2009 Standards FAQs

Standards Frequently Asked Questions
Comprehensive Accreditation Manual for Hospitals (CAMH)


Status Definitions


Emergency Management

The 96-hour RequirementNewMar 09, 2009
Emergency ExercisesUpdatedNov 24, 2008
Emergency ManagementUpdatedNov 24, 2008
Tabletop DrillsRevisedNov 24, 2008
Use of Paper Patient During Emergency ExercisesUpdatedNov 24, 2008
When The Community Will Not Participate With Emergency PlanningNewJan 13, 2009

Environment of Care

Defibrillators - Life Support or Non-life Support EquipmentNewJun 15, 2009
Designating Controlled and/or Sensitive AreasNewJan 13, 2009
Environment of Care Management Plans in Several SettingsUpdatedNov 24, 2008
Eyewashes - Frequency of FlushingUpdatedNov 24, 2008
Hazardous MaterialUpdatedNov 24, 2008
Identification Badge RequirementsNewJan 13, 2009
Infant or Pediatric Abduction DrillsNewJan 13, 2009
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
Maintaining Medical Waste ManifestsNewJan 13, 2009
Maintaining Supplies During An EmergencyNewMar 09, 2009
Management Plans in Business OccupanciesUpdatedNov 24, 2008
Material Safety Data Sheets (MSDS) RequirementsUpdatedSep 04, 2009
Material Safety Data Sheet (MSDS) AlternativesNewJan 13, 2009
Mounting Sharps Boxes/ContainersRevisedMar 09, 2009
Patient Owned EquipmentNewNov 24, 2008
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
SOC: PFI or Work Order?NewJan 06, 2009
Undersink StorageUpdatedJun 29, 2009
Utility System and Acquired IllnessUpdatedNov 24, 2008
Use of FansUpdatedMay 18, 2009

Human Resources

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
Requirements for Criminal Background ChecksUpdatedNov 24, 2008

Infection Prevention and Control

Food And Drinks In Patient Care AreasRevisedNov 24, 2008
Infection Control Applicability to Offsite Interpretive Reading ProvidersUpdatedNov 24, 2008
Licensed Independent Practitioner Health ScreeningUpdatedNov 24, 2008
“Penny in a Cup"NewNov 24, 2008

Information Management

Acceptable Abbreviation ListRevisedNov 24, 2008
Authentication of DocumentationUpdatedNov 24, 2008
Credentialing And Privileging For Providers From Joint Commission Accredited OrganizationUpdatedNov 24, 2008
Laboratory Report Requirements In The Medical RecordUpdatedNov 24, 2008
Minimum Patient Information - MedicationUpdatedNov 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
Temporary Construction BarriersUpdatedNov 24, 2008

Medical Staff

Documenting CME'sUpdatedNov 24, 2008
Core/Bundled PrivilegesUpdatedNov 24, 2008
Credentialing Non-Medical Staff Member Licensed Independent Practitioners Who Order tests and Treatments from a Joint Commission Accredited OrganizationUpdatedNov 24, 2008
Credentialing and Privileging in Hospital-Based* Long Term Care surveyed under the Comprehensive Accreditation Manual for Long Term CareUpdatedNov 24, 2008
Credentialing and Privileging in Hospital-Based* Behavioral Health Care settings surveyed under the Comprehensive Accreditation Manual for Behavioral Health CareUpdatedNov 24, 2008
Delegation of the History and Physical ExaminationUpdatedNov 24, 2008
Expediting the MEC FunctionUpdatedNov 24, 2008
Focused Professional Practice EvaluationRevisedOct 13, 2008
History And Physical For Hospital Outpatient ProceduresUpdatedNov 24, 2008
Medical Students Doing H&PUpdatedNov 24, 2008
Ongoing Professional Practice Evaluation (OPPE)UpdatedMay 27, 2009
Organ Procurement Team PrivilegingUpdatedNov 24, 2008
Peer ReferencesUpdatedNov 24, 2008
Permission to Administer Moderate SedationUpdatedFeb 11, 2009
Podiatrists and Dentists Performing the Entire History and Physical for Inpatient and Outpatient CareUpdatedNov 24, 2008
Primary Source Verification of Education for Licensed Independent PractitionersUpdatedNov 24, 2008
Reappointment/Reprivileging DatesUpdatedNov 24, 2008
Time Periods for Completing the Credentialing ProcessUpdatedNov 24, 2008

Medication Management

Define Concentrated KCLRevisedNov 24, 2008
Diagnosis, Condition, Indication-For-Use In OrderUpdatedNov 24, 2008
Medication Refrigeration Temperature LogsUpdatedNov 24, 2008
Monitoring Patient ResponseUpdatedNov 24, 2008
Pharmacy Review for Licensed Independent Practitioner (LIP) Controlled MedicatonRevisedNov 24, 2008
Sample MedicationsUpdatedNov 24, 2008
Security of Anesthesia Cart 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.01.03.01

Transfusion Administration SafetyNewDec 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.03.04.01

Labeling in Procedural AreasNewDec 09, 2008

NPSG.03.05.01

Anticoagulation TherapyNewDec 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.07.03.01

Multiple Drug-Resistant Organisms (MDRO)NewDec 09, 2008

NPSG.07.04.01

Central Line-Associated Bloodstream Infection (CLABSI)NewDec 09, 2008

NPSG.07.05.01

Surgical Site Infection (SSI)NewDec 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 9 - Patient Falls


NPSG.09.02.01

Fall Reduction ProgramNewDec 09, 2008

NPSG 13 - Patient Involvement


NPSG.13.01.01 Patient involvement

Patient involvementNewDec 09, 2008

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


NPSG.15.01.01

Suicide risk reductionNewDec 09, 2008

Universal Protocol


General

ApplicabilityNewNov 24, 2008
Potential Barriers and Risks for Unintended ConsequencesNewNov 24, 2008
Requirement or AdviceNewNov 24, 2008
Statement and Persistence of the ProblemNewNov 24, 2008

Pre-procedure Verification

ChecklistNewNov 24, 2008
Procedures Outside the ORNewNov 24, 2008
Verification in Pre-procedure AreaNewNov 24, 2008

Procedure Site marking

Dental proceduresRevisedNov 24, 2008
Exceptions to Site MarkingUpdatedFeb 12, 2009
Obvious wound or lesionRevisedNov 24, 2008
Refusal of site markingRevisedNov 24, 2008
ResidentsUpdatedFeb 17, 2009
Spinal surgery casesRevisedNov 24, 2008
Who should mark the siteNewNov 24, 2008
Bilateral ProceduresNewMar 11, 2009

Procedure Time out

Time-out Prior to AnesthesiaNewNov 23, 2008
Time-out without the SurgeonNewNov 24, 2008
Two Time-outsNewNov 24, 2008
Documentation of Time-OutNewMar 11, 2009

Performance Improvement

Staffing EffectivenessRevisedNov 24, 2008

Provision of Care, Treatment, and Services

Adverse Tissue Reaction PoliciesUpdatedNov 24, 2008
Admissions by oral and maxillofacial surgeonsNewApr 09, 2009
Authentication of the H&P in 24 HoursUpdatedNov 24, 2008
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
Nutritional, Functional, And Pain Assessments And ScreensRevisedNov 24, 2008
Permission to Administer Moderate SedationUpdatedFeb 11, 2009
Podiatrists and Dentists Performing the Entire History and Physical for Inpatient and Outpatient CareUpdatedNov 24, 2008
Pre-Induction Assessment For Sedation And AnesthesiaUpdatedNov 24, 2008
Preprocedure VerificationNewJan 13, 2009
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
Restraint /Seclusion For Hospitals That Use The Joint Commission For Deemed Status PurposesUpdatedOct 06, 2009
Restraint Standards For Hospitals Using The Joint Comission For Non-Deemed PurposesNewOct 06, 2009
Sedation and AnesthesiaUpdatedNov 24, 2008
Special Interventions (Behavioral Health Restraints & Seclusion)UpdatedNov 24, 2008
Spiritual AssessmentRevisedNov 24, 2008
Tissue Source Facilities - Verification of Licensing & RegistrationUpdatedNov 24, 2008
Traceability of RecordsUpdatedNov 24, 2008
Updates to the Patient's ConditionRevisedNov 24, 2008
Using the Prenatal Record for the H&PRevisedNov 24, 2008

Record of Care, Treatment, and Services

Summary ListsNewAug 05, 2009
Dictated H&P for SurgeryUpdatedFeb 09, 2009
One LIP Signing for AnotherUpdatedNov 24, 2008

Rights and Responsibilities of the Individual

Filming And RecordingUpdatedNov 24, 2008
Organ DonationUpdatedNov 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
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
Screening Vs. DefinitiveUpdatedNov 24, 2008
Survey Of Urine Drug Testing In A Behavioral Health Care FacilityUpdatedNov 24, 2008
Waived Testing & Proficiency TestingUpdatedNov 24, 2008