HCO ID:


Activity as of:
Accreditation
Programs
Accreditation
Decision
Effective
Date
Last Full
Survey Date
Last On-Site
Survey Date
 
Hospital
Accredited
12/21/2018
12/20/2018
1/11/2019
 
3/16/2019
Quality Report
Accreditation
Programs
Accreditation
Decision
Effective
Date
Last Full
Survey Date
Last On-Site
Survey Date
 
Behavioral Health Care
Accredited
12/20/2018
12/19/2018
12/19/2018
 
Hospital
Accredited
12/21/2018
12/20/2018
1/11/2019
 
1/17/2019
Quality Report
Accreditation
Programs
Accreditation
Decision
Effective
Date
Last Full
Survey Date
Last On-Site
Survey Date
 
Behavioral Health Care
Accredited
2/4/2016
12/19/2018
12/19/2018
 
Hospital
Accredited
12/6/2017
12/20/2018
1/11/2019
 
12/29/2018
Quality Report
Accreditation
Programs
Accreditation
Decision
Effective
Date
Last Full
Survey Date
Last On-Site
Survey Date
 
Behavioral Health Care
Accredited
2/4/2016
12/19/2018
12/19/2018
 
Hospital
Accredited
12/6/2017
12/20/2018
12/20/2018
 
12/12/2018
Quality Report
Accreditation
Programs
Accreditation
Decision
Effective
Date
Last Full
Survey Date
Last On-Site
Survey Date
 
Behavioral Health Care
Accredited
2/4/2016
2/3/2016
5/11/2017
 
Hospital
Accredited
12/6/2017
2/3/2016
11/27/2018
 
2/21/2018
Quality Report
Accreditation
Programs
Accreditation
Decision
Effective
Date
Last Full
Survey Date
Last On-Site
Survey Date
 
Behavioral Health Care
Accredited
2/4/2016
2/3/2016
5/11/2017
 
Hospital
Accredited
12/6/2017
2/3/2016
12/5/2017
 
12/7/2017
Quality Report
Accreditation
Programs
Accreditation
Decision
Effective
Date
Last Full
Survey Date
Last On-Site
Survey Date
 
Behavioral Health Care
Accredited
2/4/2016
2/3/2016
5/11/2017
 
Hospital
Accreditation with Follow-up Survey
7/27/2017
2/3/2016
12/5/2017
 
8/12/2017
Quality Report
Accreditation
Programs
Accreditation
Decision
Effective
Date
Last Full
Survey Date
Last On-Site
Survey Date
 
Behavioral Health Care
Accredited
2/4/2016
2/3/2016
5/11/2017
 
Hospital
Accreditation with Follow-up Survey
7/27/2017
2/3/2016
7/27/2017
 
Accreditation
Programs
Accreditation
Decision
Effective
Date
Last Full
Survey Date
Last On-Site
Survey Date
 
Behavioral Health Care
Accredited
2/4/2016
2/3/2016
5/11/2017
 
Hospital
Preliminary Denial of Accreditation
5/11/2017
2/3/2016
5/31/2017
 

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.

  • The organization collects information to monitor conditions in the environment.
  • Identify patients at risk for suicide. Note: This requirement applies only to psychiatric hospitals and patients being treated for emotional or behavioral disorders in general hospitals.
  • Leaders create and maintain a culture of safety and quality throughout the hospital
  • Leaders establish priorities for performance improvement.
  • Staff are competent to perform their responsibilities.
  • The governing body is ultimately accountable for the safety and quality of care, treatment, and services.
  • The hospital collects data to monitor its performance.
  • The hospital compiles and analyzes data
  • The hospital complies with law and regulation.
  • 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 evaluates the effectiveness of its medication management system. Note: This evaluation includes reconciling medication information.
  • The hospital has an organizationwide, integrated patient safety program within its performance improvement activities.
  • The hospital has written policies and procedures that guide the use of restraint or seclusion.
  • The hospital initiates restraint or seclusion based on an individual order.
  • The hospital maintains complete and accurate medical records for each individual patient.
  • The hospital makes food and nutrition products available to its patients
  • The hospital manages safety and security risks
  • The hospital protects the privacy of health information.
  • The hospital provides care, treatment, and services as ordered or prescribed, and in accordance with law and regulation.
  • The hospital respects, protects, and promotes patient rights.
  • The hospital safely stores medications.
  • The hospital trains staff to safely implement the use of restraint or seclusion.
  • The hospital uses data and information to guide decisions and to understand variation in the performance of processes supporting safety and quality.
  • The hospital uses restraint or seclusion safely.
  • The hospital verifies staff qualifications
  • The nurse executive directs the hospital’s nursing services.
  • The nurse executive directs the implementation of nursing policies and procedures, nursing standards, and a nurse staffing plan(s).
  • 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 organized medical staff oversees the quality of patient care, treatment, and services provided by practitioners privileged through the medical staff process.
  • The patient and his or her family have the right to have complaints reviewed by the hospital.
  • Those who work in the hospital are focused on improving safety and quality
  • Existence at time of survey of a condition, which in the Joint Commission's view, poses a threat to patients or other individuals served.
5/12/2017
Quality Report
Accreditation
Programs
Accreditation
Decision
Effective
Date
Last Full
Survey Date
Last On-Site
Survey Date
 
Behavioral Health Care
Accredited
2/4/2016
2/3/2016
2/3/2016
 
Hospital
Preliminary Denial of Accreditation
5/11/2017
2/3/2016
7/27/2016
 

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.

  • The organization collects information to monitor conditions in the environment.
  • Identify patients at risk for suicide. Note: This requirement applies only to psychiatric hospitals and patients being treated for emotional or behavioral disorders in general hospitals.
  • Leaders create and maintain a culture of safety and quality throughout the hospital
  • Leaders establish priorities for performance improvement.
  • Staff are competent to perform their responsibilities.
  • The governing body is ultimately accountable for the safety and quality of care, treatment, and services.
  • The hospital collects data to monitor its performance.
  • The hospital compiles and analyzes data
  • The hospital complies with law and regulation.
  • 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 evaluates the effectiveness of its medication management system. Note: This evaluation includes reconciling medication information.
  • The hospital has an organizationwide, integrated patient safety program within its performance improvement activities.
  • The hospital has written policies and procedures that guide the use of restraint or seclusion.
  • The hospital initiates restraint or seclusion based on an individual order.
  • The hospital maintains complete and accurate medical records for each individual patient.
  • The hospital makes food and nutrition products available to its patients
  • The hospital manages safety and security risks
  • The hospital protects the privacy of health information.
  • The hospital provides care, treatment, and services as ordered or prescribed, and in accordance with law and regulation.
  • The hospital respects, protects, and promotes patient rights.
  • The hospital safely stores medications.
  • The hospital trains staff to safely implement the use of restraint or seclusion.
  • The hospital uses data and information to guide decisions and to understand variation in the performance of processes supporting safety and quality.
  • The hospital uses restraint or seclusion safely.
  • The hospital verifies staff qualifications
  • The nurse executive directs the hospital’s nursing services.
  • The nurse executive directs the implementation of nursing policies and procedures, nursing standards, and a nurse staffing plan(s).
  • 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 organized medical staff oversees the quality of patient care, treatment, and services provided by practitioners privileged through the medical staff process.
  • The patient and his or her family have the right to have complaints reviewed by the hospital.
  • Those who work in the hospital are focused on improving safety and quality
  • Existence at time of survey of a condition, which in the Joint Commission's view, poses a threat to patients or other individuals served.
7/29/2016
Quality Report
Accreditation
Programs
Accreditation
Decision
Effective
Date
Last Full
Survey Date
Last On-Site
Survey Date
 
Behavioral Health Care
Accredited
2/4/2016
2/3/2016
2/3/2016
 
Hospital
Accredited
7/28/2016
2/3/2016
7/27/2016
 
4/29/2016
Quality Report
Accreditation
Programs
Accreditation
Decision
Effective
Date
Last Full
Survey Date
Last On-Site
Survey Date
 
Behavioral Health Care
Accredited
2/4/2016
2/3/2016
2/3/2016
 
Hospital
Accreditation with Follow-up Survey
2/4/2016
2/3/2016
3/18/2016
 

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.

  • All licensed independent practitioners and other practitioners privileged through the medical staff process participate in continuing education.
  • Before the hospital discharges or transfers a patient, it informs and educates the patient about his or her follow-up care, treatment, and services.
  • For hospitals that use Joint Commission accreditation for deemed status purposes: The hospital uses restraint or seclusion safely.
  • Identify patients at risk for suicide. Note: This requirement applies only to psychiatric hospitals and patients being treated for emotional or behavioral disorders in general hospitals.
  • Medication orders are clear and accurate.
  • Qualified staff receive and record verbal orders.
  • Resuscitation services are available throughout the hospital.
  • Staff and licensed independent practitioners performing waived tests are competent.
  • Staff are competent to perform their responsibilities.
  • The hospital assesses and reassesses its patients.
  • The hospital assesses the needs of patients who receive treatment for emotional and behavioral disorders.
  • 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 evaluates the effectiveness of its emergency management planning activities.
  • The hospital evaluates the effectiveness of its Emergency Operations Plan.
  • The hospital has an Emergency Operations Plan. Note: The hospital’s Emergency Operations Plan (EOP) is designed to coordinate its communications, resources and assets, safety and security, staff responsibilities, utilities, and patient clinical and support activities during an emergency (refer to Standards EM.02.02.01, EM.02.02.03, EM.02.02.05, EM.02.02.07, EM.02.02.09, and EM.02.02.11). Although emergencies have many causes, the effects on these areas of the organization and the required response effort may be similar. This "all hazards" approach supports a general response capability that is sufficiently nimble to address a range of emergencies of different duration, scale, and cause. For this reason, the Plan’s response procedures address the prioritized emergencies but are also adaptable to other emergencies that the organization may experience.
  • 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 maintains the integrity of the means of egress.
  • The hospital manages risks associated with its utility systems.
  • The hospital plans the patient’s care.
  • 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, and services as ordered or prescribed, and in accordance with law and regulation.
  • The hospital provides patient education and training based on each patient’s needs and abilities.
  • The hospital verifies staff qualifications.
  • The organized medical staff defines the circumstances requiring monitoring and evaluation of a practitioner’s professional performance.
  • The organized medical staff oversees the quality of patient care, treatment, and services provided by practitioners privileged through the medical staff process.
Accreditation
Programs
Accreditation
Decision
Effective
Date
Last Full
Survey Date
Last On-Site
Survey Date
 
Behavioral Health Care
Accredited
2/9/2013
2/3/2016
2/3/2016
 
Hospital
Accredited
1/16/2015
2/3/2016
2/3/2016
 
2/26/2016
Quality Report
Accreditation
Programs
Accreditation
Decision
Effective
Date
Last Full
Survey Date
Last On-Site
Survey Date
 
Behavioral Health Care
Accredited
2/9/2013
2/8/2013
2/8/2013
 
Hospital
Accredited
1/16/2015
2/7/2013
11/21/2014
 
12/5/2014
Quality Report
Accreditation
Programs
Accreditation
Decision
Effective
Date
Last Full
Survey Date
Last On-Site
Survey Date
 
Behavioral Health Care
Accredited
2/9/2013
2/8/2013
2/8/2013
 
Hospital
Accredited
2/8/2013
2/7/2013
11/21/2014
 
8/12/2013
Quality Report
Accreditation
Programs
Accreditation
Decision
Effective
Date
Last Full
Survey Date
Last On-Site
Survey Date
 
Behavioral Health Care
Accredited
2/9/2013
2/8/2013
2/8/2013
 
Hospital
Accredited
2/8/2013
2/7/2013
2/7/2013
 
Accreditation
Programs
Accreditation
Decision
Effective
Date
Last Full
Survey Date
Last On-Site
Survey Date
 
Behavioral Health Care
Accredited
2/19/2010
2/8/2013
2/8/2013
 
Hospital
Accredited
2/20/2010
2/7/2013
2/7/2013