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.
- Based on the identified risks, the organization sets goals to minimize the possibility of transmitting infections. Note: See NPSG.07.01.01 for hand hygiene guidelines.
- For organizations that elect The Joint Commission Primary Care Medical Home option: The organization provides patients with information about the functions and services of the primary care medical home.
- Medication orders are clear and accurate.
- Medications are labeled. Note: This standard is applicable to all organizations that prepare and administer medications.
- Staff and licensed independent practitioners performing waived tests are competent.
- Staff are competent to perform their responsibilities.
- The organization addresses the safe use of look-alike/sound-alike medications.
- The organization assesses and manages the patient's pain.
- The organization complies with law and regulation.
- The organization defines staff qualifications.
- The organization effectively manages its programs, services, or sites.
- The organization identifies risks for acquiring and transmitting infections.
- The organization implements infection prevention and control activities.
- The organization inspects, tests, and maintains emergency power systems. Note: This standard does not require organizations to have the types of emergency power equipment discussed below. However, if these types of equipment exist within the building, then the following maintenance, testing, and inspection requirements apply.
- The organization inspects, tests, and maintains medical equipment.
- The organization maintains records for waived testing.
- The organization manages risks related to hazardous materials and waste.
- The organization performs quality control checks for waived testing on each procedure. Note: Internal quality controls may include electronic, liquid, or control zone. External quality controls may include electronic or liquid.
- The organization 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 organization provides orientation to licensed independent practitioners.
- The organization provides orientation to staff.
- The organization reduces the risk of infections associated with medical equipment, devices, and supplies.
- The organization safely manages emergency medications.
- The organization safely manages high-alert and hazardous medications.
- The organization safely stores medications.
- The organization verifies staff qualifications.
|