Joint Commission Online - April 3, 2024

May 17, 2024

The Joint Commission regularly analyzes standards compliance data to identify trends and tailor education related to challenging standards and National Patient Safety Goals (NPSGs).

Below are the Top 5 Joint Commission requirements and corresponding elements of performance (EPs) identified most frequently as “not compliant” (in the higher Survey Analysis for Evaluating Risk^® or SAFER^® categories) during surveys and reviews from Jan. 1 through Dec. 31, 2023. For more information, see the April issue of Perspectives.

Ambulatory Care

• IC.02.02.01, EP 2: The organization implements infection prevention and control activities while doing the following: Performing intermediate and high-level disinfection and sterilization of medical equipment, devices, and supplies.
• IC.02.01.01, EP 2: The organization uses standard precautions, including the use of personal protective equipment, to reduce the risk of infection.
• MM.01.01.03, EP 2: The organization follows a process for managing high-alert and hazardous medications.
• MM.01.02.01, EP 2: The organization takes action to avoid errors involving the interchange of medications on its list of look-alike/sound-alike medication.
• EC.02.05.01, EP 7: In areas designed to control airborne contaminants (such as biological agents, gases, fumes, dust), the ventilation system provides appropriate pressure relationships, air-exchange rates, filtration efficiencies, relative humidity, and temperature. For new health care facilities or altered, renovated, or modernized portions of existing ventilation systems or individual components (constructed or plans approved on or after July 5, 2016), heating, cooling, and ventilation are in accordance with NFPA 99-2012, which includes 2008 ASHRAE 170, or state design requirements if more stringent. Existing systems are in compliance with the ventilation standards that were in effect at the time the facility was constructed or last modified.

Behavioral Health Care and Human Services

• NPSG.15.01.01, EP 5: Follow written policies and procedures addressing the care of individuals served identified as at risk for suicide. At a minimum, these should include the following:
  • Training and competence assessment of staff who care for individuals served at risk for suicide.
  • Guidelines for reassessment.
  • Monitoring individuals served who are at high risk for suicide.
• NPSG.15.01.01, EP 1: The organization conducts an environmental risk assessment that identifies features in the physical environment that could be used to attempt suicide and takes necessary action to minimize the risk(s) (for example, removal of anchor points, door hinges, and hooks that can be used for hanging).
• NPSG.15.01.01, EP 2: Screen all individuals served for suicidal ideation using a validated screening tool.
• HRM.01.06.01, EP 3: The organization conducts an initial assessment of staff competence. This assessment is documented.
• NPSG.15.01.01, EP 4: Document individuals’ overall level of risk for suicide and the plan to mitigate the risk for suicide.

Critical Access Hospital

• IC.02.02.01, EP 2: The critical access hospital implements infection prevention and control activities when doing the following: Performing intermediate and high-level disinfection and sterilization of medical equipment, devices, and supplies.
• MM.06.01.01, EP 3: Before administration, the individual administering the medication does the following:
  • Verifies that the medication selected matches the medication order and product label.
  • Visually inspects the medication for particulates, discoloration, or other loss of integrity.
  • Verifies that the medication has not expired.
  • Verifies that no contraindications exist.
  • Verifies that the medication is being administered at the proper time, in the prescribed dose, and by the correct route.
  • Discusses any unresolved concerns about the medication with the patient’s physician or other licensed practitioner, prescriber (if different from the physician or licensed practitioner), and/or staff involved with the patient’s care, treatment, and services.
• EC.02.05.01, EP 15: In critical care areas designed to control airborne contaminants (such as biological agents, gases, fumes, dust), the ventilation system provides appropriate pressure relationships, air-exchange rates, filtration efficiencies, temperature, and humidity. For new and existing health care facilities, or altered, renovated, or modernized portions of existing systems or individual components (constructed or plans approved on or after July 5, 2016), heating, cooling, and ventilation are in accordance with NFPA 99-2012, which includes 2008 ASHRAE 170, or state design requirements if more stringent.
• PC.02.01.11, EP 2: Resuscitation equipment is available for use based on the needs of the population served.
• EC.02.02.01, EP 5: The critical access hospital minimizes risks associated with selecting, handling, storing, transporting, using, and disposing of hazardous chemicals.

Home Care

• IC.02.01.01, EP 2: The organization uses standard precautions, including the use of personal protective equipment, to reduce the risk of infection.
• RC.02.01.01, EP 2: The patient record contains the following clinical information:
  • Any medications administered, including dose.
  • Any activity restrictions.
  • Any changes in the patient’s condition.
  • Any summaries of the patient’s care, treatment, or services furnished to the patient’s physician or allowed practitioner.
  • The patient’s medical history.
  • Any allergies to medications.
  • Any adverse drug reactions.
  • The patient’s functional status.
  • Any diet information or any dietary restrictions.
  • Diagnostic and therapeutic tests, procedures, and treatments, and their results.
  • Any specific notes on care, treatment, or services.
  • The patient’s response to care, treatment, or services.
  • Any assessments relevant to care, treatment, or services.
  • Physician or allowed practitioner orders.
  • Any information required by organization policy, in accordance with law and regulation.
  • A list of medications, including dose, strength, frequency, route, date and time of administration for prescription and nonprescription medications, herbal products, and home remedies that relate to the patient’s care, treatment, or services.
  • The plan(s) of care.
  • For DMEPOS suppliers serving Medicare beneficiaries: The DMEPOS prescription, any certificates of medical necessity (CMN), and pertinent documentation from the beneficiary’s prescribing physician or allowed practitioner.
• PC.01.03.01, EP 10: For home health agencies that elect to use The Joint Commission deemed status option: The individualized plan of care specifies the care and services necessary to meet the needs identified in the comprehensive assessment and addresses the following:
  • All pertinent diagnoses.
  • Mental, psychosocial, and cognitive status.
  • Types of services, supplies, and equipment required.
  • The frequency and duration of visits.
  • The patient’s prognosis.
  • The patient’s potential for rehabilitation.
  • The patient’s functional limitations.
  • The patient’s permitted activities.
  • The patient’s nutritional requirements.
  • All medications and treatments.
  • Safety measures to protect against injury.
  • A description of the patient’s risk for emergency department visits and hospital readmission, and all necessary interventions to address the underlying risk factors.
  • Patient-specific interventions and education.
  • Measurable outcomes and goals identified by the organization and patient as a result of implementing and coordinating the plan of care.
  • Patient and caregiver education and training to facilitate timely discharge.
  • Information related to any advance directives.
  • Identification of the disciplines involved in providing care.
  • Any other relevant items, including additions, revisions, and deletions that the home health agency, physician, or allowed practitioner may choose to include.
• LD.04.01.07, EP 1: Leaders review, approve, and manage the implementation of policies and procedures that guide and support patient care, treatment, or services.
• PC.01.03.01, EP 5: The written plan of care is based on the patient’s goals and the time frames, settings, and services required to meet those goals.

Hospital

• IC.02.02.01, EP 2: The hospital implements infection prevention and control activities when doing the following: Performing intermediate and high-level disinfection and sterilization of medical equipment, devices, and supplies.
• MM.06.01.01, EP 3: Before administration, the individual administering the medication does the following:
  • Verifies that the medication selected matches the medication order and product label.
  • Visually inspects the medication for particulates, discoloration, or other loss of integrity.
  • Verifies that the medication has not expired.
  • Verifies that no contraindications exist.
  • Verifies that the medication is being administered at the proper time, in the prescribed dose, and by the correct route.
  • Discusses any unresolved concerns about the medication with the patient’s physician or other licensed practitioner, prescriber (if different from the physician or other licensed practitioner), and/or staff involved with the patient’s care, treatment, and services.
• NPSG.15.01.01, EP 1: For psychiatric hospitals and psychiatric units in general hospitals: The hospital conducts an environmental risk assessment that identifies features in the physical environment that could be used to attempt suicide; the hospital takes necessary action to minimize the risk(s) (for example, removal of anchor points, door hinges, and hooks that can be used for hanging). For nonpsychiatric units in general hospitals: The organization implements procedures to mitigate the risk of suicide for patients at high risk for suicide, such as one-to-one monitoring, removing objects that pose a risk for self-harm if they can be removed without adversely affecting the patient’s medical care, assessing objects brought into a room by visitors, and using safe transportation procedures when moving patients to other parts of the hospital.
• EC.02.05.01, EP 15: In critical care areas designed to control airborne contaminants (such as biological agents, gases, fumes, dust), the ventilation system provides appropriate pressure relationships, air exchange rates, filtration efficiencies, temperature, and humidity. For new and existing health care facilities, or altered, renovated, or modernized portions of existing systems or individual components (constructed or plans approved on or after July 5, 2016), heating, cooling, and ventilation are in accordance with NFPA 99-2012, which includes 2008 ASHRAE 170, or state design requirements if more stringent.
• EC.02.06.01, EP 1: Interior spaces meet the needs of the patient population and are safe and suitable to the care, treatment, and services provided.

Laboratory and Point-of-Care Testing

• QSA.02.08.01, EP 2: The laboratory performs correlations at least once every six months. The correlations are documented.
• QSA.01.02.01, EP 2: The laboratory conducts an investigation of all potential causes, provides evidence of review, and performs corrective action for the following:
  • Individual unacceptable proficiency testing results.
  • Late submission of proficiency testing results (score is zero).
  • Nonparticipation in the proficiency testing event (score is zero).
  • Lack of consensus among all laboratories participating in the proficiency testing event (score is ungradable). These actions are documented.
• QSA.02.11.01, EP 7: The laboratory performs review of other records (for example, work records, equipment records, quality control summaries) at a frequency defined by the laboratory, but at least monthly. The review is documented.
• EC.02.04.03, EP 7: The laboratory performs preventive maintenance, periodic inspection, and performance testing of each instrument of piece of equipment. These activities are documented.
• HR.01.06.01, EP 18: The staff member’s competency assessment includes the following:
  • Direct observations of routine patient test performance, including patient preparation, if applicable, and specimen collection, handling, processing, and testing.
  • Monitoring, recording, and reporting of test results.
  • Review of intermediate test results or worksheets, quality control, proficiency testing, and preventive maintenance performance.
  • Direct observation of performance of instrument maintenance function checks and calibration.
  • Test performance as defined by laboratory policy (for example, testing previously analyzed specimens, internal blind testing samples, external proficiency, or testing samples).
  • Problem-solving skills as appropriate to the job.

Nursing Care Center

• EC.02.02.01, EP 5: The organization minimizes risks associated with selecting, handling, storing, transporting, using, and disposing of hazardous chemicals.
• IC.02.02.01, EP 4: The organization implements infection prevention and control activities when doing the following: Storing medical equipment, devices, and supplies.
• HR.02.01.04, EP 1: Before permitting licensed practitioners new to the organization to provide care, treatment, and services, the organization does the following:
  • Documents current licensure and any disciplinary actions against the license available through the primary source.
  • Verifies the identity of the individual by viewing a valid state or federal government-issued picture identification (for example, a driver’s license or passport).
  • Obtains and documents information from the National Practitioner Data Bank (NPDB). The medical director evaluates this information.
  • Determines and documents that the practitioner is currently privileged at a Joint Commission-accredited organization; this determination is verified through the accredited organization. If the organization cannot verify that the practitioner is currently privileged at a Joint Commission-accredited organization, the medical director oversees the monitoring of the practitioner’s performance and reviews the results of the monitoring. This monitoring continues until it is determined that the practitioner is able to provide the care, treatment, and services that they are being permitted to provide.
• WT.03.01.01, EP 5: Competency for waived testing is assessed using at least two of the following methods per person per test:
  • Performance of a test on a blind specimen.
  • Periodic observation of routine work by the supervisor or qualified designee.
  • Monitoring of each user’s quality control performance.
  • Use of a written test specific to the test assessed.
• PC.02.02.03, EP 11: The organization stores food and nutrition products, including those brought in by patients and residents or their families, under proper conditions of sanitation, temperature, light, moisture, ventilation, and security.

Office-Based Surgery

• IC.02.02.01, EP 2: The practice implements infection prevention and control activities when doing the following: Performing intermediate and high-level disinfection and sterilization of medical equipment, devices, and supplies.
• IC.02.01.01, EP 2: The practice uses standard precautions, including the use of personal protective equipment, to reduce the risk of infection.
• LD.04.01.07, EP 1: Leaders review, approve, and manage the implementation of policies and procedures that guide and support patient care, treatment, or services.
• EC.02.04.03, EP 4: The practice conducts performance testing of and maintains all sterilizers. These activities are documented.
• HR.01.06.01, EP 5: Staff competence is initially assessed and documented as part of orientation.