2009 Standards FAQs

Standards Frequently Asked Questions
Comprehensive Accreditation Manual for Behavioral Health Care (CAMBHC)


Status Definitions


Environment of Care

Designating Controlled and/or Sensitive AreasNewJan 13, 2009
Emergency ExercisesUpdatedNov 24, 2008
Emergency ManagementUpdatedNov 24, 2008
Eyewashes - Frequency of FlushingUpdatedNov 24, 2008
Hazardous MaterialUpdatedNov 24, 2008
Installation of Call ButtonsRevisedAug 07, 2009
Labeling Oxygen and other Compressed Gas CylindersNewNov 24, 2008
Locking of Electrical PanelsNewNov 24, 2008
Locking Soiled Utility RoomsNewNov 24, 2008
Material Safety Data Sheets (MSDS) RequirementsUpdatedSep 04, 2009
Material Safety Data Sheet (MSDS) alternativesNewJan 13, 2009
Mounting Sharps Boxes/ContainersRevisedMar 09, 2009
Placement of Alcohol Based Hand Rub (ABHR) DispensersNewNov 24, 2008
Posting of No Smoking SignsNewJan 13, 2009
Security of Syringes and NeedlesUpdatedNov 24, 2008
Smoking Distance RequirementsNewJan 13, 2009
Smoke-free CampusNewNov 24, 2008
Staff Only RefrigeratorsUpdatedNov 24, 2008
Standpipe Fire Hose TestingUpdatedNov 24, 2008
Tabletop DrillsRevisedNov 24, 2008
Temporary Construction BarriersUpdatedNov 24, 2008
Undersink StorageUpdatedJun 29, 2009
Utility System and Acquired IllnessUpdatedNov 24, 2008
Use of FansUpdatedMay 18, 2009

Human Resources

Credentialing and Privileging in Hospital-Based* Behavioral Health Care settings surveyed under the Comprehensive Accreditation Manual for Behavioral Health CareUpdatedNov 24, 2008
Health Care Industry/Vendor RepresentativesNewApr 15, 2009
Human Resource Standards Applicability to Contracted and Volunteer PersonnelUpdatedNov 24, 2008
Peer ReferencesUpdatedNov 24, 2008
Permission to Administer Moderate SedationUpdatedFeb 11, 2009
Primary Source VerificationUpdatedNov 24, 2008
Primary Source Verification of Education for Licensed Independent PractitionersUpdatedNov 24, 2008
Reappointment Assigned Clinical Responsibilities DatesUpdatedNov 24, 2008
Reappointment/Reprivileging DatesUpdatedNov 24, 2008
Requirements for Criminal Background ChecksUpdatedNov 24, 2008
Time Periods for Completing the Credentialing ProcessUpdatedNov 24, 2008

Infection Prevention and Control

Food and Drinks in Patient Care AreasUpdatedNov 24, 2008
Licensed Independent Practitioner Health ScreeningUpdatedNov 24, 2008

Information Management

Authentication of DocumentationUpdatedNov 24, 2008
Credentialing And Privileging For Providers From Joint Commission Accredited OrganizationUpdatedNov 24, 2008
Minimum Patient Information - MedicationUpdatedNov 24, 2008

Leadership

Use of ConsultantsUpdatedNov 24, 2008

Life Safety

Computers on WheelsUpdatedMay 26, 2009
Exit MapsUpdatedNov 24, 2008
One-Time Extension Based on Unforeseen ConditionsUpdatedNov 24, 2008
SOC PFI Extension RequestNewJan 27, 2009
SOC: PFI or Work Order?NewJan 06, 2009

Medication Management

Define Concentrated KCLRevisedNov 24, 2008
Medication Refrigeration Temperature LogsUpdatedNov 24, 2008
Monitoring Patient ResponseUpdatedNov 24, 2008
Sample MedicationsUpdatedNov 24, 2008
Strength and Dosage Form ListingUpdatedNov 24, 2008

National Patient Safety Goals


NPSG 1 - Patient Identification


NPSG.01.01.01

Two_Patient_IdentifiersNewDec 09, 2008

NPSG 2 - Communication Among Caregivers


NPSG.02.01.01

Read Back OrdersNewDec 09, 2008

NPSG.02.02.01

Do Not Use AbbreviationsNewDec 09, 2008

NPSG.02.03.01

Critical Tests, Results and ValuesNewDec 09, 2008

NPSG.02.05.01

Hand-off CommunicationsNewDec 09, 2008

NPSG 3 - Medication Safety


NPSG.03.03.01

Look-Alike/Sound-Alike DrugsNewDec 09, 2008

NPSG 7 - Health Care - Associated Infections


NPSG.07.01.01

Hand HygieneUpdatedJun 04, 2009

NPSG.07.02.01

Infection-Related Sentinel EventsNewDec 09, 2008

NPSG 8 - Medication Reconciliation


NPSG.08.01.01

Reconciliation Upon ArrivalNewDec 09, 2008

NPSG.08.02.01

Reconciliation Upon TransferNewDec 09, 2008

NPSG.08.03.01

Reconciliation Upon DepartureNewDec 09, 2008

NPSG 13 - Patient Involvement


NPSG.13.01.01

Patient InvolvementNewDec 09, 2008

NPSG 15 - Focused Risk Assessment (Suicide; Home Fires)


NPSG.15.01.01

Suicide Risk ReductionNewDec 09, 2008

Provision of Care, Treatment, and Services

Breathalyzers, Continuous Glucose Monitoring Systems, Pulse Oximeters & Transcutaneous BilirubinometersRevisedNov 24, 2008
Content of the History and PhysicalRevisedNov 24, 2008
Delegation of the History and Physical ExaminationUpdatedNov 24, 2008
H&P from non-credentialed practitionersUpdatedNov 24, 2008
LPNs Performing AssessmentRevisedNov 24, 2008
Medical Students Doing H&PUpdatedNov 24, 2008
Residents or House Staff Writing Orders and/or Evaluating a Patient for Restraint or Seclusion for Behavioral Health ReasonsUpdatedNov 24, 2008
Restraint and SeclusionUpdatedOct 06, 2009
Special Interventions (Behavioral Health Restraints & Seclusion)UpdatedNov 24, 2008

Record of Care, Treatment, and Services

One LIP Signing for AnotherUpdatedNov 24, 2008

Rights and Responsibilities of the Individual

Filming And RecordingUpdatedNov 24, 2008
Patient Rights and Informed Consent When Videotaping or FilmingRevisedNov 24, 2008

Waived Testing

Color-Blind TestingUpdatedNov 24, 2008
Patient/Client Self Glucose TestingUpdatedNov 24, 2008
Physician Competency For Waived & P.P.M.P. TestingUpdatedNov 24, 2008
Professional Vs. Home Use Tests (Glucose Meters, Etc.)UpdatedNov 24, 2008
Provider Performed Microscopy Procedures (P.P.M.P.)UpdatedNov 24, 2008
Reagents Stored With Medications Or SpecimensUpdatedNov 24, 2008
Reference Ranges In Medical/Clinical RecordUpdatedNov 24, 2008
Screening Vs. DefinitiveUpdatedNov 24, 2008
Survey Of Urine Drug Testing In A Behavioral Health Care FacilityUpdatedNov 24, 2008
Waived Testing & Proficiency TestingUpdatedNov 24, 2008
Waived Testing LogsUpdatedNov 24, 2008