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Tuesday 1:52 CST, May 3, 2016

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Standards FAQ

Licensed Independent Practitioners - Health Screening Requirements

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Are non-employed physicians and other licensed independent practitioners included in the health requirements specified in IC.02.03.01? Do we need to screen them for TB infection as well as immunity to other diseases?

04/11/2016
Standards FAQ

Personnel Records - Protected Health Information

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Do personnel records of the staff need to be separated, with one for general information and the other with personal health information?  

04/11/2016
Standards FAQ

Medical Record - Security

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We contract with an after hours cleaning service. Our medical records are stored in an unlocked area or on open shelves with in a secure area. The after hours cleaning crew members sign confidentiality statements. Is this acceptable or should we store the records under lock and key?

04/11/2016
Standards FAQ

Two Patient Identifiers - Outpatient Settings1

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A lot of our outpatients-those who come for a medication administration or specimen collection do not have an armband. Would asking them their name and comparing it to any paperwork we have constitute two identifiers? NPSG.01.01.01

Related Items: npsg.01.01.01

04/11/2016
Standards FAQ

Consultants - Requirements

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We have been told by other sources that the Joint Commission wants behavioral health care organizations to use one or two consultants, every three years. Where is the documentation on this and what is your stance?   .

04/11/2016
Standards FAQ

History and Physical - Medical Student

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What patient care activities, such as the History and Physical, can a medical student perform and document in the medical record? 

04/11/2016
Standards FAQ

Two Patient Identifiers - Same Identifiers Throughout The Organization1

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Do the same two identifiers have to be used throughout the organization? NPSG.01.01.01

Related Items: npsg.01.01.01

04/11/2016
Standards FAQ

History and Physical - Delegation to Non Licensed Independent Practitioners

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Can the responsibility for performing the admission history and physical examination be delegated to a practitioner such as an advanced practice nurse, physician's assistant, or registered nurse who are not licensed independent practitioners?  

04/11/2016
Standards FAQ

Restraint and Seclusion - Telemedicine

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Is the use of a telemedicine link allowed for use by the LIP who conducts the in-person evaluations of an individual in restraint or seclusion?  

04/11/2016
Standards FAQ

Restraint or Seclusion - Role of Medical Student

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Can residents or house staff write orders and/or evaluate a patient for restraint or seclusion for behavioral health reasons?  

04/11/2016
Standards FAQ

History and Physical - Non-Credentialed Practitioners

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Can the organization utilize a history and physical that has been performed by someone who is not authorized/privileged by the organization? 

04/11/2016
Standards FAQ

Test Category - Monitoring Devices

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Are the following devices considered laboratory tests - breathalyzers, continuous glucose monitoring systems, pulse oximeters, and transcutaneous bilirubin meters?  

04/11/2016
Standards FAQ

Primary Source Verification - Definition

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What is Primary Source Verification? Who does it apply to?  

04/11/2016
Standards FAQ

Criminal Background Checks - Requirements

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What is the Joint Commission requirement for criminal background checks and for which type of individual must it be performed?    

04/11/2016
Standards FAQ

Contracted Services - Human Resource Record Review During Survey

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During a Joint Commission survey of an organization, is the surveyor required to manually verify human resource files/documents for employees, or independent contractors, of a Joint Commission accredited or certified contracted service?

04/11/2016
Standards FAQ

Agreement or Contract - Signature

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Does the agreement or contract need to be signed by the staffing firm’s customer?

04/11/2016
Standards FAQ

Two Patient Identifiers - No Wristbands

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We are a behavioral health care facility. The individuals in our care do not wear wristbands. What other methods are acceptable for the "two identifiers"? NPSG.01.01.01

Related Items: npsg.01.01.01

04/11/2016
Standards FAQ

Two Patient Identifiers - Home Identification

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What about the home care situation? Do we need to keep checking two identifiers each time we give a medication? NPSG.01.01.01

Related Items: npsg.01.01.01

04/11/2016
Standards FAQ

Multiple Drug-resistant Organism - Surveillance

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Must we perform surveillance on all MDROs, or is targeted surveillance okay?  

Related Items: npsg.07.03.01

04/11/2016
Standards FAQ

Two Patient Identifiers - Exceptions

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Are there any exceptions for active involvement of the individual or responsible caregiver? Does this mean the individual's nurse needs to help identify non-communicative or confused individuals whenever other healthcare workers, such as lab, use two patient identifiers? NPSG.01.01.01

Related Items: npsg.01.01.01

04/11/2016
Standards FAQ

Catheter-Associated Urinary Tract Infection (CAUTI) - Surveillance

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My facility performs a risk assessment every year as required by IC.01.03.01. We consider a wide range of infection risks, and we rank them per IC.01.03.01 EP 5. Our risk assessment shows CAUTI is a very low patient risk; there are many other higher priorities. Must I perform surveillance for CAUTI because of the NPSG.07.06.01 even though my risk assessment does not identify it as a priority?

Related Items: npsg.07.06.01

04/11/2016
Standards FAQ

Identify Risks With Home Oxygen Therapy - Safety Risk Assessment

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NPSG.15.02.01 EP 1 appears to require our home care clinicians to conduct a task that they are neither trained for nor qualified to perform such as verifying the working order of smoke detectors and fire extinguishers.

Related Items: npsg.15.02.01

04/11/2016
Standards FAQ

Data Collection Timeline - Initial Certification

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Can a firm apply for certification in May and request an on-site review in August if four months of data have not been collected for each performance measure?

04/11/2016
Standards FAQ

Certification Measure Information Process (CMIP) - Submission Directions

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How do firms submit data via CMIP?

04/11/2016
Standards FAQ

Contracts - Joint Commission Certification Required Elements

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The contracts that we have with health care organizations are frequently written by the health care organization, and as a result do not include all of the required elements that The Joint Commission certification requires.  How can we meet the requirements when the health care organization will not modify the contract?

04/11/2016