Effective July 1, 2015, The Joint Commission has added and revised several requirements for hospitals and revised one requirement for critical access hospitals to better align with changes made in the Centers for Medicare & Medicaid Services (CMS) Conditions of Participation (CoPs) for hospitals. The CoP changes resulted from the May 12, 2014, final rule, which was part of CMS’s effort to remove requirements that were determined to be unnecessary, obsolete, or burdensome.
The changes to Joint Commission requirements are primarily for hospitals with swing beds. One revision—to a Medical Staff (MS) requirement—applies to both hospitals and critical access hospitals. For information about previous changes (effective September 29, 2014) related to the May
2014 final rule, see the October 2014 issue of Perspectives.
The new and revised language, underlined in the box below, is currently available at http://jointcommission.org/ standards_information/prepublication_standards.aspx and will be published in the spring E-dition® update for both hospitals and critical access hospitals. The revisions will be published in print this spring in the 2015 Update 1 to the Comprehensive Accreditation Manual for Hospitals and this fall in the Comprehensive Accreditation Manual for Critical Access Hospitals.
For more information, please contact Laura Smith, project director, Department of Standards and Survey Methods, The Joint Commission, at lsmith@jointcommission
.org. P
Official Publication of Joint Commission Requirements
ApplicAble to HospitAls
Effective July 1, 2015
Medical Staff (MS)
Standard MS.01.01.01
Medical staff bylaws address self-governance and account- ability to the governing body.
Element of Performance for MS.01.01.01
A 13. The medical staff bylaws include the following require- ments, in accordance with Element of Performance 3: Qualifications for appointment to the medical staff.
Note: For hospitals that use Joint Commission accreditation for deemed status purposes: The medical staff must be composed of doctors of medicine
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or osteopathy. In accordance with state law, includ- ing scope of practice laws, the medical staff may also include other categories of physicians as listed at 482.12(c)(1) and nonphysician practitioners who are determined to be eligible for appointment by the gov- erning body.
Provision of Care, Treatment, and Services (PC)
Standard PC.02.02.01
The hospital coordinates the patient’s care, treatment, and services based on the patient’s needs.
Elements of Performance for PC.02.02.01
C 9. For hospitals that use Joint Commission accredita- tion for deemed status purposes and have swing beds: The hospital provides services (directly or through referral) to facilitate family support, social work, nursing care, dental care, rehabilitation, primary physi- cian care, or discharge. M
Note: For hospitals that use Joint Commission accreditation for deemed status purposes and have swing beds: The hospital promptly refers residents with lost or damaged dentures to a dentist.
A 12. For hospitals that use Joint Commission accredita- tion for deemed status purposes and have swing beds: The hospital provides 24-hour emergency dental
services directly or through arrangement with an exter- nal provider.
Note: For hospitals that use Joint Commission accreditation for deemed status purposes and have swing beds: The hospital may charge a Medicare resident an additional amount for routine and emergency dental services.
Standard PC.04.01.03
The hospital discharges or transfers the patient based on his or her assessed needs and the organization’s ability to meet those needs.
Element of Performance for PC.04.01.03
C 3. The patient, the patient’s family, licensed independent practitioners, physicians, clinical psychologists, and staff involved in the patient’s care, treatment, and services participate in planning the patient’s discharge or transfer. M
Note 1: The definition of “physician” is the same as that used by the Centers for Medicare & Medicaid Services (CMS) (refer to the Glossary).
Note 2: For psychiatric hospitals that use Joint Commission accreditation for deemed status pur- poses: Social service staff responsibilities include, but are not limited to, participating in discharge planning,
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arranging for follow-up care, and developing mecha- nisms for exchange of information with sources outside the hospital.
Note 3: For hospitals that use Joint Commission accreditation for deemed status purposes and have swing beds: The hospital notifies the resident and, if known, a family member or legal representative of the resident of the transfer or discharge and reasons for the move in writing. The hospital also provides sufficient preparation and orientation to residents to make sure that transfer or discharge from the hospital is safe and orderly.
Standard PC.04.01.07
For hospitals that use Joint Commission accreditation for deemed status purposes and have swing beds: Residents are not transferred or discharged from the hospital unless they meet specific criteria, in accordance with law and regulation.
Element of Performance for PC.04.01.07
C 1. For hospitals that use Joint Commission accredita- tion for deemed status purposes and have swing beds: The hospital transfers or discharges residents only when at least one of the following conditions is met: M
l The resident’s health has improved to the point where he or she no longer needs the hospital’s services.
l The transfer or discharge is necessary for the resident’s benefit or if the hospital cannot meet the resident’s needs.
l The health or safety of the resident is endangered by remaining in the hospital.
l The health or safety of individuals in the facility is endangered.
l The hospital has provided the resident, who has not paid for his or her stay, with reasonable notice of transfer or discharge, as defined by the hospital and in accordance with law and regulation.
l The hospital ceases operation.
l The resident leaves against medical advice and signs a form stating that his or her action runs con- trary to medical advice.
Record of Care, Treatment, and Services (RC)
Standard RC.02.04.01
The hospital documents the patient’s discharge information.
Element of Performance for RC.02.04.01
C 1. For hospitals that use Joint Commission accredita- tion for deemed status purposes and have swing
beds: Documentation in the medical record includes discharge information provided to the resident and/or to the receiving organization. There is documentation in the resident’s medical record by the resident’s physi- cian when the resident is transferred or discharged, either when the transfer is due to the resident improving and no longer needing long term care services or when the resident’s needs cannot be met in the hospital’s swing bed. There is documentation in the resident’s medical record by a physician when the resident is being transferred or discharged because the safety of other residents would otherwise be endangered. M
Rights and Responsibilities of the Individual (RI)
Standard RI.01.01.01
The hospital respects, protects, and promotes patient rights.
Element of Performance for RI.01.01.01
C 7. The hospital respects the patient’s right to privacy. (See also IM.02.01.01, EPs 1–5) M
Note 1: This element of performance (EP) addresses a patient’s personal privacy. For EPs addressing the privacy of a patient’s health information, please refer to Standard IM.02.01.01.
Note 2: For hospitals that use Joint Commission accreditation for deemed status purposes and have swing beds: The resident’s right to privacy includes privacy and confidentiality of his or her personal records and written communications, including the right to send and receive mail promptly.
Standard RI.01.06.03
The patient has the right to be free from neglect; exploitation; and verbal, mental, physical, and sexual abuse.
Elements of Performance for RI.01.06.03
A 1. The hospital determines how it will protect the patient from neglect, exploitation, and abuse that could occur while the patient is receiving care, treatment, and services.
Note: For hospitals that use Joint Commission accreditation for deemed status purposes and have swing beds: The hospital also determines how it will protect residents from corporal punishment and involuntary seclusion.
C 3. The hospital reports allegations, observations, and suspected cases of neglect, exploitation, and abuse to appropriate authorities based on its evaluation of the suspected events, or as required by law. (See also PC.01.02.09, EPs 6 and 7)
Note: For hospitals that use Joint Commission accreditation for deemed status purposes and have swing beds: Alleged violations of mistreatment, neglect, or abuse and misappropriation of resident property are reported immediately to the administrator of the hospital.
A 4. D For hospitals that use Joint Commission accredi- tation for deemed status purposes and have swing beds: The hospital develops and implements written policies and procedures that prohibit mistreatment, neglect, and abuse of residents and misappropriation of resident property.
A 5. D For hospitals that use Joint Commission accredi- tation for deemed status purposes and have swing beds: The hospital has evidence that all alleged violations are thoroughly investigated and that it prevents further abuse while the investigation is in progress. The results of all investigations are reported to the administrator or his or her designated representa- tive within five working days of the incident.
Standard RI.01.07.07
For psychiatric hospital settings that provide longer term care (more than 30 days) and for hospitals that use Joint Commission accreditation for deemed status purposes and have swing beds: The hospital protects the rights of patients and residents who work for or on behalf of the hospital.
Element of Performance for RI.01.07.07
A 3. For psychiatric hospital settings that provide longer term care (more than 30 days) and for hospitals that
use Joint Commission accreditation for deemed status purposes and have swing beds: Wages paid to patients and residents who work for or on behalf of the hospital are in accordance with law and regulation.
Note: For hospitals that use Joint Commission accreditation for deemed status purposes and have swing beds: The plan of care specifies whether the work performed is voluntary or paid.
ApplicAble to criticAl Access HospitAls
Effective July 1, 2015
Medical Staff (MS)
Standard MS.01.01.01
Medical staff bylaws address self-governance and account- ability to the governing body.
Element of Performance for MS.01.01.01
A 13. The medical staff bylaws include the following require- ments, in accordance with Element of Performance 3: Qualifications for appointment to the medical staff.
Note: For rehabilitation and psychiatric distinct part units in critical access hospitals: The medical staff must be composed of doctors of medicine or osteopa- thy. In accordance with state law, including scope of practice laws, the medical staff may also include other categories of physicians as listed at 482.12(c)(1) and nonphysician practitioners who are determined to be eligible for appointment by the governing body.