2012 Comprehensive Accreditation Manual for Table of Changes September 2012 To update your manual, please remove and recycle the pages listed in this table of changes, and insert the replacement pages included in this packet. Check boxes have been provided in the table of changes for your convenience to track the removal and addition of pages. Major changes that appear in this update to reuirements for accreditation, policies, procedures, and other information include the following: n A description of the new Intracycle Monitoring (ICM) process and the Focused Standards Assessment (FSA), which are waived for long term care in 2013, in The Accreditation Process (ACC) chapter n Accreditation decision rules for 2013 in the ACC chapter, effective January 1, 2013 n Revised the reuirements for uality control checks in WT.04.01.01, EP 4 effective May 23, 2012 Refer to the table beginning on page 2 and the actual update pages for more details about revisions included in this update. Revisions to content within this update are highlighted in shaded text within your replacement pages. 1
Title Page and Contents Page Title page and Updated title page and contents page Effective contents page immediately How to Use This Manual (HM) Entire chapter Minor editorial changes Effective Revised Table 1. Acronyms Used in immediately This Manual Changed references from Periodic Performance Review (PPR) to Focused Standards Assessment (FSA) and the Intracycle Monitoring (ICM) process throughout chapter as applicable Revised Figure 1. Components of a reuirements chapter Updated the description of the indirect impact reuirement icon in the Understanding the Icons Used in the Manual Revised tips for organizations in the Keys to Successfully Using This Manual Included new resources and updated existing resources listed in Sidebar 2. Where Should I Go for More Information? 2
Reuirements for Accreditation Accreditation Participation Reuirements (APR) Entire chapter d PPR with FSA in chapter Effective outline and chapter overview January 1, 2013 d PPR with FSA in Standard APR.03.01.01, rationale, EPs 1, 3, 4, 6, 7 d PPR with FSA in note to APR.06.01.01, EP 1 Minor editorial changes Infection Prevention and Control (IC) IC-5 IC-16 Made minor editorial changes Effective with January 1, 2013 IC-5 IC-18 Life Safety (LS) LS-3 LS-8 Made minor editorial changes Effective LS-15 LS-16 Changed PPR to FSA in About This January 1, 2013 LS-19 LS-20 Chapter Record of Care, Treatment, and Services (RC) RC-5 RC-6 Made minor editorial change to Effective RC.02.01.01, EP 1 January 1, 2013 Waived Testing (WT) WT-7 WT-10 Revised reuirements for uality con- Effective trol checks and deleted note in May 23, 2012 WT.04.01.01, EP 4 3
Policies, Procedures, and Other Information The Accreditation Process (ACC) ACC-1 Made minor editorial changes and Effective ACC-50 with policy clarifications January 1, 2013 ACC-1 Added footnote defining complex orga- ACC-50b nization to Complex Organization ACC-59 Survey Process ACC-68 Changed references from Periodic ACC-73 Performance Review (PPR) to Fo- ACC-92 with cused Standards Assessment (FSA) ACC-73 throughout chapter as applicable ACC-92b Reformatted and made minor editorial changes to Public Information Policy Updated Sidebar 1. Early Survey Policy and Eligibility for Preliminary Accreditation to reflect that an organization s Preliminary Accreditation decision will change to Unaccredited if it is not ready for a second survey at six months Updated Forfeiture of Survey Deposit Added new or revised subprocesses to PFA categories Communication, Infection Control, Orientation & Training, and Physical Environment Revised Table 1. Exceptions to Unannounced Surveys Added Second Generation Tracers Revised definition of Contingent Accreditation in Accreditation Decision Categories 4
Added new Intracycle Monitoring to the Between Accreditation Surveys d Periodic Performance Review (PPR) with new Focused Standards Assessment (FSA) Updated Accreditation Status of Organizations That Cease Provision of Services for a Period of Time regarding the need to notify The Joint Commission if an organization ceases to provide services Updated 2013 Accreditation Decision Rules, including deleting Contingent Accreditation (CONT) decision rule CONT04 adding CONT06 adding CONT07 deleting On-site MOS Survey and decision rule MOS02 The Joint Commission Quality Report (QR) Entire chapter Minor editorial changes Effective January 1, 2013 Medicare/Medicaid Certification Based Accreditation Standards (MC) MC-9 MC-18 Deleted PPR from chapter overview Effective MC-51 MC-54 and footnote in APR chapter January 1, 2013 with MC-51 d PPR with FSA in note to MC-54d APR.06.01.01, EP 1 MC-101 Minor editorial changes MC-108 Revised when date became effective for Standard IC.02.04.01, EPs 1 4, 7, 9 5
Revised reuirements for uality con- Effective trol checks and deleted note in May 23, 2012 WT.04.01.01, EP 4 Appendix A: Reference Guide of Selected Medicare Reuirements to Relevant Joint Commission Reuirements (AXA) Entire chapter Updated calendar year Effective January 1, 2013 Glossary Entire chapter Made minor editorial changes Effective Revised definitions for the terms Ac- January 1, 2013 credited and Contingent Accreditation within the accreditation decisions entry and for accreditation survey Expanded behavioral health care definition to include developmental disabilities and community-based settings Added new terms Focused Standards Assessment (FSA)and Intracycle Monitoring (ICM) Deleted the definition for the term Periodic Performance Review (PPR) and in its place created a cross reference to the new term Focused Standards Assessment (FSA) Revised surveyor definition with additional information that type of surveyor(s) assigned is determined by the program and its services Index Entire chapter Updated index Effective immediately 6