What's New January 2017 Release

Transcription

1 Comprehensive Accreditation Manual for What's New January Release What s New is intended to help you understand the substantive changes in the most recent E-dition release. Please refer to the following table and to E-dition screens for more details about changes included in this release. Standards revisions can be easily found by clicking on Filters in the blue navigation bar across the top of the screen and checking the New/Changed EPs as of selected effective date box. Major changes to reuirements for accreditation policies, procedures, and other important information in this update include the following: n Clarified, augmented, and reorganized content throughout the former How to Use This Manual (HM) chapter and renamed it Introduction: How The Joint Commission Can Help You Move Toward High Reliability n Replaced the scoring methodology described in The Accreditation Process (ACC) chapter with the Survey Analysis for Evaluating Risk (SAFER ) approach, which provides organizations with additional information related to risk of deficiencies to help prioritize and focus corrective actions n Eliminated the A and C designations, Measures of Success, and patient care impact icons throughout the manual to align with the revised scoring and decision process n Removed icon key from all standards chapters Please refer to the table that begins on the following page for more details about this update. Revisions to content within the nonscoring chapters are highlighted using shaded text., January i

2 Introduction: How The Joint Commission Can Help You Move Toward High Reliability (INTRO) Revised chapter title from How to Use This Manual (HM) to Introduction: How The Joint Commission Can Help You Move Toward High Reliability (INTRO) Updated and clarified content throughout the chapter and reorganized it into four parts: Part I: Provides a brief overview of Joint Commission accreditation Part II: Explains the organization and content of the manual Part III: Explains how to use the manual for compliance with Joint Commission standards Part IV: Provides a comprehensive list of contacts and resources for more information at The Joint Commission and Joint Commission Resources Added new Figure 1. Achieve, Maintain, and Demonstrate Consistent Excellence Table 1. Acronyms Used in This Manual: Updated program-specific terms and added the term Survey Analysis for Evaluating Risk (SAFER) Accreditation Reuirements: Revised standards chapter descriptions Understanding the Organization of the Standards Chapters: Added section describing the organizing components of a standards chapter Figure 1: Updated figure with revised components of standards chapters and renumbered as Figure 3 Understanding the Icons Used in the Manual: Removed descriptions of scoring categories A and C, Measure of Success (MOS), and patient care impact icons. Added Note explaining revision to The Joint Commission scoring and decision process Removed Sidebar 1. Icons in This Manual Added new Figure 4. Key Milestones in the Accreditation Process ii, January

3 Sidebar 2. Where Should I Go for More Information?: Updated information and moved to Part IV. Get Extra Help Accreditation Reuirements Accreditation Participation Reuirements (APR) Removed scoring category icons from all EPs and patient care impact icons from affected EPs Prompts to Assess Your Compliance: Added uestion regarding an organization s update of its average daily census in the E-App Written Documentation Checklist updated to match standards revisions APR , EP 4: Added documentation icon APR , EP 3: Added documentation icon Environment of Care (EC) Removed scoring category icons from all EPs and patient care impact icons and MOS icons from affected EPs Minor editorial revisions Categorical Waivers to Certain Reuirements: Deleted section. Other Issues for Consideration: Specified that intervals of a month and a week mean once per calendar month and once per calendar week EC , EP 1: Clarified the organization needs a process to identify risks, added documentation icon, and deleted standards cross-reference EC , EP 3: Added documentation icon EC : Renumbered former EP 10 combined with EP 9, added documentation icon, and deleted standards cross-reference January 9, January 9,, January iii

4 Made the following changes to EC : Added to EP 1 a documentation icon and moved a Note to EP 1 permitting alternative methods to audible alarms to notify staff during drills conducted between 9 P.M. and 6 A.M. Added documentation icon to EP 2 Moved Note in EP 4 regarding alternative methods besides audible alarms to EP 1 Deleted standards cross-reference in EP 5 Made the following changes to EC : Clarified in EP 1 that results and dates must be documented; updated Note 1 reference to NFPA ; added Note 2 explaining what elements are included in supervisory signals Clarified in EP 2 the types of water flow devices that should be tested every six months and that results and dates must be documented; updated Note 1 reference to NFPA ; added Note 2 regarding testing of mechanical water-flow devices Removed in EP 3 electromechanical-releasing devices from list of items to be tested; clarified that results and dates must be documented; updated Note reference to NFPA Added door-releasing devices to items to be tested in EP 4 ; clarified that results and dates must be documented; updated Note reference to NFPA Expanded testing time frame of fire alarm euipment in EP 5 from every uarter to every 12 months; clarified that results and dates must be documented; updated Note reference to NFPA Changed time frames in EP 6 to monthly for electric motor driven fire pumps and retained weekly test reuirement for diesel engine-driven fire pumps; clarified that results and dates must be documented; updated Note reference to NFPA iv, January

5 Clarified in EPs 7 11 that test results and dates must be documented; made minor editorial updates; updated Note references to NFPA Added reuirement in EP 12 for hydrostatic tests in addition to water-flow tests for standpipe systems; clarified that test results and dates must be documented; updated reference to NFPA Clarified in EP 13 that test results and dates must be documented; updated reference to NFPA Clarified in EP 14 that test results and dates must be documented; added Note 2 with reference to NFPA Clarified in EP 15 that test results and dates must be documented; revised Note 2 regarding inspection of and access to fire extinguishers; updated Note 3 reference to NFPA Included recharging as part of reuired yearly maintenance in EP 16; added reuirement that individuals performing such maintenance must be certified; clarified that results and dates must be documented; updated Note reference to NFPA Clarified in EP 17 that test results and dates must bedocumented; updated references to NFPA and NFPA Added reuirement in EP 18 that fire and smoke dampers be operated one year after installation to verify they fully close, in addition to every four years; clarified that test results and dates must be documented; updated Note reference to NFPA 90A- 2012, NFPA , and NFPA Clarified in EP 19 that test results and dates must be documented; updated reference to NFPA 90A-2012 Added in EP 20 smoke-barrier sliding or rolling doors and corridor walls and partitions to be tested every 12 months; clarified that test results and dates must be documented; updated Note reference to NFPA and NFPA , January v

6 Added new EP 25 reuiring written documentation of annual inspection and testing of door assemblies Clarified in EP 26 that test results and dates must be documented; updated reference to NFPA and NFPA Made the following changes to EC : Deleted standards cross-references in EPs 3 and 4 Added new EP 16 and Note addressing ventilation systems in non-critical areas Renumbered former EP 16 as EP 17 on maintenance and repair of euipment Added new EP 18 on medical gas storage rooms and transfer and manifold rooms complying with NFPA Added new EP 19 on maintaining the emergency power supply system s euipment and environment Made the following changes to EC : Added new EP 1 regarding essential electrical systems per NFPA Renumbered former EP 1 as EP 2; added time frame of providing emergency power within 10 seconds ; updated references in Note to NFPA and NFPA Renumbered former EPs 2 and 3 as EPs 3 and 4; added time frame of within 10 seconds ; added new Notes with references to NFPA and NFPA Added new EP 10 to address emergency lighting at emergency generator locations and new Note with reference to NFPA and NFPA Made the following changes to EC : Added new EP 1 to address an organization s process for managing risk during repair or maintenance activities Renumbered former EP 1 as EP 2; clarified that dates and results of testing are documented vi, January

7 Renumbered former EP 2 as EP 3; clarified that dates and results of testing are documented; deleted standards cross-reference Added new EP 7 about meeting Health Care Facilities Code reuirements for electrical distribution and a new Note applicable to hospices that elect deemed status Made the following changes to EC : Added to EP 1 a reuirement for visual inspection of EXIT signs; clarified that test results and dates must be documented; added new Note with reference to NFPA Clarified in EP 2 that test results and dates must be documented Differentiated in EP 3 between Level 1 (monthly) and Level 2 (uarterly) tests of stored emergency power supply systems (SEPSS); clarified that test results and dates must be documented; clarified Note 2 refers to Level 1 SEPSS; updated reference to NFPA under Note 3 Added new EP 4 regarding weekly inspection of emergency power supply system, with a Note referencing NFPA Renumbered former EP 4 as EP 5; specified that the cool down period is not part of the 30 continuous minutes of a test; clarified that results and dates must be documented Renumbered former EP 5 as EP 6; updated standards crossreference; decreased testing time total from 2 to 1 ½ hours (by deleting reuirement for 30 minutes of nameplate testing) Renumbered former EP 6 as EP 7; clarified that results and dates must be documented Added new EP 9 regarding the testing of emergency generators at least once every 36 months with a Note referencing NPFA Added new EP 10 regarding the 36-month test of diesel-powered emergency generators including nameplate testing Renumbered former EPs 9 and 10 as EPs 11 and 12 on reuirements if an emergency power system test fails, January vii

8 EC , EP 13: Deleted EP on maintaining suitable ventilation, temperature, and humidity levels EC , EP 12: Added documentation icon and deleted standards cross-references EC , EP 1: Deleted standards cross-reference Minor editorial revisions Written Documentation Checklist: Updated to match standards revisions Emergency Management (EM) Removed scoring category icons from all EPs and patient care impact icons from affected EPs Euipment Management (EQ) Removed scoring category icons from all EPs and patient care impact icons and MOS icons from affected EPs Human Resources (HR) Removed scoring category icons from all EPs and patient care impact icons and MOS icons from affected EPs HR , EP 2: Added documentation icon Written Documentation Checklist: Updated to match standards revisions Infection Prevention and Control (IC) Removed scoring category icons from all EPs and patient care impact icons and MOS icons from affected EPs Information Management (IM) Removed scoring category icons from all EPs and patient care impact icons and MOS icons from affected EPs January 9, viii, January

9 Leadership (LD) Removed scoring category icons from all EPs and patient care impact icons and MOS icons from affected EPs Life Safety (LS) Removed scoring category icons from all EPs and patient care impact icons and MOS icons from affected EPs Made the following changes to LS : Renumbered former EP 3 as EP 1 regarding written interim life safety measure (ILSM) policy to cover situations when Life Safety Code deficiencies cannot be immediately corrected or during periods of construction; added reference to the reuirements that follow in LS , EPs 2-14 Renumbered former EPs 1 and 2 as EPs 2 and 3; added lead-in referring to when Life Safety Code deficiencies cannot be immediately corrected or during periods of construction Applicability of the Standards: Moved information from the Note about standards applicable to hospices to the text About This Chapter: Changed date of determination between existing and new health care occupancies from March 1, 2003, to July 5, 2016; updated NFPA references to ; clarified the Life Safety Code may contain provisions, rather than exceptions Managing Compliance with the NFPA Life Safety Code: Deleted section (as euivalencies are not part of the process) Categorical Waivers to Certain Reuirements: Deleted section. Made the following changes to LS : Added new EP 2 to clarify that organizations will perform a building assessment to determine compliance with LS standards in time frames defined by the organization January 9,, January ix

10 Renumbered former EP 3 as EP 4; adapted to address the Survey-Related Plan for Improvement (SPFI); applied a standard 60-day time frame; removed standards cross-reference; added four Notes addressing time-limited waivers, euivalencies, waivers, and a reference to NFPA Added new EP 6 on life safety features reuired for new construction Made the following changes to LS : Deleted in EP 1 standards cross-reference Revised EP 2 to add evacuation as an option; clarified the length of time for how long the fire alarm system (4 out of 24 hours) and sprinkler system (10 out of 24 hours) can be out of service; updated reference to NFPA and NFPA Deleted standards cross references in EPs 2 14 Made the following changes to LS : Removed height reuirement in EP 1 per updated reference to NFPA Deleted former EP 2 on sprinkler systems Added new EP 2 on incorporating Chapter 43, Building Rehabilitation during times of building rehabilitation; updated reference to NFPA Deleted former EP 3 on height and width of fire-rated walls Added new EP 3 on the continuity of fire barriers, including interstitial spaces Deleted former EP 4 on openings in 2-hour fire-rated walls Added new EP 4 on fire rating for common walls Added new EP 5 on fire protection ratings for various opening protectives x, January

11 Renumbered former Standard LS , EP 4, as EP 6 on fire ratings of exit stairs Renumbered and combined former EPs 5 and 6 as EP 7; prohibited blocking or wedging fire-rated doors; updated reference NFPA and NFPA Renumbered former EP 7 as EP 8; specified informational signs are applied with adhesive only; updated reference to NFPA Renumbered former EP 8 as EP 9; clarified specific time durations for various penetrations; updated reference to NFPA and NFPA 90A-2012 Renumbered former EP 9 as EP 10 ; clarified reuirement; updated reference in Note to NFPA and removed mention of exceptions Renumbered former EP 10 as EP 11 and updated reference to NFPA Made the following changes to LS : Updated references to NFPA and removed mention of exceptions from NFPA references throughout Clarified in EP 1 that compliant locking configurations may be used for doors in a means of egress Changed EP 2 to apply reuirement from an occupancy of 50 or more to a room or area with occupancy of 50 or more; included exception for doors in existing smoke barriers; removed mention of exceptions in NFPA reference Removed in EP 3 standards cross-reference Renumbered and updated former EP 5 as EP 4 on horizontal exits doors in existing buildings; added exception for doors in existing construction Renumbered former EP 6 as EP 5 on horizontal exit walls Renumbered former EP 4 as EP 6 regarding outside exit stairs, January xi

12 Renumbered former EP 29 as EP 8 regarding signage in stairs serving five or more stories Renumbered former EP 8 as EP 9 on exits discharging to the outside Added new EP 10 on the allowable use of exit enclosures Renumbered former EP 13 as EP 11 on keeping means of egress clear of obstruction; added two new Notes detailing what is allowed, including wheeled euipment and secured furniture, if certain reuirements are met Split former EP 9 as EPs 11 and 12 on activating closure of all doors in a stairway Renumbered former EP 15 as EP 13 regarding the reuirement for two exits from floors and compartments Renumbered and split former EP 11 as EP 14 on width of exit corridors in new buildings and EP 15 in existing buildings, including modifications of existing buildings Renumbered former EP 14 as EP 16 on keeping exit access and exit doors free from coverings Renumbered former EP 10 as EP 17 on prohibiting automatic release devices on doors to new boiler, heater, and mechanical euipment rooms located in a means of egress Renumbered and slightly clarified former EP 12 as EP 18 on wall projections in corridors Renumbered former EP 26 as EP 19 regarding the length of dead-end corridors in new buildings Renumbered former EP 21 as EP 20 regarding the direct opening from patient sleeping rooms to an exit access corridor xii, January

13 Renumbered and combined former EP 16 as EP 21 on suites of patient sleeping rooms larger than 1,000 feet and former EP 17 on suites not used as patient sleeping rooms which are larger than 2,500 suare feet; split information about patient sleeping rooms into EP 25 Updated EP 22 to allow doors to patient sleeping rooms to be locked under certain clinical or specialized security circumstances if staff can readily unlock doors at all times Deleted former EP 23 on travel distance to a room door within a patient sleeping room Added new EP 23 regarding the separation of suites from the remainder of the building Added new EP 24 on partitioning suites Renumbered former EP 16 as EP 25 regarding two exit doors from suites of patient sleeping rooms larger than 1,000 suare feet; added reuirement for one door to exit to corridor; moved information about suites of patient sleeping rooms to EP 21 Renumbered former EP 17 as EP 26 regarding two exit doors from suites not used as patient sleeping rooms which are larger than 2,500 suare feet; added reuirement for one door to exit to corridor; moved information about suites of patient sleeping rooms to EP 21 Renumbered EP 18 as EP 27 limiting suites of patient sleeping rooms in existing buildings to 5,000 suare feet or less; 7,500 suare feet or less if automatically sprinklered; or 10,000 suare feet if the suite also has direct visual supervision Added new EP 28 limiting suites of patient sleeping rooms in new buildings to 7,500 suare feet or less or 10,000 suare feet if the suite also has total coverage smoke detection and direct visual supervision Added new EP 29 limiting suites not used for sleeping to 10,000 suare feet, January xiii

14 Renumbered, combined, and revised former EPs 19 and 20 and EPs 24 and 25 as new EPs 30 (new buildings) and EP 31 (existing buildings) regarding travel distance in sleeping or nonsleeping patient care suites to exit doors Renumbered former EP 27 as EP 32 regarding adeuate illumination of all points in a means of egress Renumbered former EP 28 as EP 33 regarding planning for the failure of illumination along the means of egress; clarified illumination must not be < 0.2 foot candles Renumbered and clarified former EP 31 as EP 34 on the adeuacy of exit signs Renumbered former EP 30 as EP 35 on NO EXIT signs Renumbered former EP 32 as EP 36 on meeting all other Life Safety Code means of egress reuirements Made the following revisions to LS : Updated references to NFPA , NFPA 90A-2012, NFPA , and NFPA throughout Updated EP 1 on vertical openings Split former EP 2 into EPs 2 and 3 on walls and doors for new and existing hazardous areas Deleted former EP 3 on fire ratings for gift shops with combustibles Added new EP 4 permitting a cooking facility to be open to the corridor Added new EP 5 permitting alcohol-based hand rub (ABHR) dispensers in smoke compartments Renumbered former EP 4 as EP 6 on wall and ceiling interior finishes Renumbered and revised former EP 5 as EP 7 on newly installed and existing interior floor finishes xiv, January

15 Deleted former EP 7 Split and updated former EP 6 as EPs 8, 9, and 10 on fire resistance rating of corridor wall partitions Deleted former EP 10 on protective plates on corridor doors Deleted former EP 11 on corridor doors Split and updated former EP 9 as EPs 11 and 12 on constructed and existing corridor doors, including prohibiting roller latches Renumbered former EP 8 as EP 13 on fixed fire windows Renumbered former EP 12 as EP 14 on openings in vision panels or doors in corridor walls Renumbered and updated former EP 13 as EP 15 on corridors serving adjoining areas Updated EP 16, and consolidated with former EPs 15 and 19, on smoke compartments in new buildings Renumbered and revised former EP 14 as EP 17 on smoke compartments in existing buildings; added information on fire resistance rating and travel distance Deleted former EP 17 on the size of smoke compartments Added a new Note to EP 18 on polyurethane expanding foam Renumbered and revised former EP 23 as EP 19 on doors in smoke barriers Renumbered former EP 22 as EP 20 on fixed fire windows in smoke barrier doors Renumbered and updated former EP 20 as EP 21 on smoke dampers and ducts Renumbered former EP 21 as EP 22 on approved smoke dampers protecting air transfer openings Added new EP 23 on outside windows and doors for patient sleeping rooms Added new EP 24 on window sill height in patient sleeping rooms, January xv

16 Moved former EP 24 on exit stairs for three or fewer floors to LS , EP 6 Deleted Note about ABHR in EP 25 Made the following changes to LS : Streamlined EP 1 by eliminating bulleted list and referring to provisions of NFPA Clarified in EP 2 that the fire alarm control panel be located in an area with a smoke detector or in a continuously occupied and protected environment Added new EP 3 on the ceiling membrane Deleted former EP 3 on remote ancillary annunciator panels Updated reference in EP 4 to NFPA Made the following changes to LS : Updated references to NFPA , NFPA , NFPA , NFPA , and NFPA throughout Added to EP 5 a reuirement for escutcheon plates Deleted former EP 7 on a shutoff valve for limited-area sprinkler systems Added new EP 8 on sprinkler protection for clothing closets in patient sleeping rooms Added new EP 9 on uick response sprinklers Renumbered former EP 8 as EP 10 on portable fire extinguishers and clarified details about their placement Renumbered and updated former EP 9 as EP 11 on Class K-type portable fire extinguishers; added reuirement to post a notice about activating the fire protection system prior to their use Renumbered former EP 10 as EP 12 on exhaust hoods for grease-producing cooking devices Consolidated former EPs into revised EP 13 on automatic fire extinguishing systems for grease-producing cooking devices xvi, January

17 Made the following changes to LS : Deleted former EP 1 on windowless buildings or portions thereof Renumbered former EP 2 as EP 1 on automatic sprinkler systems in high-rise buildings; added new Note on time period to install in existing buildings; updated reference to NFPA Added new EP 2 on meeting all other Life Safety Code automatic extinguishing reuirements Made the following changes to LS : Updated references to NFPA and NFPA throughout Consolidated former EPs 1 3 as EP 1 on fireplaces in patient sleeping rooms Renumbered former EP 4 as EP 2 on euipping new elevators Renumbered former EP 8 as EP 3 on the fire rating of inlet door assemblies Renumbered former EP 9 as EP 4 on latching devices for linen and waste chute inlet and discharge service doors Renumbered former EP 10 as EP 5 and clarified that the fire rating of chutes must be matched to their discharge door assemblies Deleted former EP 6 on vent openings for linen and trash chutes Renumbered former EP 7 as EP 6 on automatic sprinkler system installations in chutes Renumbered and revised former EP 5 as EP 7 on trash chutes; added reuirement about fire resistance rating; included exception for approved automatic sprinkler system Deleted former EP 11 on fire rating of walls in collection rooms Renumbered former EP 12 as EP 8 on meeting all other related Life Safety Code reuirements, January xvii

18 Made the following revisions to LS : Updated references to NFPA throughout Added new EP 1 on prohibiting smoking and related reuired signage Added new EP 2 to address use of safely-designed ashtrays in areas where smoking is permitted Renumbered EP 1 as EP 3 but revised to clarify under what conditions decorations may be attached to walls, ceilings, and non-fire-rated doors Renumbered former EP 2 as EP 4; removed reference to recycling containers; Added Note that addresses permissible storage areas for containers 96 gallons and less Renumbered former EP 3 as EP 5 on portable space heaters ; added exception for non-sleeping rooms occupied by staff; added Note classifying nurses stations as patient-treatment areas for this EP Renumbered former EP 4 as EP 6 on meeting all other related Life Safety Code reuirements Written Documentation Checklist: Updated to match standards revisions Minor editorial revisions Medication Management (MM) Removed scoring category icons from all EPs and patient care impact icons and MOS icons from affected EPs National Patient Safety Goals (NPSG) Removed scoring category icons from all EPs and patient care impact icons and MOS icons from affected EPs xviii, January

19 Provision of Care, Treatment, and Services (PC) Removed scoring category icons from all EPs and patient care impact icons and MOS icons from affected EPs Performance Improvement (PI) Removed scoring category icons from all EPs and MOS icon from affected EP Record of Care, Treatment, and Services (RC) Removed scoring category icons from all EPs and patient care impact icons and MOS icons from affected EPs Rights and Responsibilities of the Individual (RI) Removed scoring category icons from all EPs and patient care impact icons and MOS icons from affected EPs Waived Testing (WT) Removed scoring category icons from all EPs and patient care impact icons and MOS icons from affected EPs Accreditation Process Information The Accreditation Process (ACC) Eligibility for Accreditation E. Pharmacy Services: Specified exclusion only of retail pharmacy practices with a walk-in business; added description for Specialty Pharmacies System Accreditation Option: Revised policy by changing number of sites that must be reviewed, identifying high-risk and low-risk services, and adding time frames for extension surveys Concurrent Survey Option: Deleted bullet stating that hospices under one organization will receive one accreditation decision Currently, January xix

20 Integrated Care Certification Option: Added section describing optional certification for entities that are integrating patient care across the continuum Information Accuracy and Truthfulness Policy: Minor editorial revisions Good Faith Participation in Accreditation/Certification: Minor editorial revisions Made the following revisions to the Public Information Policy: Publicly Available Accreditation and Certification Information: Standards text for Reuirements for Improvement (RFIs) identified for organizations that receive Accreditation with Follow-up Survey decisions are no longer posted on Quality Check Release of Aggregate Complaint-Related Information: Number of written, standards-related complaints and summary of applicable standards areas are no longer provided upon reuest to any party Minor editorial revisions Early Survey Policy: Officially changed Preliminary Accreditation to Limited, Temporary Accreditation Forfeiture of Survey Deposit: Added language clarifying that organizations that already have Joint Commission accreditation are not reuired to pay a deposit Survey Agenda: Revised the Life Safety Code Building Assessment session section by deleting language about reviewing/accepting the Statement of Conditions (SOC) Plan for Improvement (PFI) items as the surveyor no longer performs this task Immediate Threat to Health or Safety During Initial Survey: Added statement to reflect that an organization cannot withdraw from the accreditation process once an Immediate Threat to Health or Safety situation is identified xx, January

21 Changes to the Site of Care of Care, Treatment, or Services: Updated section by replacing reuirement to complete SOC, Basic Building Information, and PFI with reuirement to evaluate for Life Safety Code deficiencies and document corrective actions and Interim Life Safety Measures (ILSM) On-site Follow-up Survey for a Condition-level Deficiency: Revised to reflect that an unsuccessful second survey results in recommending a PDA decision to the Joint Commission executive leadership Replaced the term Accreditation Committee with executive leadership throughout Complex Organization Survey Process: Updated the reference to How to Use this Manual (HM) to Introduction: How The Joint Commission Can Help You Move Toward High Reliability (INTRO) as the chapter name has changed Made the following changes to The Summary of Survey Findings Report: Deleted references to Category C observations and Opportunities for Improvement Deleted statement about open Plan for Improvement (PFI) items being part of the final survey report Added description of SAFER matrix Made the following changes to The Scoring Process: Deleted description of scoring categories, which have been retired Deleted Sidebar 2. Scoring Categories for Elements of Performance Deleted scoring related to track record achievements Added description of new scoring methodology and Figure 4. Survey Analysis for Evaluating Risk (SAFER ) matrix, January xxi

22 Made the following changes to How Accreditation Decisions Are Made: Deleted description of former criticality model, which has been retired Deleted direct and indirect impact categories, which have been retired Updated descriptions of remaining two accreditation classifications (Immediate Threat to Health or Safety and Decision Rules) Changed Evidence of Standards Compliance (ESC) submission timeline to 60 days for all ESCs (except for organizations recommended for Preliminary Denial of Accreditation) Deleted former Figure 4. (Accreditation based on impact on patient care) The Accreditation Decision Process: Replaced information about scoring elements of performance (EPs) on a scale with information about identifying levels of compliance on the SAFER matrix; reiterated that organizations have a 60-day window to submit ESC report Made the following changes to Decision Categories for Organizations Seeking Accreditation Renewal: Officially changed Preliminary Accreditation to Limited, Temporary Accreditation in the footnote (effective August 1, 2016) Clarified that organizations are accredited if they successfully address all RFIs in an ESC in 60 days Changed Accreditation with Follow-up Survey to reflect language of revised Life Safety (LS) Standard LS , EP 4, on meeting 60-day time frames for PFIs and Survey Plan for Improvements (SPFIs) Decision Outcomes for Organizations Seeking Initial Accreditation: Changed ESC submission timeline to 60 days for all ESCs xxii, January

23 Made the following changes to Evidence of Standards Compliance (ESC) Process: Clarified ESC definition Deleted references to MOS, Categories A and C, and direct and indirect impact reuirements Stated that findings of a higher risk level reuire detailed descriptions of the leadership involvement and preventive analysis assisting in sustaining compliance Added Figure 6. SAFER matrix placement and reuired followup activities Deleted language regarding Statement of Conditions (SOC) process and Plan for Improvement (PFI) items with a projected completion date Deleted Figure 6. Evidence of Standards Compliance (ESC) Time Line (Days) and Figure 7. Measure of Success (MOS) Submission Time Line (Days); renumbered the remaining figures in the chapter Deleted Sample Sizes section Deleted Measure of Success (MOS) Report section Made the following changes to Focused Standards Assessment: Added footnote explaining that while FSA tool is being updated to reflect new scoring methodology, organizations should use current FSA tool Removed all references to MOS (including those in Sidebar 2 formerly Sidebar 3 Focused Standards Assessment Options) Noted that leadership of organizations with a PDA02 decision is reuired to participate in the Intracycle Monitoring (ICM) process Notifying The Joint Commission About Organization Changes: Revised to reflect that organizations must notify The Joint Commission and the Medicare Administrator Contractor (if Medicare certified) when additional services/locations are contemplated (rather than within 30 days after change occurs), January xxiii

24 Random Validation of Evidence of Standards Compliance: Removed references to MOS Made the following changes to Decision Rules for Organizations Seeking Reaccreditation: Removed MOS decision rule category; removed MOS reuirement from Denial of Accreditation (DA) decision rule DA04 and Accreditation with Follow-up Survey (AFS) decision rule AFS03 Deleted reference to direct impact standards from AFS01 Deleted AFS02 (as it focused on indirect impact standards) Decision Rules for Organizations Seeking Initial Accreditation: Officially renamed Preliminary Accreditation decision rule category as Limited, Temporary Accreditation (effective August 1, 2016); removed MOS decision rule category; removed MOS reuirement from Denial of Accreditation (DA) decision rules DA04 and DA08 Made the following changes to Review and Appeal Procedures: Changed references of Preliminary Accreditation to Limited, Temporary Accreditation (effective August 1, 2016) Removed references to MOS Sentinel Events (SE) Reuired Response to a Sentinel Event: Clarified who at The Joint Commission determines a change in an organization s accreditation status Submission of Comprehensive Systematic Analyses and Action Plans: Specified each approach to reviewing sentinel event response with a numbered alternative (Alternative 0 to Alternative 4) or as a Web-based option (Web-Alternative) Updated standards in Appendix section to match standards changes throughout the manual. Replaced the term Accreditation Committee with executive leadership throughout Minor editorial revisions xxiv, January

25 The Joint Commission Quality Report (QR) Updated chapter to reflect revisions to The Joint Commission Quality Check website What Will My Quality Report Contain?: Removed information about special uality awards/merit badges under Summary of Quality Information Added description of National Patient Safety Goals for clarification under Quality Indicators What Is Quality Check?: Revised list of features to reflect changes to The Quality Check website Minor editorial revisions Reuired Written Documentation (RWD) Added EPs reuiring written documentation to the following settings: Hospice Facility Based: APR , EP 4 APR , EP 3 EC , EP 1 EC , EP 3 EC , EP 9 EC , EP 1 EC , EPs 25, 26 EC , EP 3 EC , EPs 5, 7, 9, 10 EC , EP 12 LS , EP 2 Hospice Patient Residence: APR , EP 4 APR , EP 3 January 9,, January xxv

26 Durable Medical Euipment Patient Residence: HR , EP 2 Durable Medical Euipment Facility Based: EC , EP 1 HR , EP 2 Durable Medical Euipment Mail Order: HR , EP 2 Respiratory Euipment: HR , EP 2 Supplies Patient Residence: HR , EP 2 Supplies Mail Order: HR , EP 2 Prosthetics and Orthotics Patient Residence: HR , EP 2 Prosthetics and Orthotics Facility Based: EC , EP 1 EC , EP 12 HR , EP 2 Clinical Respiratory: HR , EP 2 Rehabilitation Technology Facility Based: EC EP 1 EC , EP 9 EC , EP 2 EC , EP 3 EC , EP 12 HR , EP 2 Freestanding Ambulatory Infusion: EC , EP 1 EC , EP 9 EC , EP 2 EC , EP 3 EC , EP 12 xxvi, January

27 Removed EPs from the following settings: Hospice Facility Based: EC , EP 1 Prosthetics and Orthotics Facility Based: RI , EP 16 RI , EP 1 Rehabilitation Technology Facility Based: EC , EP 2 Freestanding Ambulatory Infusion: EC , EP 2 WT , EP 6 WT , EP 1 WT , EP 1 Early Survey Policy Option (ESP) Added the following reuirements to the list of EPs applicable during the first survey of the Early Survey Policy option: EC , EP 9 EC EPs 16, 18, 19 EC , EPs 4, 10 EC , EPs 2, 7 EC , EPs 4, 12 LS , EPs 2, 6 LS , EP 11 LS , EPs LS , EPs 5, 6 Removed the following reuirements: EC , EP 10 EC , EP 10 EC , EP 13 LS , EP 7 LS , EPs 9 12, January January 9, xxvii

28 Community-Based Palliative Care (CBPC) No changes Appendix A: Medicare Reuirements for Hospice Updated the link in first paragraph Glossary Added the following term: SAFER matrix Revised the following term: accreditation decisions Deleted the following term(s): Accreditation Committee criticality direct impact reuirements indirect impact reuirements Measure of Success (MOS) situational decision rules xxviii, January