In May 2014, The Joint Commission reapplied to the Centers for Medicare & Medicaid Services (CMS) for deeming authority for psychiatric hospitals. In response to CMS’s review of its application, which is still underway, The Joint Commission developed and revised several elements of performance (EPs) for psychiatric hospitals that use Joint Commission accreditation for deemed status. These revisions, effective February 1, 2015, are designed to demonstrate that The Joint Commission meets or exceeds the current Medicare Conditions of Participation (CoPs).
prepublication_standards.aspx; in both places, new text is underlined and deleted text is shown in strikethrough. These revisions will be published electronically in a February 2015 E-dition® update and in print in the 2015 Update 1 to the Comprehensive Accreditation Manual for Hospitals in spring 2015.
Any additional changes that may result from further CMS review will be communicated in future issues of Perspectives and Joint Commission Online. For more information, please contact Laura Smith, project director, Department of Standards and Survey Methods, at lsmith@jointcommission
.org. P
ApplicAble to psychiAtric hospitAls
Effective February 1, 2015
Leadership (LD)
Standard LD.04.03.01
The hospital provides services that meet patient needs.
Elements of Performance for LD.04.03.01
A 1. The needs of the population(s) served guide decisions about which services will be provided directly or through referral, consultation, contractual arrangements, or other agreements.
Note: For psychiatric hospitals that use Joint Commission accreditation for deemed status purposes: If medical and surgical diagnostic and treatment services are not available within the hospital, the hospital has an agreement with an outside source for these services to make sure that the services
are immediately available or an agreement needs to be established for transferring patients to a general hospital that participates in the Medicare program.
A 14. For psychiatric hospitals that use Joint Commission accreditation for deemed status purposes: The psychiatric hospital provides psychological services, social work services, psychiatric nursing, and therapeutic activities.
Note: The therapeutic activities program is appropriate to the needs and interests of patients and is directed toward restoring and maintaining optimal levels of physical and psychological functioning.
Provision of Care, Treatment, and Services (PC)
Standard PC.01.02.13
The hospital assesses the needs of patients who receive treatment for emotional and behavioral disorders.
Elements of Performance for PC.01.02.13
A 2. Patients who receive treatment for emotional and behavioral disorders receive an assessment that includes the following:
l Current mental, emotional, and behavioral functioning
l Maladaptive or other behaviors that create a risk to the patient or others
l Mental status examination
l For psychiatric hospitals that use Joint Commission accreditation for deemed status purposes: Reason for admission as stated by the patient and/or others significantly involved in the patient’s care
l For psychiatric hospitals that use Joint Commission accreditation for deemed status purposes: Onset of the patient’s illness and circumstances leading to admission
l For psychiatric hospitals that use Joint Commission accreditation for deemed status purposes: Inventory of the patient’s strengths and disabilities (such as psychiatric, biopsychosocial problems requiring treatment/intervention) written in a descriptive manner on which to base a treatment plan (See also PC.01.03.01, EP 1)
C 5. Based on the patient’s age and needs, the assessment
for patients who receive treatment for emotional and behavioral disorders includes the following: M
l The patient’s family circumstances, including the composition of the family group
l The community resources currently used by the patient
l For psychiatric hospitals that use Joint Commission accreditation for deemed status purposes: A social history and reports of interviews with patients, family members, and others
C 6. Based on the patient’s age and needs, the assessment
for patients who receive treatment for emotional and behavioral disorders includes the following: M
l A psychiatric evaluation
l Psychological assessments, including intellectual, projective, neuropsychological, and personality testing
l For psychiatric hospitals that use Joint Commission accreditation for deemed status purposes: Complete neurological examination at the time of the admission physical examination, when indicated (For more information on physical examination, see PC.01.02.03, EP 4)
Standard PC.01.03.01
The hospital plans the patient’s care.
Elements of Performance for PC.01.03.01
C 1. The hospital plans the patient’s care, treatment, and services based on needs identified by the patient’s assessment, reassessment, and results of diagnostic testing. (See also RC.02.01.01, EP 2 and PC.01.02.13, EP 2) M
C 6. For psychiatric hospitals that use Joint Commission accreditation for deemed status purposes: The written plan of care includes the following: M
l A substantiated diagnosis (The substantiated diagnosis is the diagnosis identified by the treatment team to be the primary focus upon which treatment planning will be based. It evolves from the synthesis of data from various disciplines. The substantiated diagnosis may be the same as the initial diagnosis or it may differ, based on new information and assessment.)
l Documentation to justify the diagnosis and the treatment and rehabilitation activities carried out
l Documentation that demonstrates all active therapeutic efforts are included
Standard RC.02.01.01
The medical record contains information that reflects the patient’s care, treatment, and services.
Elements of Performance for RC.02.01.01
C 2. The medical record contains the following clinical information: M
l The reason(s) for admission for care, treatment, and services
l The patient’s initial diagnosis, diagnostic impression(s), or condition(s)
l Any findings of assessments and reassessments (See also PC.01.02.01, EPs 1 and 4; PC.03.01.03,
EPs 1 and 8)
l Any allergies to food
l Any allergies to medications
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l Any conclusions or impressions drawn from the patient’s medical history and physical examination
l Any diagnoses or conditions established during the patient’s course of care, treatment, and services (including complications and hospital-acquired infections). For psychiatric hospitals using Joint Commission accreditation for deemed status purposes: The diagnosis includes intercurrent diseases (diseases that may occur during the course of another disease; for example, a patient with AIDS may develop an intercurrent bout of pneumonia) and the psychiatric diagnoses.
l Any consultation reports
l Any observations relevant to care, treatment, and services
l The patient’s response to care, treatment, and services
l Any emergency care, treatment, and services provided to the patient before his or her arrival
l Any progress notes
l All orders
l Any medications ordered or prescribed
l Any medications administered, including the strength, dose, and route
l Any access site for medication, administration devices used, and rate of administration
l Any adverse drug reactions
l Treatment goals, plan of care, and revisions to the plan of care (See also PC.01.03.01, EPs 1 and 23)
l Results of diagnostic and therapeutic tests and procedures
l Any medications dispensed or prescribed on discharge
l Discharge diagnosis
l Discharge plan and discharge planning evaluation (See also PC.01.02.03, EPs 6–8)
C 10. For psychiatric hospitals that use Joint Commission accreditation for deemed status purposes: Progress notes are recorded by the following individuals involved in the active treatment of the patient: M
l The doctor of medicine or osteopathy responsible for the care of the inpatient
l A nurse
l A social worker
l Others involved in active treatment modalities The above individuals record progress notes at least weekly for the first two months of a patient’s stay and
at least monthly thereafter. The progress notes include recommendations for revisions in the plan of care
as indicated, as well as a precise assessment of the patient’s progress in accordance with the original or revised plan of care.
Standard RC.02.04.01
The hospital documents the patient’s discharge information.
Elements of Performance for RC.02.04.01
C 3. In order to provide information to other caregivers and facilitate the patient’s continuity of care, the medical record contains a concise discharge summary that includes the following: M
l The reason for hospitalization
l The procedures performed
l The care, treatment, and services provided
l The patient’s condition and disposition at discharge
l Information provided to the patient and family
l Provisions for follow-up care
Note 1: A discharge summary is not required when a patient is seen for minor problems or interventions, as defined by the medical staff. In this instance, a final progress note may be substituted for the discharge summary provided the note contains the outcome of hospitalization, disposition of the case, and provisions for follow-up care.
Note 2: When a patient is transferred to a different level of care within the hospital, and caregivers change, a transfer summary may be substituted for the discharge summary. If the caregivers do not change, a progress note may be used.
Note 3: For psychiatric hospitals that use Joint Commission accreditation for deemed status purposes: The record of each patient discharged needs to include a discharge summary with the above information. The exceptions in Notes 1 and 2 are not applicable. All patients discharged need to have a discharge summary.