Issued September 5, 07 Human Resources (HR) Chapter Standard Changes Related to EP Review Phase IV Hospital (HAP) Accreditation Program Standard HR.0.0.0 The hospital defines and verifies staff qualifications. HR.0.0.0 The hospital defines staff qualifications specific to their job responsibilities. (See also HR.0.0.05, 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 49.5-49.495. A complete description of the requirement is located at http://wwwn.cdc.gov/clia/regulatory. 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 409.7. See Appendix A for 409.7 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.0.0.0 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 49.5-49.495. A complete description of the requirement is located at http://wwwn.cdc.gov/clia/regulatory. 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 409.7. See Appendix A for 409.7 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 07 07 The Joint Commission
Hospital (HAP) Accreditation Program Issued September 5, 07 HR.0.0.05 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.0.0.05, EP 9; HR.0.0.07, 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.0.0.0 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.0.0.05 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.0.0.05, EP 9; HR.0.0.07, EP ) HR.0.0.0 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 07 07 The Joint Commission
Hospital (HAP) Accreditation Program Issued September 5, 07 HR.0.0.05 The hospital verifies and documents that the applicant has the education and experience required by the job responsibilities. (See also HR.0.0.05, EP 9) Revision Type: Moved and Revised HR.0.0.0 The hospital verifies and documents that the applicant has the education and experience required by the job responsibilities. HR.0.0.05 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.0.0.0 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.0.0.05 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.0.0.0 Staff comply with applicable health screening as required by law and regulation or hospital policy. Health screening compliance is documented. 5 HR.0.0.05 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.0.0.0 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 07 07 The Joint Commission
Hospital (HAP) Accreditation Program Issued September 5, 07 HR.0.0.0 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, 990 - 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.0.0.0 7 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, 990 - 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.0.0.0 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.0.0.0 8 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.0.0.05 6 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.0.0.0 0 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 07 07 The Joint Commission
Hospital (HAP) Accreditation Program Issued September 5, 07 HR.0.0.05 8 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.0.0.0 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.0.0.05 9 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.0.0.05, EPs ; HR.0.0.07, 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.0.0.0 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.0.0.07, 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 07 07 The Joint Commission
Hospital (HAP) Accreditation Program Issued September 5, 07 HR.0.0.05 0 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.0.0.0 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.0.0.0 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.0.0.05 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.0.0.0 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 07 07 The Joint Commission
Hospital (HAP) Accreditation Program Issued September 5, 07 HR.0.0.05 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.0.0.0 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.0.0.05 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.0.0.0 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.0.0.05 4 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.0.0.0 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 07 07 The Joint Commission
Hospital (HAP) Accreditation Program Issued September 5, 07 HR.0.0.05 5 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.0.0.0 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.0.0.05 The hospital has the necessary staff to support the care, treatment, and services it provides. HR.0.0.0 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.0.0.05 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.0.0.05 0 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 07 07 The Joint Commission
Hospital (HAP) Accreditation Program Issued September 5, 07 HR.0.0.0 8 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.0.0.05 8 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.0.0.07 The hospital determines how staff function within the organization. HR.0.0.07 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.0.0.05, EP 9) Revision Type: Revised HR.0.0.07 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.0.0.07 Staff oversee the supervision of students when they provide patient care, treatment, and services as part of their training. 5 Revision Type: Revised HR.0.0.07 Staff supervise students when they provide patient care, treatment, and services as part of their training. 5 Standard HR.0.04.0 The hospital provides orientation to staff. HR.0.04.0 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.0.04.0 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 07 07 The Joint Commission
Hospital (HAP) Accreditation Program Issued September 5, 07 HR.0.04.0 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.0.05.0, EP 6) HR.0.04.0 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.0.04.0 The hospital orients staff on the following: Relevant hospitalwide and unitspecific policies and procedures. Completion of this orientation is documented. HR.0.04.0 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.0.04.0 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.0.05.0, EP 6; IC.0.0.0, EP 7; IC.0.04.0, EP ; RI.0.0.0, EP 8) 4 HR.0.04.0 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 07 07 The Joint Commission
Hospital (HAP) Accreditation Program Issued September 5, 07 HR.0.04.0 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.0.04.0 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.0.04.0 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.0.04.0 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.0.05.0 Staff participate in ongoing education and training. HR.0.05.0 Staff participate in ongoing education and training to maintain or increase their competency. Staff participation is documented. HR.0.05.0 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 07 07 The Joint Commission
Hospital (HAP) Accreditation Program Issued September 5, 07 HR.0.05.0 Staff participate in ongoing education and training whenever staff responsibilities change. Staff participation is documented. 4 HR.0.05.0 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.0.0.0 The hospital identifies the individual(s) responsible for the infection prevention and control program. IC.0.0.0 The hospital assigns responsibility for the daily management of infection prevention and control activities. (See also HR.0.0.0, EP ; LD.0.06.0, 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.0.0.0 The hospital assigns responsibility for the daily management of infection prevention and control activities. (See also HR.0.0.0, EP ; LD.0.06.0, 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.0.0.0 The hospital identifies risks for acquiring and transmitting infections. IC.0.0.0 The hospital identifies risks for acquiring and transmitting infections based on the following: Its geographic location, community, and population served. (See also NPSG.07.0.0, EP ) IC.0.0.0 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.07.0.0, EP ) Page of 5 Tuesday, Sep 07 07 The Joint Commission
Hospital (HAP) Accreditation Program Issued September 5, 07 IC.0.0.0 The hospital identifies risks for acquiring and transmitting infections based on the following: The care, treatment, and services it provides. (See also NPSG.07.0.0, EP ) IC.0.0.0 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.07.0.0, EP ) IC.0.0.0 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.07.0.0, EP ; TS.0.0.0, EP ) IC.0.0.0 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.07.0.0, EP ) IC.0.0.0 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.07.0.0, EP ) 4 Revision Type: Moved IC.0.0.0 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.07.0.0, EP ) IC.0.0.0 The hospital prioritizes the identified risks for acquiring and transmitting infections. These prioritized risks are documented. (See also NPSG.07.0.0, EP ) 5 Revision Type: Moved IC.0.0.0 The hospital prioritizes the identified risks for acquiring and transmitting infections. These prioritized risks are documented. (See also NPSG.07.0.0, EP ) Page of 5 Tuesday, Sep 07 07 The Joint Commission
Hospital (HAP) Accreditation Program Issued September 5, 07 Standard IC.0.04.0 Based on the identified risks, the hospital sets goals to minimize the possibility of transmitting infections. Note: See NPSG.07.0.0 for hand hygiene guidelines. IC.0.04.0 The hospital's written infection prevention and control goals include the following: Addressing its prioritized risks. IC.0.04.0 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.07.0.0, EP ) IC.0.04.0 The hospital's written infection prevention and control goals include the following: Limiting unprotected exposure to pathogens. IC.0.04.0 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.07.0.0, EP ) Page 4 of 5 Tuesday, Sep 07 07 The Joint Commission
Hospital (HAP) Accreditation Program Issued September 5, 07 IC.0.04.0 The hospital's written infection prevention and control goals include the following: Limiting the transmission of infections associated with procedures. IC.0.04.0 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.07.0.0, EP ) IC.0.04.0 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.0.04.0 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.07.0.0, EP ) IC.0.04.0 The hospital's written infection prevention and control goals include the following: Improving compliance with hand hygiene guidelines. (See also NPSG.07.0.0, EP ) 5 IC.0.04.0 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.07.0.0, EP ) Page 5 of 5 Tuesday, Sep 07 07 The Joint Commission
Hospital (HAP) Accreditation Program Issued September 5, 07 Standard IC.0.0.0 The hospital works to prevent the transmission of infectious disease among patients, licensed independent practitioners, and staff. IC.0.0.0 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.0.0.0 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.0.0.0 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.0.0.0 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.0.0.0 The hospital evaluates the effectiveness of its infection prevention and control plan. IC.0.0.0 The hospital evaluates the effectiveness of its infection prevention and control plan annually and whenever risks significantly change. IC.0.0.0 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.07.0.0, EP ) - Implementation of the infection prevention and control plan s activities. Page 6 of 5 Tuesday, Sep 07 07 The Joint Commission
Hospital (HAP) Accreditation Program Issued September 5, 07 IC.0.0.0 The evaluation includes a review of the following: The infection prevention and control plan's prioritized risks. IC.0.0.0 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.07.0.0, EP ) - Implementation of the infection prevention and control plan s activities. IC.0.0.0 The evaluation includes a review of the following: The infection prevention and control plan's goals. (See also NPSG.07.0.0, EP ) IC.0.0.0 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.07.0.0, EP ) - Implementation of the infection prevention and control plan s activities. IC.0.0.0 The evaluation includes a review of the following: Implementation of the infection prevention and control plan s activities. 4 IC.0.0.0 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.07.0.0, EP ) - Implementation of the infection prevention and control plan s activities. Page 7 of 5 Tuesday, Sep 07 07 The Joint Commission
Rights and Responsibilities of the Individual (RI) Chapter Hospital (HAP) Accreditation Program Issued September 5, 07 Standard RI.0.0.0 The hospital respects, protects, and promotes patient rights. RI.0.0.0 The hospital respects the patient s right to pain management. (See also HR.0.04.0, EP 4; PC.0.0.07, EP ; MS.0.0.0, EP ) 8 Revision Type: Revised RI.0.0.0 The hospital respects the patient s right to pain management. (See also LD.04.0., EP ) 8 Standard RI.0.0.0 The hospital respects the patient's right to receive information in a manner he or she understands. RI.0.0.0 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.0.0.0 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 07 07 The Joint Commission
Hospital (HAP) Accreditation Program Issued September 5, 07 Standard RI.0.0.0 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.0.0.0 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.0.0.0 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.0.0.07, EP 5; RI.0.0.0, EP ) RI.0.0.0 The hospital provides the patient with written information about the right to refuse care, treatment, and services. RI.0.0.0 The hospital provides the patient or surrogate decision-maker with written information about the right to refuse care, treatment, and services. (See also PC.0.0.07, EP 5) RI.0.0.0 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.0.0.0 The hospital provides the patient or surrogate decision-maker with written information about the right to refuse care, treatment, and services. (See also PC.0.0.07, EP 5) RI.0.0.0 The hospital respects the patient s right to refuse care, treatment, and services, in accordance with law and regulation. RI.0.0.0 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.0.0.07, EP 5) 4 Page 9 of 5 Tuesday, Sep 07 07 The Joint Commission
Hospital (HAP) Accreditation Program Issued September 5, 07 RI.0.0.0 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.0.0.0 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.0.0.07, EP 5) 4 RI.0.0.0 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.0.0.0 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.0.0.07, EP 5) 8 RI.0.0.0 0 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.0.0.0 0 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 07 07 The Joint Commission
Hospital (HAP) Accreditation Program Issued September 5, 07 RI.0.0.0 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.0.0.0 0 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.0.0.0 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.0.0.0 0 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 07 07 The Joint Commission