|
Accreditation Programs
|
Accreditation Decision
|
Effective Date
|
Last Full Survey Date
|
Last On-Site Survey Date
|
|
Hospital
|
Accredited
|
9/23/2023
|
9/22/2023
|
12/1/2023
|
|
Laboratory
|
Accredited
|
7/22/2022
|
7/21/2022
|
7/21/2022
|
|
|
Accreditation Programs
|
Accreditation Decision
|
Effective Date
|
Last Full Survey Date
|
Last On-Site Survey Date
|
|
Hospital
|
Accreditation with Follow-up Survey
|
9/23/2023
|
9/22/2023
|
12/1/2023
|
|
Laboratory
|
Accredited
|
7/22/2022
|
7/21/2022
|
7/21/2022
|
|
|
Accreditation Programs
|
Accreditation Decision
|
Effective Date
|
Last Full Survey Date
|
Last On-Site Survey Date
|
|
Hospital
|
Accreditation with Follow-up Survey
|
9/23/2023
|
9/22/2023
|
10/31/2023
|
|
Laboratory
|
Accredited
|
7/22/2022
|
7/21/2022
|
7/21/2022
|
|
|
Accreditation Programs
|
Accreditation Decision
|
Effective Date
|
Last Full Survey Date
|
Last On-Site Survey Date
|
|
Hospital
|
Accredited
|
1/21/2023
|
9/22/2023
|
9/22/2023
|
|
Laboratory
|
Accredited
|
7/22/2022
|
7/21/2022
|
7/21/2022
|
|
|
Accreditation Programs
|
Accreditation Decision
|
Effective Date
|
Last Full Survey Date
|
Last On-Site Survey Date
|
|
Hospital
|
Accredited
|
1/21/2023
|
6/18/2021
|
1/20/2023
|
|
Laboratory
|
Accredited
|
7/22/2022
|
7/21/2022
|
7/21/2022
|
|
|
Accreditation Programs
|
Accreditation Decision
|
Effective Date
|
Last Full Survey Date
|
Last On-Site Survey Date
|
|
Hospital
|
Accredited
|
4/7/2022
|
6/18/2021
|
1/20/2023
|
|
Laboratory
|
Accredited
|
7/22/2022
|
7/21/2022
|
7/21/2022
|
|
|
Accreditation Programs
|
Accreditation Decision
|
Effective Date
|
Last Full Survey Date
|
Last On-Site Survey Date
|
|
Hospital
|
Accredited
|
4/7/2022
|
6/18/2021
|
4/7/2022
|
|
Laboratory
|
Accredited
|
7/22/2022
|
7/21/2022
|
7/21/2022
|
|
|
Accreditation Programs
|
Accreditation Decision
|
Effective Date
|
Last Full Survey Date
|
Last On-Site Survey Date
|
|
Hospital
|
Accredited
|
4/7/2022
|
6/18/2021
|
1/20/2023
|
|
Laboratory
|
Accredited
|
7/22/2022
|
7/21/2022
|
7/21/2022
|
|
|
Accreditation Programs
|
Accreditation Decision
|
Effective Date
|
Last Full Survey Date
|
Last On-Site Survey Date
|
|
Hospital
|
Accredited
|
4/7/2022
|
6/18/2021
|
4/7/2022
|
|
Laboratory
|
Accredited
|
7/22/2022
|
7/21/2022
|
7/21/2022
|
|
|
Accreditation Programs
|
Accreditation Decision
|
Effective Date
|
Last Full Survey Date
|
Last On-Site Survey Date
|
|
Hospital
|
Accredited
|
4/7/2022
|
6/18/2021
|
4/7/2022
|
|
Laboratory
|
Accredited
|
1/16/2020
|
7/21/2022
|
7/21/2022
|
|
|
Accreditation Programs
|
Accreditation Decision
|
Effective Date
|
Last Full Survey Date
|
Last On-Site Survey Date
|
|
Hospital
|
Accredited
|
4/7/2022
|
6/18/2021
|
4/7/2022
|
|
Laboratory
|
Accredited
|
1/16/2020
|
1/15/2020
|
1/15/2020
|
|
|
Accreditation Programs
|
Accreditation Decision
|
Effective Date
|
Last Full Survey Date
|
Last On-Site Survey Date
|
|
Hospital
|
Accredited
|
4/6/2022
|
6/18/2021
|
4/7/2022
|
|
Laboratory
|
Accredited
|
1/16/2020
|
1/15/2020
|
1/15/2020
|
|
|
Accreditation Programs
|
Accreditation Decision
|
Effective Date
|
Last Full Survey Date
|
Last On-Site Survey Date
|
|
Hospital
|
Accredited
|
4/6/2022
|
6/18/2021
|
4/5/2022
|
|
Laboratory
|
Accredited
|
1/16/2020
|
1/15/2020
|
1/15/2020
|
|
|
Accreditation Programs
|
Accreditation Decision
|
Effective Date
|
Last Full Survey Date
|
Last On-Site Survey Date
|
|
Hospital
|
Accredited
|
4/6/2022
|
6/18/2021
|
8/27/2021
|
|
Laboratory
|
Accredited
|
1/16/2020
|
1/15/2020
|
1/15/2020
|
|
|
Accreditation Programs
|
Accreditation Decision
|
Effective Date
|
Last Full Survey Date
|
Last On-Site Survey Date
|
|
Hospital
|
Accredited
|
8/27/2021
|
6/18/2021
|
8/27/2021
|
|
Laboratory
|
Accredited
|
1/16/2020
|
1/15/2020
|
1/15/2020
|
|
|
Accreditation Programs
|
Accreditation Decision
|
Effective Date
|
Last Full Survey Date
|
Last On-Site Survey Date
|
|
Hospital
|
Accreditation with Follow-up Survey
|
8/27/2021
|
6/18/2021
|
8/20/2021
|
|
Laboratory
|
Accredited
|
1/16/2020
|
1/15/2020
|
1/15/2020
|
|
|
Accreditation Programs
|
Accreditation Decision
|
Effective Date
|
Last Full Survey Date
|
Last On-Site Survey Date
|
|
Hospital
|
Preliminary Denial of Accreditation
|
6/19/2021
|
6/18/2021
|
7/6/2021
|
|
Laboratory
|
Accredited
|
1/16/2020
|
1/15/2020
|
1/15/2020
|
|
The following information provides a general description of the areas in which performance issues were found. Each of these areas typically has many specific requirements. The area is listed if one or more of the specific requirements were determined to require improvement.
- A pharmacist reviews the appropriateness of all medication orders for medications to be dispensed in the hospital.
- Building and fire protection features are designed and maintained to minimize the effects of fire, smoke, and heat.
- Leaders create and maintain a culture of safety and quality throughout the hospital.
- Maintain and communicate accurate patient medication information.
- Medical staff bylaws address self-governance and accountability to the governing body.
- Medication orders are clear and accurate.
- Medications are labeled.
- Staff and licensed independent practitioners performing waived tests are competent.
- Staff participate in ongoing education and training.
- The governing body is ultimately accountable for the safety and quality of care, treatment, and services.
- The hospital assesses and reassesses the patient and his or her condition according to defined time frames.
- The hospital collects data to monitor its performance.
- The hospital complies with law and regulation.
- The hospital conducts fire drills.
- The hospital defines and verifies staff qualifications.
- The hospital effectively manages its programs, services, sites, or departments.
- The hospital establishes and maintains a safe, functional environment.
Note: The environment is constructed, arranged, and maintained to foster patient safety, provide facilities for diagnosis and treatment, and provide for special services appropriate to the needs of the community.
- The hospital has a reliable emergency electrical power source.
- The hospital has an organizationwide, integrated patient safety program within its performance improvement activities.
- The hospital honors the patient's right to give or withhold informed consent.
- The hospital implements its infection prevention and control plan.
- The hospital inspects, tests, and maintains medical gas and vacuum systems.
Note: This standard does not require hospitals to have the medical gas and vacuum systems discussed below. However, if a hospital has these types of systems, then the following inspection, testing, and maintenance requirements apply.
- The hospital inspects, tests, and maintains utility systems.
Note: At times, maintenance is performed by an external service. In these cases, hospitals are not required to possess maintenance documentation but must have access to such documentation during survey and as needed.
- The hospital maintains complete and accurate medical records for each individual patient.
- The hospital maintains fire safety equipment and fire safety building features.
Note: This standard does not require hospitals to have the types of fire safety equipment and building features described below. However, if these types of equipment or features exist within the building, then the following maintenance, testing, and inspection requirements apply.
- The hospital makes space and equipment available as needed for the provision of care, treatment, and services.
- The hospital manages risks associated with its utility systems.
- The hospital manages risks related to hazardous materials and waste.
- The hospital manages safety and security risks.
- The hospital provides and maintains building features to protect individuals from the hazards of fire and smoke.
- The hospital provides and maintains systems for extinguishing fires.
- The hospital provides care, treatment, services, and an environment that pose no risk of an “Immediate Threat to Health or Safety,” also known as “Immediate Threat to Life” or ITL situation.
- The hospital respects the patient's right to participate in decisions about his or her care, treatment, and services.
Note: For hospitals that use Joint Commission accreditation for deemed status purposes: This right is not to be construed as a mechanism to demand the provision of treatment or services deemed medically unnecessary or inappropriate.
- The hospital respects, protects, and promotes patient rights.
- The hospital safely prepares medications.
- The organized medical staff oversees the quality of patient care, treatment, and services provided by practitioners privileged through the medical staff process.
- Those who work in the hospital are focused on improving safety and quality.
|
|
Accreditation Programs
|
Accreditation Decision
|
Effective Date
|
Last Full Survey Date
|
Last On-Site Survey Date
|
|
Hospital
|
Preliminary Denial of Accreditation
|
6/19/2021
|
6/18/2021
|
7/6/2021
|
|
Laboratory
|
Accredited
|
1/16/2020
|
1/15/2020
|
1/15/2020
|
|
The following information provides a general description of the areas in which performance issues were found. Each of these areas typically has many specific requirements. The area is listed if one or more of the specific requirements were determined to require improvement.
- Existence at time of survey of a condition, which in the Joint Commission's view, poses a threat to patients or other individuals served.
|
|
Accreditation Programs
|
Accreditation Decision
|
Effective Date
|
Last Full Survey Date
|
Last On-Site Survey Date
|
|
Hospital
|
Preliminary Denial of Accreditation
|
6/18/2020
|
9/22/2017
|
7/6/2021
|
|
Laboratory
|
Accredited
|
1/16/2020
|
1/15/2020
|
1/15/2020
|
|
The following information provides a general description of the areas in which performance issues were found. Each of these areas typically has many specific requirements. The area is listed if one or more of the specific requirements were determined to require improvement.
- Existence at time of survey of a condition, which in the Joint Commission's view, poses a threat to patients or other individuals served.
|
|
Accreditation Programs
|
Accreditation Decision
|
Effective Date
|
Last Full Survey Date
|
Last On-Site Survey Date
|
|
Hospital
|
Preliminary Denial of Accreditation
|
6/18/2020
|
6/18/2021
|
6/18/2021
|
|
Laboratory
|
Accredited
|
1/16/2020
|
1/15/2020
|
1/15/2020
|
|
The following information provides a general description of the areas in which performance issues were found. Each of these areas typically has many specific requirements. The area is listed if one or more of the specific requirements were determined to require improvement.
- Existence at time of survey of a condition, which in the Joint Commission's view, poses a threat to patients or other individuals served.
- A pharmacist reviews the appropriateness of all medication orders for medications to be dispensed in the hospital.
- Building and fire protection features are designed and maintained to minimize the effects of fire, smoke, and heat.
- Leaders create and maintain a culture of safety and quality throughout the hospital.
- Maintain and communicate accurate patient medication information.
- Medical staff bylaws address self-governance and accountability to the governing body.
- Medication orders are clear and accurate.
- Medications are labeled.
- Staff and licensed independent practitioners performing waived tests are competent.
- Staff participate in ongoing education and training.
- The governing body is ultimately accountable for the safety and quality of care, treatment, and services.
- The hospital assesses and reassesses the patient and his or her condition according to defined time frames.
- The hospital collects data to monitor its performance.
- The hospital complies with law and regulation.
- The hospital conducts fire drills.
- The hospital defines and verifies staff qualifications.
- The hospital effectively manages its programs, services, sites, or departments.
- The hospital establishes and maintains a safe, functional environment.
Note: The environment is constructed, arranged, and maintained to foster patient safety, provide facilities for diagnosis and treatment, and provide for special services appropriate to the needs of the community.
- The hospital has a reliable emergency electrical power source.
- The hospital has an organizationwide, integrated patient safety program within its performance improvement activities.
- The hospital honors the patient's right to give or withhold informed consent.
- The hospital implements its infection prevention and control plan.
- The hospital inspects, tests, and maintains medical gas and vacuum systems.
Note: This standard does not require hospitals to have the medical gas and vacuum systems discussed below. However, if a hospital has these types of systems, then the following inspection, testing, and maintenance requirements apply.
- The hospital inspects, tests, and maintains utility systems.
Note: At times, maintenance is performed by an external service. In these cases, hospitals are not required to possess maintenance documentation but must have access to such documentation during survey and as needed.
- The hospital maintains complete and accurate medical records for each individual patient.
- The hospital maintains fire safety equipment and fire safety building features.
Note: This standard does not require hospitals to have the types of fire safety equipment and building features described below. However, if these types of equipment or features exist within the building, then the following maintenance, testing, and inspection requirements apply.
- The hospital makes space and equipment available as needed for the provision of care, treatment, and services.
- The hospital manages risks associated with its utility systems.
- The hospital manages risks related to hazardous materials and waste.
- The hospital manages safety and security risks.
- The hospital provides and maintains building features to protect individuals from the hazards of fire and smoke.
- The hospital provides and maintains systems for extinguishing fires.
- The hospital provides care, treatment, services, and an environment that pose no risk of an “Immediate Threat to Health or Safety,” also known as “Immediate Threat to Life” or ITL situation.
- The hospital respects the patient's right to participate in decisions about his or her care, treatment, and services.
Note: For hospitals that use Joint Commission accreditation for deemed status purposes: This right is not to be construed as a mechanism to demand the provision of treatment or services deemed medically unnecessary or inappropriate.
- The hospital respects, protects, and promotes patient rights.
- The hospital safely prepares medications.
- The organized medical staff oversees the quality of patient care, treatment, and services provided by practitioners privileged through the medical staff process.
- Those who work in the hospital are focused on improving safety and quality.
|
|
Accreditation Programs
|
Accreditation Decision
|
Effective Date
|
Last Full Survey Date
|
Last On-Site Survey Date
|
|
Hospital
|
Preliminary Denial of Accreditation
|
6/18/2021
|
9/22/2017
|
3/25/2021
|
|
Laboratory
|
Accredited
|
1/16/2020
|
1/15/2020
|
1/15/2020
|
|
The following information provides a general description of the areas in which performance issues were found. Each of these areas typically has many specific requirements. The area is listed if one or more of the specific requirements were determined to require improvement.
- Existence at time of survey of a condition, which in the Joint Commission's view, poses a threat to patients or other individuals served.
|
|
Accreditation Programs
|
Accreditation Decision
|
Effective Date
|
Last Full Survey Date
|
Last On-Site Survey Date
|
|
Hospital
|
Accredited
|
3/26/2021
|
9/22/2017
|
3/25/2021
|
|
Laboratory
|
Accredited
|
1/16/2020
|
1/15/2020
|
1/15/2020
|
|
|
Accreditation Programs
|
Accreditation Decision
|
Effective Date
|
Last Full Survey Date
|
Last On-Site Survey Date
|
|
Hospital
|
Accredited
|
9/23/2017
|
9/22/2017
|
3/25/2021
|
|
Laboratory
|
Accredited
|
1/16/2020
|
1/15/2020
|
1/15/2020
|
|
|
Accreditation Programs
|
Accreditation Decision
|
Effective Date
|
Last Full Survey Date
|
Last On-Site Survey Date
|
|
Hospital
|
Accredited
|
9/23/2017
|
9/22/2017
|
3/27/2018
|
|
Laboratory
|
Accredited
|
1/16/2020
|
1/15/2020
|
1/15/2020
|
|
|
Accreditation Programs
|
Accreditation Decision
|
Effective Date
|
Last Full Survey Date
|
Last On-Site Survey Date
|
|
Hospital
|
Accredited
|
9/23/2017
|
9/22/2017
|
3/27/2018
|
|
Laboratory
|
Accredited
|
2/1/2018
|
1/15/2020
|
1/15/2020
|
|
|
Accreditation Programs
|
Accreditation Decision
|
Effective Date
|
Last Full Survey Date
|
Last On-Site Survey Date
|
|
Hospital
|
Accredited
|
9/23/2017
|
9/22/2017
|
3/27/2018
|
|
Laboratory
|
Accredited
|
2/1/2018
|
1/31/2018
|
1/31/2018
|
|
|
Accreditation Programs
|
Accreditation Decision
|
Effective Date
|
Last Full Survey Date
|
Last On-Site Survey Date
|
|
Hospital
|
Accredited
|
9/23/2017
|
9/22/2017
|
3/27/2018
|
|
Laboratory
|
Accredited
|
2/1/2018
|
1/31/2018
|
1/31/2018
|
|
|
Accreditation Programs
|
Accreditation Decision
|
Effective Date
|
Last Full Survey Date
|
Last On-Site Survey Date
|
|
Hospital
|
Accredited
|
9/23/2017
|
9/22/2017
|
12/11/2017
|
|
Laboratory
|
Accredited
|
2/1/2018
|
1/31/2018
|
1/31/2018
|
|
|
Accreditation Programs
|
Accreditation Decision
|
Effective Date
|
Last Full Survey Date
|
Last On-Site Survey Date
|
|
Hospital
|
Accreditation with Follow-up Survey
|
12/11/2017
|
9/22/2017
|
12/11/2017
|
|
Laboratory
|
Accredited
|
1/8/2016
|
1/7/2016
|
1/7/2016
|
|
|
Accreditation Programs
|
Accreditation Decision
|
Effective Date
|
Last Full Survey Date
|
Last On-Site Survey Date
|
|
Hospital
|
Preliminary Denial of Accreditation
|
9/22/2017
|
9/22/2017
|
9/22/2017
|
|
Laboratory
|
Accredited
|
1/8/2016
|
1/7/2016
|
1/7/2016
|
|
The following information provides a general description of the areas in which performance issues were found. Each of these areas typically has many specific requirements. The area is listed if one or more of the specific requirements were determined to require improvement.
- Existence at time of survey of a condition, which in the Joint Commission's view, poses a threat to patients or other individuals served.
|
|
Accreditation Programs
|
Accreditation Decision
|
Effective Date
|
Last Full Survey Date
|
Last On-Site Survey Date
|
|
Hospital
|
Preliminary Denial of Accreditation
|
9/22/2017
|
12/12/2014
|
12/12/2014
|
|
Laboratory
|
Accredited
|
1/8/2016
|
1/7/2016
|
1/7/2016
|
|
The following information provides a general description of the areas in which performance issues were found. Each of these areas typically has many specific requirements. The area is listed if one or more of the specific requirements were determined to require improvement.
- Existence at time of survey of a condition, which in the Joint Commission's view, poses a threat to patients or other individuals served.
|