Standards FAQ

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Hospitals (CAMH)

New Standards FAQs

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Topic	Chapter	Status	Publish Date
Summary Lists	Record of Care, Treatment, and Services	Revised	May 01, 2013
Summary Lists- Divergent Components	Record of Care, Treatment, and Services	Updated	May 01, 2013

Emergency Management

Topic	Status	Publish Date
Emergency Management	Updated	November 24, 2008
Tabletop Drills	Revised	November 24, 2008
The 96-hour Requirement	Current	March 09, 2009
Use of Paper Patient During Emergency Exercises	Updated	November 24, 2008
When The Community Will Not Participate With Emergency Planning	Current	January 13, 2009

Environment of Care

Topic	Status	Publish Date
Defibrillators - Life Support or Non-life Support Equipment	Current	June 15, 2009
Designating Controlled and/or Sensitive Areas	Current	January 13, 2009
Environment of Care Management Plans in Several Settings	Updated	November 24, 2008
Eyewashes - Frequency of Flushing	Updated	November 24, 2008
Hazardous Material	Updated	November 24, 2008
Identification badge requirements	Current	January 13, 2009
Infant or Pediatric Abduction Drills	Current	January 13, 2009
Installation of Call Buttons	Revised	August 07, 2009
Labeling Oxygen and other Compressed Gas Cylinders	Current	November 24, 2008
Locking of Electrical Panels	Current	November 24, 2008
Locking Soiled Utility Rooms	Current	November 24, 2008
Maintaining Medical Waste Manifests	Current	January 13, 2009
Maintaining Supplies During An Emergency	Current	March 09, 2009
Management Plans in Business Occupancies	Updated	November 24, 2008
Material Safety Data Sheets (MSDS) alternatives	Current	January 13, 2009
Material Safety Data Sheets (MSDS) Requirements	Updated	September 04, 2009
Mounting Sharps Boxes/Containers	Revised	March 09, 2009
Patient Owned Equipment	Current	November 24, 2008
Placement of Alcohol Based Hand Rub (ABHR) Dispensers	Current	November 24, 2008
Posting of no smoking signs	Current	January 13, 2009
Security of Syringes and Needles	Updated	November 24, 2008
Smoke-free Campus	Current	November 24, 2008
Smoking Distance Requirements	Current	January 13, 2009
SOC: PFI or work order?	Current	January 06, 2009
Staff Only Refrigerators	Updated	November 24, 2008
Standpipe Fire Hose Testing	Updated	November 24, 2008
Undersink Storage	Updated	June 29, 2009
Use of Fans	Updated	November 24, 2008
Utility System and Acquired Illness	Updated	November 24, 2008

Human Resources

Topic	Status	Publish Date
Human Resource Standards Applicability to Contracted and Volunteer Personnel	Revised	May 10, 2011
Laboratory and Point-of-Care Testing Personnel - Evidence of Qualifications	Revised	October 31, 2012
Laboratory and Point-of-Care Testing Personnel - Primary Source Verification	Current	April 13, 2010
Non-licensed, Non-employee Individuals	Revised	July 09, 2012
Peer References	Updated	November 24, 2008
Permission to Administer Moderate Sedation	Updated	July 07, 2010
Primary Source Verification	Updated	November 24, 2008
Requirements for Criminal Background Checks	Updated	November 24, 2008
Use of Unlicensed Persons Acting as Scribes	Revised	July 12, 2012

Infection Prevention and Control

Topic	Status	Publish Date
"Penny in a Cup"	Current	November 28, 2008
Contact precautions: Do gowns need to be worn whenever entering the room?	Current	February 18, 2010
Food And Drinks In Patient Care Areas	Revised	November 24, 2008
Infection Control Applicability to Offsite Interpretive Reading Providers	Updated	November 24, 2008
Influenza vaccination for licensed independent practitioners and staff	Current	May 30, 2012
Laryngoscope Blades	New	October 24, 2011
Licensed Independent Practitioner Health Screening	Updated	November 24, 2008
Screening patients for MRSA with Active Surveillance Cultures	New	July 18, 2011

Information Management
Topic Status Publish Date
Acceptable Abbreviation List Revised November 24, 2008
Leadership

Topic	Status	Publish Date
Acceptable Abbreviation List	Revised	November 24, 2008

Topic	Status	Publish Date
Contracted Services	Current	April 08, 2010
Patient Flow and Boarding	New	February 04, 2013

Life Safety

Topic	Status	Publish Date
Capacity of Soiled Linen and Trash Receptacles	Current	December 16, 2009
Computers on wheels	Updated	May 26, 2009
Exit Maps	Updated	November 24, 2008
One-Time Extension Based on Unforeseen Conditions	Updated	November 24, 2008
SOC PFI extension request	Current	January 27, 2009
SOC: PFI or work order?	Current	January 06, 2009
Temporary Construction Barriers	Updated	November 24, 2008

Medical Staff

Topic	Status	Publish Date
Core/Bundled Privileges	Updated	November 24, 2008
Credentialing and Privileging in Hospital-Based* Behavioral Health Care settings surveyed under the Comprehensive Accreditation Manual for Behavioral Health Care	Updated	November 24, 2008
Credentialing and Privileging in Hospital-Based* Long Term Care surveyed under the Comprehensive Accreditation Manual for Long Term Care	Updated	November 24, 2008
Credentialing Non-Medical Staff Member Licensed Independent Practitioners Who Order tests and Treatments from a Joint Commission Accredited Organization	Updated	November 24, 2008
Delegation of the History and Physical Examination	Updated	November 24, 2008
Documenting CME's	Updated	November 24, 2008
Expediting the MEC Function	Updated	November 24, 2008
Focused Professional Practice Evaluation	Revised	January 31, 2013
History And Physical For Hospital Outpatient Procedures	Updated	November 24, 2008
Medical Students Doing H&P	Updated	November 24, 2008
MS 01.01.01	Current	March 10, 2011
Ongoing Professional Practice Evaluation (OPPE)	Revised	March 06, 2013
Ongoing Professional Practice Evaluation for Medical/Cognitive Specialties	Updated	March 15, 2010
Organ Procurement Team Privileging	Updated	November 24, 2008
Peer References	Updated	November 24, 2008
Permission to Administer Moderate Sedation	Updated	July 07, 2010
Podiatrists and Dentists Performing the Entire History and Physical for Inpatient and Outpatient Care	Updated	November 24, 2008
Primary Source Verification of Education for Licensed Independent Practitioners	Updated	November 24, 2008
Querying the National Practitoner DatabankUsing the "Proactive Disclosure Service" (PDS)?	Current	March 16, 2010
Reappointment/Reprivileging Dates	Updated	November 24, 2008
Time Periods for Completing the Credentialing Process	Updated	November 24, 2008
Using Data from Outside Organizations to Accomplish the Ongoing Professional Practice Evaluation/Low Volume Practitioners	Current	March 23, 2010
Verifying Affiliations/Privlege or Work History at other Healthcare Organizations	Current	March 24, 2010

Medication Management

Topic	Status	Publish Date
Define Concentrated KCL	Revised	November 24, 2008
Medication Refrigeration Temperature Logs	Updated	November 24, 2008
Monitoring Patient Response	Updated	November 24, 2008
Multi-dose Vials	Current	July 20, 2010
Pharmacy Review for Licensed Independent Practitioner (LIP) Controlled Medicaton	Revised	November 24, 2008
Sample Medications	Updated	November 24, 2008
Security of Anesthesia Cart Medications	Updated	November 24, 2008
Strength and Dosage Form Listing	Updated	November 24, 2008

NPSG

Topic	Status	Publish Date
Anticoagulation Therapy - NPSG - Goal 3 - 03.05.01	Revised	December 09, 2008
Central Line-associated bloodstream infections (CLABSI) - NPSG - Goal 7- 07.04.01	Updated	February 23, 2010
Critical Tests, Results, and Values - NPSG - Goal 2 - 02.03.01	Revised	November 24, 2008
Fall Reduction Program - NPSG - Goal 9 - 09.02.01	Current	December 09, 2008
Hand Hygiene - NPSG - Goal 7 - 07.01.01	Revised	June 08, 2010
Monitoring of Hand Hygiene - NPSG - Goal 7 - 07.01.01	Current	July 14, 2010
Multiple Drug-resistant Organism (MDRO) - NPSG - Goal 7 - 07.03.01	Updated	February 23, 2010
Suicide Risk Reduction - NPSG - Goal 15 - 15.01.01	Revised	December 09, 2008
Surgical Site Infections (SSI) - NPSG - Goal 7 - 07.05.01	Revised	February 23, 2010
Surveillance Requirements for CAUTI	Current	July 18, 2011
Transfusion Administration Safety - NPSG - Goal 1 - 01.03.01	Revised	December 09, 2008
Two Patient Identifiers - NPSG - Goal 1 - 01.01.01	Current	December 09, 2008

Provision of Care, Treatment, and Services

Topic	Status	Publish Date
Admissions by oral and maxillofacial surgeons	Current	April 09, 2009
Authentication of the H&P in 24 Hours	Updated	November 24, 2008
Breathalyzers, Continuous Glucose Monitoring Systems, Pulse Oximeters & Transcutaneous Bilirubinometers	Revised	November 24, 2008
Content of the History and Physical	Revised	November 24, 2008
Delegation of the History and Physical Examination	Updated	November 24, 2008
H&P from non-credentialed practitioners	Updated	November 24, 2008
LPNs Performing Assessment	Revised	November 24, 2008
Medical Students Doing H&P	Updated	November 24, 2008
Moderate Sedation Medication and Patient Monitoring	Revised	November 24, 2008
Nutritional, Functional, And Pain Assessments And Screens	Revised	November 24, 2008
Patient Flow and Boarding	New	February 04, 2013
Patient-centered communication standards for hospitals	Current	February 09, 2011
Permission to Administer Moderate Sedation	Updated	July 07, 2010
Podiatrists and Dentists Performing the Entire History and Physical for Inpatient and Outpatient Care	Updated	November 24, 2008
Pre-Induction Assessment For Sedation And Anesthesia	Updated	November 24, 2008
Preprocedure Verification	Current	January 13, 2009
Residents or House Staff Writing Orders and/or Evaluating a Patient for Restraint or Seclusion for Behavioral Health Reasons	Updated	November 24, 2008
Restraint /Seclusion For Hospitals That Use The Joint Commission For Deemed Status Purposes	Revised	October 06, 2009
Restraint and Seclusion for Organizations that Do Not Use Joint Commission Accreditation for Deemed Status	Revised	December 24, 2009
Restraint Standards for Hospitals Using The Joint Commission for Non-Deemed Status purposes	Updated	October 06, 2009
Sedation and Anesthesia	Updated	November 24, 2008
Special Interventions (Behavioral Health Restraints & Seclusion)	Updated	November 24, 2008
Spiritual Assessment	Revised	November 24, 2008
Using the Prenatal Record for the H&P	Revised	November 24, 2008

Record of Care, Treatment, and Services

Topic	Status	Publish Date
Authentication of Documentation	Updated	November 24, 2008
Diagnosis, Condition, Indication-For-Use In Order	Updated	November 24, 2008
Dictated H&P for Surgery	Revised	February 09, 2009
Laboratory Report Requirements In The Medical Record	Revised	August 15, 2012
Minimum Patient Information - Medication	Updated	November 24, 2008
One LIP Signing for Another	Updated	November 24, 2008
Patient-centered communication standards for hospitals	Current	February 09, 2011
Summary Lists	Revised	May 01, 2013
Summary Lists- Divergent Components	Updated	May 01, 2013
Texting Orders	New	November 10, 2011

Rights and Responsibilities of the Individual

Topic	Status	Publish Date
Filming And Recording	Updated	November 24, 2008
Format for collecting patient race and ethnicity data	New	December 10, 2012
Organ Donation	Updated	November 24, 2008
Patient Race and Ethnicity Data Collection	New	August 19, 2011
Patient Rights and Informed Consent When Videotaping or Filming	Revised	November 24, 2008
Patient-centered communication standards for hospitals	Current	February 09, 2011

Transplant Safety

Topic	Status	Publish Date
Adverse Tissue Reaction Policies	Updated	October 01, 2010
Tissue - Standards Applicability	New	March 23, 2011
Tissue Source Facilities - Verification of Licensing & Registration	Updated	October 01, 2010
Traceability of Records	Updated	October 01, 2010

Waived Testing

Topic	Status	Publish Date
Color-Blind Testing	Updated	November 24, 2008
Laboratory Director for Waived Testing	New	April 15, 2011
Laboratory Director Of Record	New	March 23, 2011
Patient/Client Self Glucose Testing	Updated	November 24, 2008
Professional Vs. Home Use Tests (Glucose Meters, Etc.)	Updated	May 05, 2011
Provider Performed Microscopy Procedures (P.P.M.P.)	Updated	May 05, 2011
Rapid Group Strep A Strep Testing & Culture Follow-up	New	March 23, 2011
Reagents Stored With Medications Or Specimens	Updated	November 24, 2008
Screening Vs. Definitive	Updated	May 05, 2011
Survey Of Urine Drug Testing In A Behavioral Health Care Facility	Updated	November 24, 2008
Test Complexity - Waived, Moderate and High	New	March 30, 2011
Waived Testing & Proficiency Testing	Updated	November 24, 2008

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