 Modifications Summary SEPTEMBER 30, 2016 PURPOSE, SCOPE, AND DEFINITIONS 4732.0100 PURPOSE AND SCOPE. No changes at this time. 4732.0110 DEFINITIONS. Amend and update existing definitions.
More informationMedication Administration Through Existing Vascular Access
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 Medication Administration Through Existing Vascular Access After a study of evidentiary documentation
More informationThe Practice Standards for Medical Imaging and Radiation Therapy. Medical Dosimetry Practice Standards
The Practice Standards for Medical Imaging and Radiation Therapy Medical Dosimetry Practice Standards 2017 American Society of Radiologic Technologists. All rights reserved. Reprinting all or part of this
More information2012 Medical Staff Update 2011 CHALLENGING STANDARDS/NPSGS
2012 Medical Staff Update Laurel McCourt, M.D. TJC Surveyor: Hospital and Office-Based Surgery Programs, and Special Survey Unit 2011 CHALLENGING STANDARDS/NPSGS 2 Standard/NPSG 2010 Non Compliance 3 2011
More informationThe Practice Standards for Medical Imaging and Radiation Therapy. Radiologist Assistant Practice Standards
The Practice Standards for Medical Imaging and Radiation Therapy Radiologist Assistant Practice Standards 2017 American Society of Radiologic Technologists. All rights reserved. Reprinting all or part
More informationAREAS EMPLOYERS STRATEGIES/INFORMATION PHYSICAL THERAPY
HEALTHCARE SCIENCES Physical & Occupational Therapy, Cytotechnology, Dental Hygiene, Health Information Management, Clinical Laboratory Science, Nuclear Medicine Technology What can I do with these majors?
More information+ COURSE OUTLINE. Course Title: Radiation Protection. Prerequisites: RAD107, RAD119, RAD127. Co-Requisites: RAD120, RAD128, BIO104
Course Number: RAD114 Lecture Hours: 2 + COURSE OUTLINE Course Title: Radiation Protection Prerequisites: RAD107, RAD119, RAD127 Co-Requisites: RAD120, RAD128, BIO104 Credits: 2 Catalog Description (2017-2018):
More informationPage 3, Introduction (correcting a typo) Accreditation Participation Requirements (APR)
Issued 4 December 2013 Page 3, Introduction (correcting a typo) Accreditation Participation Requirements (APR) The Accreditation Participation Requirements (APR) section, new to JCI in this edition, is
More informationHome Health Agency Updated Conditions of Participation. Thursday, December 7, :00 4:00 PM EST
Home Health Agency Updated Conditions of Participation Thursday, December 7, 2017 2:00 4:00 PM EST Home Health Agency (HHA) Training Session Presented by: Peggye Wilkerson Director, Division of Continuing
More informationStanford Health Care Lucile Packard Children s Hospital Stanford
Practitioners Page 1 of 11 I. PURPOSE To outline individuals who are authorized to provide care as an Allied Health Provider as well as describe which categories of individuals who will be processed under
More information2014 Medical Staff Update
John Herringer, Associate Director Standards Interpretation Group The Joint Commission 2013 Most Frequently Scored Medical Staff Standards and EPs 2 MS.01.01.01 EP 3 13.01% Scored when any element of performance
More informationUS ): [42CFR ]:
GEN.53400 Section Director (Technical Supervisor) Qualifications/Responsibilities Phase II Section Directors/Technical Supervisors meet defined qualifications and fulfill the expected responsibilities.
More informationONE ID Alternative Registry Standard. Version: 1.0 Document ID: 1807 Owner: Senior Director, Integrated Solutions & Services
ONE ID Alternative Registry Standard Version: 1.0 Owner: Senior Director, Integrated Solutions & Services ehealth Ontario ONE ID Alternative Registry Standard Copyright Notice Copyright 2014, ehealth Ontario
More informationMandatory Licensure for Radiologic Personnel. Christopher Jason Tien
Mandatory Licensure for Radiologic Personnel Christopher Jason Tien Licensure Permission to perform a given occupation 3 rd party examinations State hands out licenses Occupations licensed: teachers, architects,
More informationThe Practice Standards for Medical Imaging and Radiation Therapy. Radiation Therapy Practice Standards
The Practice Standards for Medical Imaging and Radiation Therapy Radiation Therapy Practice Standards 2017 American Society of Radiologic Technologists. All rights reserved. Reprinting all or part of this
More informationThe ASRT is seeking public comment on proposed revisions to the Practice Standards for Medical Imaging and Radiation Therapy titled Medical Dosimetry.
The ASRT is seeking public comment on proposed revisions to the Practice Standards for Medical Imaging and Radiation Therapy titled Medical Dosimetry. To submit comments please access the public comment
More informationClinical Staffing. Primary Reviewer: Clinical Expert Secondary Reviewer: Governance/Administrative Expert, if needed
Health Center Program Site Visit Protocol Clinical Staffing Primary Reviewer: Clinical Expert Secondary Reviewer: Governance/Administrative Expert, if needed Authority: Sections 330(a)(1), (b)(1)-(2),
More informationARRT Rules and Regulations
ARRT Rules and Regulations Last Revised: September 1, 20156 Published: September 1, 20156 ARTICLE I. CERTIFICATION AND REGISTRATION Section 1.01 General. The American Registry of Radiologic Technologists
More informationMedical Radiologic Technology
Medical Radiologic Technology 207 Medical Radiologic Technology Location: Trenholm Campus - Bldg. H Program Information The Medical Radiologic Technology program at Trenholm State provides students with
More informationInterpretation of The Joint Commission Standards Related to Pain Management. Agenda. The Joint Commission Mission 9/6/2012
Interpretation of The Joint Commission Standards Related to Pain Management ASPMN 22 nd National Conference Baltimore, MD September 13, 2012 Pat Adamski, RN, MS, MBA, FACHE Director, Standards Interpretation
More informationACCREDITATION STANDARDS FOR
ACCREDITATION STANDARDS FOR ACUTE CARE HOSPITALS TABLE OF CONTENTS GOVERNANCE & LEADERSHIP... 1 GL-1: Establishment of a Governing Body... 1 GL-2: Compliance to Law & Regulation... 1 GL-3: Establishment
More informationLOUISIANA REVISED STATUTE 37: THE LOUISIANA RADIOLOGIC TECHNOLOGIST LICENSING LAW
LOUISIANA REVISED STATUTE 37: 3200-3221 THE LOUISIANA RADIOLOGIC TECHNOLOGIST LICENSING LAW LOUISIANA STATE RADIOLOGIC TECHNOLOGY BOARD OF EXAMINERS 3108 CLEARY AVENUE, SUITE 207 METAIRIE, LOUISIANA 70002
More information(a) Licensure. A facility must be licensed under applicable State and local law.
42 C.F.R. 483.705. Administration. A facility must be administered in a manner that enables it to use its resources effectively and efficiently to attain or maintain the highest practicable physical, mental,
More informationEligibility Introduction Practice Ethics and Patient Rights and Responsibilities (RI)... 6
Table of Contents Eligibility... 2 Introduction... 3 Practice Ethics and Patient Rights and Responsibilities (RI)... 6 Provision of Care, Treatment, and Services (PC)... 8 Medication Management (MM)...
More informationJOB DESCRIPTION Position: Registered Radiologic Technologist
JOB DESCRIPTION Position: Registered Radiologic Technologist POSITION TITLE: Registered Radiologic Technologist APPROVED BY: Medical Imaging Services Manager LATEST REVIEW OF JOB DESCRIPTION: 9/16 FORMER
More informationa. Principles of administration including budgeting, accounting, records management, organization, personnel, and business management.
DEPARTMENT OR REGULATORY AGENCIES State Board of Examiners of Nursing Home Administrators RULES AND REGULATIONS FOR NURSING HOME ADMINISTRATORS 3 CCR 717-1 RULE 1. LICENSING EXAMINATION 1. All applicants
More informationNUCLEAR MEDICINE PRACTITIONER COMPETENCIES
NUCLEAR MEDICINE PRACTITIONER COMPETENCIES INTRODUCTION The Society of Nuclear Medicine Technologist Section adopted the proposal for the development of a middle level practice provider, Nuclear Medicine
More informationGuidelines for Mammography Additional Qualification
FORM 298 HEALTH PROFESSIONS COUNCIL OF SOUTH AFRICA PROFESSIONAL BOARD OF RADIOGRAPHY AND CLINICAL TECHNOLOGY Guidelines for Mammography Additional Qualification Guidelines to be used by educational institutions
More informationDoing Business As name (if applicable): 2. Mailing Address: (Street Address/City/State/Zip) 3. Physical Location: (Street Address/City/State/Zip)
ZZ113-120 REGISTRATION APPLICATION FOR USERS OF RADIATION MACHINES HEALING ARTS, DENTAL, VETERINARY MEDICINE AND MEDICAL ACADEMIC FACILITIES TEXAS DEPARTMENT OF STATE HEALTH SERVICES (DSHS) RADIATION SAFETY
More informationComputed Tomography and Magnetic Resonance Imaging Technology - CT Imaging Technology Expanded Traditional Clinical Certificate
Forsyth Technical Community College 2100 Silas Creek Parkway Winston-Salem, NC 27103-5197 Computed Tomography and Magnetic Resonance Imaging Technology - CT Imaging Technology Expanded Traditional Clinical
More informationBecoming a professional: When good is not good enough
Becoming a professional: When good is not good enough Elwin R. Tilson, R.T.(R)(M)(QM)(CT), FAEIRS elwin.tilson@gmail.com RIS as Professionals Practitioners in the radiologic and imaging sciences have always
More informationJCI 6 th ed. Hospital Standards Review: Patient-Centered Standards
JCI 6 th ed. Hospital Standards Review: Patient-Centered Standards Standards Overview This presentation provides a general sense of what types of issues and themes are covered in our Patient- Centered
More informationTitle 18 RCW Chapter
WA 2007 RCW 18.130.020 Definitions. Title 18 RCW Chapter 18.250 The definitions in this section apply throughout this chapter unless the context clearly requires otherwise. (1) "Board" means any of those
More informationEffective Date: January 1, 2014
Effective Date: January 1, 2014 Program: Hospital Chapter: Medical Staff Overview: The self-governing organized medical staff provides oversight of the quality of care, treatment, and services delivered
More informationNon-Employed Advanced Practice Professionals Nurse Practitioner and Physician Assistants who not employees of the hospital.
Stanford and Clinics Lucile Packard Children s Page 1 of 8 I. PURPOSE The purpose of this policy is to outline educational requirements for all Medical Staff and non-employed Advance Practice Professionals
More informationDiagnostic Imaging: Surveyor Education, Survey Experience, and Trends
Compliance with the AAPM CT Clinical Practice and Joint Commission Guidelines Diagnostic Imaging: Surveyor Education, Survey Experience, and Trends On-Site Survey focused on patient care: Patient Tracer
More informationINPATIENT ACUTE REHABILITATION HOSPITAL LIMITATIONS, SCOPE AND INTENSITY OF CARE
INPATIENT ACUTE REHABILITATION HOSPITAL LIMITATIONS, SCOPE AND INTENSITY OF CARE Bacharach Institute for Rehabilitation offers a number of in and outpatient rehabilitation programs and services designed
More informationSchool of Health Sciences
Milwaukee Area Technical College Available Certifications and Licensures by School School of Health Sciences Anesthesia Associate Degree Certified Anesthesia Tech (CerAT) Certification American Society
More informationLong Term Care Home Care Opioid Treatment Program
This document contains the Office of Minority Health National Culturally and Linguistically Appropriate Services (CLAS) Standards Crosswalked to Joint Commission 2007 Standards for Hospitals, Ambulatory,
More informationThe Who, What, When, and Wheres
Ambulatory Care Program: The Who, What, When, and Wheres of Credentialing and Privileging The Who, What, When, and Wheres The Who, What, When, and Wheres Note that this was originally documented as a three-part
More informationHealth Sciences Faculty Hiring Guidelines For credit-bearing instruction only
NWTC is looking for people who are passionate about the work they do and have the desire to inspire students and transform lives. who embrace the NWTC Values: Customer Focus, Everyone Has Worth, Passion
More informationHEALTH COMMUNITY COLLEGE OF ALLEGHENY COUNTY
HEALTH DEGREE, CERTIFICATE & DIPLOMA PROGRAMS MICHAEL SIMON Associate of Science in Nursing CCAC Class of 2014 Master of Science in Nursing Administration IUP Class of 2018 Nursing Manager Allegheny Health
More informationMedical Radiation Technologists. A guide for newcomers to British Columbia
Contents 1. Working as a Medical Radiation Technologist... 2 2. Skills, Education and Experience... 7 3. Finding Jobs... 9 4. Applying for a Job... 12 5. Getting Help from Industry Sources... 13 1. Working
More informationPrepublication Requirements
Issued Prepublication Requirements The Joint Commission has approved the following revisions for prepublication. While revised requirements are published in the semiannual updates to the print manuals
More informationAll Health Care Salary Survey
2014 All Health Care Salary Survey Executive Summary 8575 164 th Ave NE, Suite 100 Redmond, WA 98052 USA Telephone: 877.210.6563 Fax: 877.239.2457 Email: survey.sales@erieri.com www.salary surveys.erieri.com
More informationContact Evelyn Knolle, AHA senior associate director of policy, at (202) or American Hospital Association 1
Further Questions: Contact Evelyn Knolle, AHA senior associate director of policy, at (202) 626-2963 or eknolle@aha.org. American Hospital Association 1 November 7, 2014 CMS PROPOSES UPDATES TO REQUIREMENTS
More informationNew Elements of Performance for Rehabilitation and Psychiatric Distinct Part Units in Critical Access Hospitals
New Elements of Performance for Rehabilitation and Psychiatric Distinct Part Units in Critical ccess Hospitals Effective January 1, 2010 Critical ccess Hospital ccreditation Program Standard LD.0001 The
More informationPrepublication Requirements
Issued Prepublication Requirements The Joint Commission has approved the following revisions for prepublication. While revised requirements are published in the semiannual updates to the print manuals
More informationIC Chapter 2. Criminal History of Home Health Care Operators and Workers
IC 16-27-2 Chapter 2. Criminal History of Home Health Care Operators and Workers IC 16-27-2-0.2 Application of prior law to employees of home health agencies Sec. 0.2. The addition of IC 16-10-2.6 (before
More informationMedical Physicist Credentials: The Regulatory Path. Outline. Objective
Medical Physicist Credentials: The Regulatory Path Douglas Pfeiffer, MS, DABR Boulder Community Hospital Chair, AAPM Governmental and Regulatory Affairs Committee Outline Regulation vs. Licensure What
More informationOlder Americans Act: Adult adult day service.
ACTION: Original DATE: 04/18/2016 5:01 PM 173-3-06.1 Older Americans Act: Adult adult day service. (A) "Adult day service" ("ADS") means a regularly-scheduled service delivered at an ADS center, which
More informationRadiation Therapy. 1. Introduction. 2. Documentation of Compliance. 3. Didactic Competency Requirements. 4. Clinical Competency Requirements
PRIMARY CERTIFICATION AND REGISTRATION Radiation Therapy 1. Introduction Candidates for certification and registration are required to meet the Professional Education Requirements specified in the ARRT
More informationHospital Administration Manual
PATIENT RIGHTS POLICY Hospital Administration Manual Effective Date: PC-33 HAM 5/1/2017 PURPOSE At the Milton S. Hershey Medical Center (MSHMC), our goal is to provide excellent health care to every patient.
More informationNUCLEAR MEDICINE TECHNOLOGY CERTIFICATION EXAMINATION
THE NUCLEAR MEDICINE TECHNOLOGY CERTIFICATION BOARD, INC. NUCLEAR MEDICINE TECHNOLOGY CERTIFICATION EXAMINATION Alternate Eligibility Application Form NMTCB 3558 HABERSHAM AT NORTHLAKE BUILDING I TUCKER,
More informationEP Review Project: The Joint Commission Deletes 225 Hospital Requirements
PR Review Project: The Joint Commission Deletes 225 Hospital Requirements Project REFRESH (see related articles on pages 1 and 3) includes a project first announced in the December 2015 Perspectives: the
More informationCOMAR Title 10 MARYLAND DEPARTMENT OF HEALTH
Board of Nursing proposed regulatory changes, Published November 13, 2017, in MD Register. Comment period ends December 14, 2017. COMAR Title 10 MARYLAND DEPARTMENT OF HEALTH 10.27.01 Examination and Licensure
More informationPage 17, APR.10 (new text for clarity)
Page 17, APR.10 (new text for clarity) Requirement: APR.10 Translation and interpretation services arranged by the hospital for an accreditation survey and any related activities are provided by licensed
More informationT A B L E O F C O N T E N T S. Medicare Hospice CoPs California Hospice Standards Title 22 Regulation Page No.(s) SAMPLE
TABLE OF CONTENTS.. [ Subpart A ] - 418.3 Definitions Article 1 - Definitions Article 1 - Definitions Hospice Hospice 74600. Home Health Agency 1 Hospice Care No Equivalent No Equivalent 2 No Equivalent
More informationCAMH. Table of Changes March 2013 CAMH Update 1
2013 Comprehensive Accreditation Manual for Table of Changes March 2013 To update your manual, please remove and recycle the pages listed in this table of changes, and insert the replacement pages provided
More informationContact Hours FL (CE version ONLY) Suggested Target Audience. staff that provide care to patients. Page 1 of 8 Updated: 10/30/2017
PA CE 1 Active Shooter Response in Healthcare Settings - An HCCS Regulatory 1/8/2016 1 1 N/A 20 N/A N/A all staff 2 Advance Directives - An HCCS Regulatory 10/15/2015 1 1 N/A 54 N/A N/A all staff 3 Annual
More informationAPPLICATION FOR ADMISSION TO THE UW-L NUCLEAR MEDICINE TECHNOLOGY PROGRAM
APPLICATION FOR ADMISSION TO THE UW-L NUCLEAR MEDICINE TECHNOLOGY PROGRAM Please type responses. Hand-written applications will not be accepted. Name Local Mailing Address (La Crosse Address for UW-L Students)
More informationODA provider certification: Adult adult day service.
ACTION: Original DATE: 04/18/2016 5:01 PM 173-39-02.1 ODA provider certification: Adult adult day service. (A) "Adult day service" ("ADS") means a regularly-scheduled service delivered at an ADS center,
More informationPOLICIES AND PROCEDURES
POLICIES AND PROCEDURES POLICY: 535.10 TITLE: EFFECTIVE: 4/13/17 REVIEW: 4/2022 SUPERCEDES: APPROVAL SIGNATURES ON FILE IN EMS OFFICE PAGE: 1 of 14 I. AUTHORITY Division 2.5, California Health and Safety
More informationTable of Contents. Page ADMINISTRATIVE JOINT COMMISSION. Washington
Table of Contents Page ADMINISTRATIVE 1.001.1 Definition of Organization LD.04.01.01 040(b) 1.001.2 Mission Statement, Goals, and LD.02.01.01 Philosophy 1.002.1 Services Offered LD.01.03.01 LD.04.01.05
More informationNew CoPs - Overview -
New CoPs - Overview - A Patient- Centered, Data-Driven, Outcome Oriented Philosophy P r e s e n te d b y : Sharon M. Litwin, RN, BSHS, MHA, HCS-D Senior Managing Partner 5 Star Consultants Objectives Participants
More informationRADIATION CONTROL - REGISTRATION OF RADIATION MACHINES, FACILITIES AND SERVICES REGISTRATION OF RADIATION MACHINES, FACILITIES AND SERVICES
DEPARTMENT OF PUBLIC HEALTH AND ENVIRONMENT STATE BOARD OF HEALTH RADIATION CONTROL - REGISTRATION OF RADIATION MACHINES, FACILITIES AND SERVICES 6 CCR 1007-1 Part 02 [Editor s Notes follow the text of
More informationCOMPETENCY BASED CLINICAL EDUCATION STANDARD
New Jersey Department of Environmental Protection Radiologic Technology Board of Examiners Po Box 420, Mail Code 25-01 Trenton, New Jersey 08625-420 609-984-5890 www.xray.nj.gov COMPETENCY BASED CLINICAL
More informationHealth Care Careers 1
Health Care Careers 1 5 Health Care Pathways Health Care Occupations are Organized into 5 Pathways. Therapeutic Services Diagnostic Services Health Informatics Support Services Biotechnology Research and
More informationMEMO. DATE June Licensed Speech-Language Pathologist and Audiologist, Applicants for licenses and other interested persons
MEMO DATE June 2009 TO: FROM: Licensed Speech-Language Pathologist and Audiologist, Applicants for licenses and other interested persons Health Occupations Program PHONE: 651-201-3726 SUBJECT: Answers
More informationEmployment Opportunity
Employment Opportunity Student Health Services Nurse Practitioner (75% categorically-funded assignment) CR14-02 College Web Address: www.cabrillo.edu Initial screening of applications will begin on Thursday,
More informationCOLORADO. Downloaded January 2011
COLORADO Downloaded January 2011 PART 1. GOVERNING BODY 1.1 GOVERNING BODY. The governing body is the individual, group of individuals, or corporate entity that has ultimate authority and legal responsibility
More information