Standard Changes Related to EP Review Phase IV · PDF fileStandard Changes Related to EP...

Hospital (HAP) Accreditation Program

Standard Changes Related to EP Review Phase IV

Issued September 25, 2017

Human Resources (HR) Chapter

The hospital defines and verifies staff qualifications.

Standard HR.01.01.01Requirement Text:

The hospital defines staff qualifications specific to their job responsibilities. (See also HR.01.02.05, EP 19; IC.01.01.01, EP 3; RI.01.01.03, EP 2) Note 1: Qualifications for infection control may be met through ongoing education, training, experience, and/or certification (such as that offered by the Certification Board for Infection Control). Note 2: Qualifications for laboratory personnel are described in the Clinical Laboratory Improvement Amendments of 1988 (CLIA '88), under Subpart M: “Personnel for Nonwaived Testing” §493.1351-§493.1495. A complete description of the requirement is located at http://wwwn.cdc.gov/clia/Regulatory. Note 3: For hospitals that use Joint Commission accreditation for deemed status purposes: Qualified physical therapists, physical therapist assistants, occupational therapists, occupational therapy assistants, speech-language pathologists, or audiologists (as defined in 42 CFR 484.4) provide physical therapy, occupational therapy, speech-language pathology, or audiology services, if these services are provided by the hospital. The provision of care and staff qualifications are in accordance with national acceptable standards of practice and also meet the requirements of 409.17. See Appendix A for 409.17 requirements. Note 4: Qualifications for language interpreters and translators may be met through language proficiency assessment, education, training, and experience. The use of qualified interpreters and translators is supported by the Americans with Disabilities Act, Section 504 of the Rehabilitation Act of 1973, and Title VI of the Civil Rights Act of 1964.

1HR.01.02.01

Current EP Text:

EP:

Revision Type:

The hospital defines staff qualifications specific to their job responsibilities. (See also HR.01.01.01, EP 32; IC.01.01.01, EP 3; RI.01.01.03, EP 2) Note 1: Qualifications for infection control may be met through ongoing education, training, experience, and/or certification (such as that offered by the Certification Board for Infection Control). Note 2: Qualifications for laboratory personnel are described in the Clinical Laboratory Improvement Amendments of 1988 (CLIA '88), under Subpart M: “Personnel for Nonwaived Testing” §493.1351-§493.1495. A complete description of the requirement is located at http://wwwn.cdc.gov/clia/Regulatory. Note 3: For hospitals that use Joint Commission accreditation for deemed status purposes: Qualified physical therapists, physical therapist assistants, occupational therapists, occupational therapy assistants, speech-language pathologists, or audiologists (as defined in 42 CFR 484.4) provide physical therapy, occupational therapy, speech-language pathology, or audiology services, if these services are provided by the hospital. The provision of care and staff qualifications are in accordance with national acceptable standards of practice and also meet the requirements of 409.17. See Appendix A for 409.17 requirements. Note 4: Qualifications for language interpreters and translators may be met through language proficiency assessment, education, training, and experience. The use of qualified interpreters and translators is supported by the Americans with Disabilities Act, Section 504 of the Rehabilitation Act of 1973, and Title VI of the Civil Rights Act of 1964.

1HR.01.01.01

New EP Text:

EP:

Moved and Revised

of 35Prepublication Requirements

Tuesday, Sep 12 2017 © 2017 The Joint Commission

Hospital (HAP) Accreditation Program Issued September 25, 2017

When law or regulation requires care providers to be currently licensed, certified, or registered to practice their professions, the hospital both verifies these credentials with the primary source and documents this verification when a provider is hired and when his or her credentials are renewed. (See also HR.01.02.05, EP 19; HR.01.02.07, EP 2) Note 1: It is acceptable to verify current licensure, certification, or registration with the primary source via a secure electronic communication or by telephone, if this verification is documented. Note 2: A primary verification source may designate another agency to communicate credentials information. The designated agency can then be used as a primary source. Note 3: An external organization (for example, a credentials verification organization [CVO]) may be used to verify credentials information. A CVO must meet the CVO guidelines identified in the Glossary.

1HR.01.02.05

Current EP Text:

EP:

Revision Type:

The hospital verifies and documents the following:- Credentials of care providers using the primary source when licensure, certification, or registration is required by law and regulation to practice their profession. This is done at the time of hire and at the time credentials are renewed.- Credentials of care providers (primary source not required) when licensure, certification, or registration is not required by law and regulation. This is done at the time of hire and at the time credentials are renewed.Note 1: It is acceptable to verify current licensure, certification, or registration with the primary source via a secure electronic communication or by telephone, if this verification is documented.Note 2: A primary verification source may designate another agency to communicate credentials information. The designated agency can then be used as a primary source.Note 3: An external organization (for example, a credentials verification organization [CVO]) may be used to verify credentials information. A CVO must meet the CVO guidelines identified in the Glossary.

2HR.01.01.01

New EP Text:

EP:

Consolidated

When the hospital requires licensure, registration, or certification not required by law and regulation, the hospital both verifies these credentials and documents this verification at time of hire and when credentials are renewed. (See also HR.01.02.05, EP 19; HR.01.02.07, EP 2)

2HR.01.02.05

Current EP Text:

EP:

Revision Type:

The hospital verifies and documents the following:- Credentials of care providers using the primary source when licensure, certification, or registration is required by law and regulation to practice their profession. This is done at the time of hire and at the time credentials are renewed.- Credentials of care providers (primary source not required) when licensure, certification, or registration is not required by law and regulation. This is done at the time of hire and at the time credentials are renewed.Note 1: It is acceptable to verify current licensure, certification, or registration with the primary source via a secure electronic communication or by telephone, if this verification is documented.Note 2: A primary verification source may designate another agency to communicate credentials information. The designated agency can then be used as a primary source.Note 3: An external organization (for example, a credentials verification organization [CVO]) may be used to verify credentials information. A CVO must meet the CVO guidelines identified in the Glossary.

2HR.01.01.01

New EP Text:

EP:

Consolidated




The hospital verifies and documents that the applicant has the education and experience required by the job responsibilities. (See also HR.01.02.05, EP 19)

3HR.01.02.05

Current EP Text:

EP:

Revision Type:

The hospital verifies and documents that the applicant has the education and experience required by the job responsibilities.

3HR.01.01.01

New EP Text:

EP:

Moved and Revised

The hospital obtains a criminal background check on the applicant as required by law and regulation or hospital policy. Criminal background checks are documented.

4HR.01.02.05

Current EP Text:

EP:

Revision Type:

The hospital obtains a criminal background check on the applicant as required by law and regulation or hospital policy. Criminal background checks are documented.

4HR.01.01.01

New EP Text:

EP:

Moved

Staff comply with applicable health screening as required by law and regulation or hospital policy. Health screening compliance is documented.

5HR.01.02.05

Current EP Text:

EP:

Revision Type:

Staff comply with applicable health screening as required by law and regulation or hospital policy. Health screening compliance is documented.

5HR.01.01.01

New EP Text:

EP:

Moved

Before providing care, treatment, and services, the hospital confirms that nonemployees who are brought into the hospital by a licensed independent practitioner to provide care, treatment, or services have the same qualifications and competencies required of employed individuals performing the same or similar services at the hospital. Note 1: This confirmation can be accomplished either through the hospital's regular process or with the licensed independent practitioner who brought in the individual. Note 2: When the care, treatment, and services provided by the nonemployee are not currently performed by anyone employed by the hospital, leadership consults the appropriate professional hospital guidelines for the required credentials and competencies.

7HR.01.02.05

Current EP Text:

EP:

Revision Type:

Before providing care, treatment, and services, the hospital confirms that nonemployees who are brought into the hospital by a licensed independent practitioner to provide care, treatment, or services have the same qualifications and competencies required of employed individuals performing the same or similar services at the hospital. Note 1: This confirmation can be accomplished either through the hospital's regular process or with the licensed independent practitioner who brought in the individual. Note 2: When the care, treatment, and services provided by the nonemployee are not currently performed by anyone employed by the hospital, leadership consults the appropriate professional hospital guidelines for the required credentials and competencies.

7HR.01.01.01

New EP Text:

EP:

Moved




For hospitals that use Joint Commission accreditation for deemed status purposes and have swing beds: The activities program is directed by a professional who meets one of the following criteria:- Is a qualified therapeutic recreation specialist or an activities professional who is licensed or registered, if applicable, by the state in which he or she practices and is eligible for certification as a therapeutic recreation specialist or as an activities professional by a recognized accrediting body on or after October 1, 1990 - Has two years of experience in a social or recreational program within the last five years, one year of which was full time in a patient activities program in a health care setting - Is a qualified occupational therapist or occupational therapy assistant - Has completed a training course approved by the state

12HR.01.02.01

Current EP Text:

EP:

Revision Type:

For hospitals that use Joint Commission accreditation for deemed status purposes and have swing beds: The activities program is directed by a professional who meets one of the following criteria:- Is a qualified therapeutic recreation specialist or an activities professional who is licensed or registered, if applicable, by the state in which he or she practices and is eligible for certification as a therapeutic recreation specialist or as an activities professional by a recognized accrediting body on or after October 1, 1990 - Has two years of experience in a social or recreational program within the last five years, one year of which was full time in a patient activities program in a health care setting - Is a qualified occupational therapist or occupational therapy assistant - Has completed a training course approved by the state

17HR.01.01.01

New EP Text:

EP:

Moved

For hospitals that use Joint Commission accreditation for deemed status purposes and have swing beds: The facility does not employ individuals who have been found guilty by a court of law of abusing, neglecting, or mistreating residents or who have had a finding entered into the state nurse aide registry concerning abuse, neglect, or mistreatment of residents or of misappropriation of their property.

13HR.01.02.01

Current EP Text:

EP:

Revision Type:

For hospitals that use Joint Commission accreditation for deemed status purposes and have swing beds: The facility does not employ individuals who have been found guilty by a court of law of abusing, neglecting, or mistreating residents or who have had a finding entered into the state nurse aide registry concerning abuse, neglect, or mistreatment of residents or of misappropriation of their property.

18HR.01.01.01

New EP Text:

EP:

Moved

For psychiatric hospitals that use Joint Commission accreditation for deemed status purposes: The director of psychiatric nursing is a registered nurse who has a master’s degree in psychiatric or mental health nursing, or its equivalent, from a school of nursing accredited by the National League for Nursing, or is qualified by education and experience in the care of the mentally ill. The director of psychiatric nursing demonstrates competence to participate in interdisciplinary formulation of individual treatment plans; to give skilled nursing care and therapy; and to direct, monitor, and evaluate the nursing care furnished.

16HR.01.02.05

Current EP Text:

EP:

Revision Type:

For psychiatric hospitals that use Joint Commission accreditation for deemed status purposes: The director of psychiatric nursing is a registered nurse who has a master’s degree in psychiatric or mental health nursing, or its equivalent, from a school of nursing accredited by the National League for Nursing, or is qualified by education and experience in the care of the mentally ill. The director of psychiatric nursing demonstrates competence to participate in interdisciplinary formulation of individual treatment plans; to give skilled nursing care and therapy; and to direct, monitor, and evaluate the nursing care furnished.

30HR.01.01.01

New EP Text:

EP:

Moved




For psychiatric hospitals that use Joint Commission accreditation for deemed status purposes: The director of the social work department or service has a master’s degree from an accredited school of social work or is qualified by education and experience in the social services needs of the mentally ill.Note: If the director does not hold a master’s degree in social work, at least one staff member has this qualification.

18HR.01.02.05

Current EP Text:

EP:

Revision Type:

For psychiatric hospitals that use Joint Commission accreditation for deemed status purposes: The director of the social work department or service has a master’s degree from an accredited school of social work or is qualified by education and experience in the social services needs of the mentally ill.Note: If the director does not hold a master’s degree in social work, at least one staff member has this qualification.

31HR.01.01.01

New EP Text:

EP:

Moved

Technologists who perform diagnostic computed tomography (CT) exams have advanced-level certification by the American Registry of Radiologic Technologists (ARRT) or the Nuclear Medicine Technology Certification Board (NMTCB) in computed tomography or have one of the following qualifications: - State licensure that permits them to perform diagnostic CT exams and documented training on the provision of diagnostic CT exams or- Registration and certification in radiography by ARRT and documented training on the provision of diagnostic CT exams or- Certification in nuclear medicine technology by ARRT or NMTCB and documented training on the provision of diagnostic CT exams (See also HR.01.02.01, EP 1; HR.01.02.05, EPs 1–3; HR.01.02.07, EPs 1 and 2)Note 1: This element of performance does not apply to CT exams performed for therapeutic radiation treatment planning or delivery, or for calculating attenuation coefficients for nuclear medicine studies.Note 2: This element of performance does not apply to dental cone beam CT radiographic imaging studies performed for diagnosis of conditions affecting the maxillofacial region or to obtain guidance for the treatment of such conditions.

19HR.01.02.05

Current EP Text:

EP:

Revision Type:

Technologists who perform diagnostic computed tomography (CT) exams have advanced-level certification by the American Registry of Radiologic Technologists (ARRT) or the Nuclear Medicine Technology Certification Board (NMTCB) in computed tomography or have one of the following qualifications: - State licensure that permits them to perform diagnostic CT exams and documented training on the provision of diagnostic CT exams or- Registration and certification in radiography by ARRT and documented training on the provision of diagnostic CT exams or- Certification in nuclear medicine technology by ARRT or NMTCB and documented training on the provision of diagnostic CT exams (See also HR.01.01.01, EP 1; HR.01.02.07, EPs 1 and 2)Note 1: This element of performance does not apply to CT exams performed for therapeutic radiation treatment planning or delivery, or for calculating attenuation coefficients for nuclear medicine studies.Note 2: This element of performance does not apply to dental cone beam CT radiographic imaging studies performed for diagnosis of conditions affecting the maxillofacial region or to obtain guidance for the treatment of such conditions.

32HR.01.01.01

New EP Text:

EP:

Moved and Revised




The hospital verifies and documents that diagnostic medical physicists who support computed tomography (CT) services have board certification in diagnostic radiologic physics or radiologic physics by the American Board of Radiology, or in Diagnostic Imaging Physics by the American Board of Medical Physics, or in Diagnostic Radiological Physics by the Canadian College of Physicists in Medicine, or meet all of the following requirements:- A graduate degree in physics, medical physics, biophysics, radiologic physics, medical health physics, or a closely related science or engineering discipline from an accredited college or university - College coursework in the biological sciences with at least one course in biology or radiation biology and one course in anatomy, physiology, or a similar topic related to the practice of medical physics - Documented experience in a clinical CT environment conducting at least 10 CT performance evaluations under the direct supervision of a board-certified medical physicist Note: This element of performance does not apply to dental cone beam CT radiographic imaging studies performed for diagnosis of conditions affecting the maxillofacial region or to obtain guidance for the treatment of such conditions.

20HR.01.02.05

Current EP Text:

EP:

Revision Type:

The hospital verifies and documents that diagnostic medical physicists who support computed tomography (CT) services have board certification in diagnostic radiologic physics or radiologic physics by the American Board of Radiology, or in Diagnostic Imaging Physics by the American Board of Medical Physics, or in Diagnostic Radiological Physics by the Canadian College of Physicists in Medicine, or meet all of the following requirements:- A graduate degree in physics, medical physics, biophysics, radiologic physics, medical health physics, or a closely related science or engineering discipline from an accredited college or university - College coursework in the biological sciences with at least one course in biology or radiation biology and one course in anatomy, physiology, or a similar topic related to the practice of medical physics - Documented experience in a clinical CT environment conducting at least 10 CT performance evaluations under the direct supervision of a board-certified medical physicist Note: This element of performance does not apply to dental cone beam CT radiographic imaging studies performed for diagnosis of conditions affecting the maxillofacial region or to obtain guidance for the treatment of such conditions.

33HR.01.01.01

New EP Text:

EP:

Moved

Physician assistants and advanced practice registered nurses who practice within the hospital are credentialed, privileged, and reprivileged through the medical staff process or an equivalent process.Note: Advanced practice registered nurses who are licensed independent practitioners are credentialed and privileged only through the medical staff credentialing and privileging process. (See the "Medical Staff" [MS] chapter)


The equivalent process for credentialing and privileging physician assistants and advanced practice registered nurses who practice within the hospital is approved by the governing body.

11HR.01.02.05

Current EP Text:

EP:

Revision Type:

The equivalent process for credentialing and privileging physician assistants and advanced practice registered nurses who practice within the hospital is approved by the governing body.

1HR.01.02.01

New EP Text:

EP:

Moved




The equivalent process for credentialing and privileging physician assistants and advanced practice registered nurses who practice within the hospital includes the following: An evaluation of the applicant’s credentials. The evaluation is documented.

12HR.01.02.05

Current EP Text:

EP:

Revision Type:

The equivalent process for credentialing and privileging physician assistants and advanced practice registered nurses who practice within the hospital includes the following:- A documented evaluation of the applicant’s credentials.- An evaluation of the applicant’s current competence. Documented peer recommendations. - Input from individuals and committees, including the medical staff, in order to make an informed decision regarding requests for privileges.

2HR.01.02.01

New EP Text:

EP:

Consolidated

The equivalent process for credentialing and privileging physician assistants and advanced practice registered nurses who practice within the hospital includes the following: An evaluation of the applicant’s current competence. The evaluation is documented.

13HR.01.02.05

Current EP Text:

EP:

Revision Type:


2HR.01.02.01

New EP Text:

EP:

Consolidated

The equivalent process for credentialing and privileging physician assistants and advanced practice registered nurses who practice within the hospital includes the following: Peer recommendations. The peer recommendations are documented.

14HR.01.02.05

Current EP Text:

EP:

Revision Type:


2HR.01.02.01

New EP Text:

EP:

Consolidated




The equivalent process for credentialing and privileging physician assistants and advanced practice registered nurses who practice within the hospital includes the following: Input from individuals and committees, including the medical staff executive committee, in order to make an informed decision regarding requests for privileges.

15HR.01.02.05

Current EP Text:

EP:

Revision Type:


2HR.01.02.01

New EP Text:

EP:

Consolidated

The hospital has the necessary staff to support the care, treatment, and services it provides.


For hospitals that use Joint Commission accreditation for deemed status purposes: The hospital has a qualified dietician on a full-time, part-time, or consultative basis.

2HR.01.01.01

Current EP Text:

EP:

Revision Type:

For hospitals that use Joint Commission accreditation for deemed status purposes: The hospital has a qualified dietician on a full-time, part-time, or consultative basis.

2HR.01.02.05

New EP Text:

EP:

Moved

Physician assistants and advanced practice registered nurses who practice within the hospital are credentialed, privileged, and re-privileged through the medical staff process or an equivalent process. Note: Advanced practice registered nurses who are licensed independent practitioners are credentialed and privileged only through the medical staff credentialing and privileging process. (See the "Medical Staff" [MS] chapter)

10HR.01.02.05

Current EP Text:

EP:

Revision Type: Deleted




For hospitals that use Joint Commission accreditation for deemed status purposes: A full-time, part-time, or consulting pharmacist develops, supervises, and coordinates all the activities of the pharmacy department or pharmacy services.

28HR.01.01.01

Current EP Text:

EP:

Revision Type:

For hospitals that use Joint Commission accreditation for deemed status purposes: A full-time, part-time, or consulting pharmacist develops, supervises, and coordinates all the activities of the pharmacy department or pharmacy services.

28HR.01.02.05

New EP Text:

EP:

Moved

The hospital determines how staff function within the organization.


All staff who provide patient care, treatment, and services possess a current license, certification, or registration, in accordance with law and regulation. (See also HR.01.02.05, EP 19)

1HR.01.02.07

Current EP Text:

EP:

Revision Type:

All staff who provide patient care, treatment, and services possess a current license, certification, or registration, in accordance with law and regulation. (See also HR.01.01.01, EP 32)

1HR.01.02.07

New EP Text:

EP:

Revised

Staff oversee the supervision of students when they provide patient care, treatment, and services as part of their training.

5HR.01.02.07

Current EP Text:

EP:

Revision Type:

Staff supervise students when they provide patient care, treatment, and services as part of their training.

5HR.01.02.07

New EP Text:

EP:

Revised

The hospital provides orientation to staff.


The hospital determines the key safety content of orientation provided to staff. (See also EC.03.01.01, EP 2)Note: Key safety content may include specific processes and procedures related to the provision of care, treatment, and services; the environment of care; and infection control.

1HR.01.04.01

Current EP Text:

EP:

Revision Type:

The hospital orients its staff to the key safety content it identifies before staff provides care, treatment, and services. Completion of this orientation is documented.Note: Key safety content may include specific processes and procedures related to the provision of care, treatment, or services; the environment of care; and infection control.

1HR.01.04.01

New EP Text:

EP:

Consolidated




The hospital orients its staff to the key safety content before staff provides care, treatment, and services. Completion of this orientation is documented. (See also IC.01.05.01, EP 6)

2HR.01.04.01

Current EP Text:

EP:

Revision Type:

The hospital orients its staff to the key safety content it identifies before staff provides care, treatment, and services. Completion of this orientation is documented.Note: Key safety content may include specific processes and procedures related to the provision of care, treatment, or services; the environment of care; and infection control.

1HR.01.04.01

New EP Text:

EP:

Consolidated

The hospital orients staff on the following: Relevant hospitalwide and unit-specific policies and procedures. Completion of this orientation is documented.

3HR.01.04.01

Current EP Text:

EP:

Revision Type:

The hospital orients staff on the following:- Relevant hospitalwide and unit-specific policies and procedures.- Their specific job duties, including those related to infection prevention and control and assessing and managing pain.- Sensitivity to cultural diversity based on their job duties and responsibilities.- Patient rights, including ethical aspects of care, treatment, or services and the process used to address ethical issues based on their job duties and responsibilities.Completion of this orientation is documented.

3HR.01.04.01

New EP Text:

EP:

Consolidated

The hospital orients staff on the following: Their specific job duties, including those related to infection prevention and control and assessing and managing pain. Completion of this orientation is documented. (See also IC.01.05.01, EP 6; IC.02.01.01, EP 7; IC.02.04.01, EP 2; RI.01.01.01, EP 8)

4HR.01.04.01

Current EP Text:

EP:

Revision Type:


3HR.01.04.01

New EP Text:

EP:

Consolidated




The hospital orients staff on the following: Sensitivity to cultural diversity based on their job duties and responsibilities. Completion of this orientation is documented.

5HR.01.04.01

Current EP Text:

EP:

Revision Type:


3HR.01.04.01

New EP Text:

EP:

Consolidated

The hospital orients staff on the following: Patient rights, including ethical aspects of care, treatment, and services and the process used to address ethical issues based on their job duties and responsibilities. Completion of this orientation is documented.

6HR.01.04.01

Current EP Text:

EP:

Revision Type:


3HR.01.04.01

New EP Text:

EP:

Consolidated

Staff participate in ongoing education and training.


Staff participate in ongoing education and training to maintain or increase their competency. Staff participation is documented.

1HR.01.05.03

Current EP Text:

EP:

Revision Type:

Staff participate in ongoing education and training to maintain or increase their competency, and as needed whenever staff responsibilities change. Staff participation is documented.

1HR.01.05.03

New EP Text:

EP:

Consolidated




Staff participate in ongoing education and training whenever staff responsibilities change. Staff participation is documented.

4HR.01.05.03

Current EP Text:

EP:

Revision Type:

Staff participate in ongoing education and training to maintain or increase their competency, and as needed whenever staff responsibilities change. Staff participation is documented.

1HR.01.05.03

New EP Text:

EP:

Consolidated

Infection Prevention and Control (IC) Chapter

The hospital identifies the individual(s) responsible for the infection prevention and control program.

Standard IC.01.01.01Requirement Text:

The hospital assigns responsibility for the daily management of infection prevention and control activities. (See also HR.01.02.01, EP 1; LD.03.06.01, EP 3)Note: Number and skill mix of the individual(s) assigned should be determined by the goals and objectives of the infection prevention and control program.

3IC.01.01.01

Current EP Text:

EP:

Revision Type:

The hospital assigns responsibility for the daily management of infection prevention and control activities. (See also HR.01.01.01, EP 1; LD.03.06.01, EP 3)Note: Number and skill mix of the individual(s) assigned should be determined by the goals and objectives of the infection prevention and control program.

3IC.01.01.01

New EP Text:

EP:

Revised

The hospital identifies risks for acquiring and transmitting infections.


The hospital identifies risks for acquiring and transmitting infections based on the following: Its geographic location, community, and population served. (See also NPSG.07.03.01, EP 1)

1IC.01.03.01

Current EP Text:

EP:

Revision Type:

The hospital identifies risks for acquiring and transmitting infections based on the following:- Its geographic location, community, and population served.- The care, treatment, and services it provides. - The analysis of surveillance activities and other infection control data.(See also NPSG.07.03.01, EP 1)

1IC.01.03.01

New EP Text:

EP:

Consolidated




The hospital identifies risks for acquiring and transmitting infections based on the following: The care, treatment, and services it provides. (See also NPSG.07.03.01, EP 1)

2IC.01.03.01

Current EP Text:

EP:

Revision Type:


1IC.01.03.01

New EP Text:

EP:

Consolidated

The hospital identifies risks for acquiring and transmitting infections based on the following: The analysis of surveillance activities and other infection control data. (See also NPSG.07.03.01, EP 1; TS.03.03.01, EP 2)

3IC.01.03.01

Current EP Text:

EP:

Revision Type:


1IC.01.03.01

New EP Text:

EP:

Consolidated

The hospital reviews and identifies its risks at least annually and whenever significant changes occur with input from, at a minimum, infection control personnel, medical staff, nursing, and leadership. (See also NPSG.07.03.01, EP 1)

4IC.01.03.01

Current EP Text:

EP:

Revision Type:

The hospital reviews and identifies its risks at least annually and whenever significant changes occur with input from, at a minimum, infection control personnel, medical staff, nursing, and leadership. (See also NPSG.07.03.01, EP 1)

2IC.01.03.01

New EP Text:

EP:

Moved

The hospital prioritizes the identified risks for acquiring and transmitting infections. These prioritized risks are documented. (See also NPSG.07.03.01, EP 1)

5IC.01.03.01

Current EP Text:

EP:

Revision Type:

The hospital prioritizes the identified risks for acquiring and transmitting infections. These prioritized risks are documented. (See also NPSG.07.03.01, EP 1)

3IC.01.03.01

New EP Text:

EP:

Moved




Based on the identified risks, the hospital sets goals to minimize the possibility of transmitting infections.Note: See NPSG.07.01.01 for hand hygiene guidelines.


The hospital's written infection prevention and control goals include the following: Addressing its prioritized risks.

1IC.01.04.01

Current EP Text:

EP:

Revision Type:

The hospital's written infection prevention and control goals include the following:- Addressing its prioritized risks.- Limiting unprotected exposure to pathogens.- Limiting the transmission of infections associated with procedures.- Limiting the transmission of infections associated with the use of medical equipment, devices, and supplies.- Improving compliance with hand hygiene guidelines. (See also NPSG.07.01.01, EP 1)

1IC.01.04.01

New EP Text:

EP:

Consolidated

The hospital's written infection prevention and control goals include the following: Limiting unprotected exposure to pathogens.

2IC.01.04.01

Current EP Text:

EP:

Revision Type:


1IC.01.04.01

New EP Text:

EP:

Consolidated




The hospital's written infection prevention and control goals include the following: Limiting the transmission of infections associated with procedures.

3IC.01.04.01

Current EP Text:

EP:

Revision Type:


1IC.01.04.01

New EP Text:

EP:

Consolidated

The hospital's written infection prevention and control goals include the following: Limiting the transmission of infections associated with the use of medical equipment, devices, and supplies.

4IC.01.04.01

Current EP Text:

EP:

Revision Type:


1IC.01.04.01

New EP Text:

EP:

Consolidated

The hospital's written infection prevention and control goals include the following: Improving compliance with hand hygiene guidelines. (See also NPSG.07.01.01, EP 1)

5IC.01.04.01

Current EP Text:

EP:

Revision Type:


1IC.01.04.01

New EP Text:

EP:

Consolidated




The hospital works to prevent the transmission of infectious disease among patients, licensed independent practitioners, and staff.


When licensed independent practitioners or staff have, or are suspected of having, an infectious disease that puts others at risk, the hospital provides them with or refers them for assessment and potential testing, prophylaxis/treatment, or counseling.

2IC.02.03.01

Current EP Text:

EP:

Revision Type:

When licensed independent practitioners or staff have, are suspected of having, or have been occupationally exposed to an infectious disease that puts others at risk, the hospital provides them with or refers them for assessment and potential testing, prophylaxis/treatment, or counseling.

2IC.02.03.01

New EP Text:

EP:

Consolidated

When licensed independent practitioners or staff have been occupationally exposed to an infectious disease, the hospital provides them with or refers them for assessment and potential testing, prophylaxis/treatment, or counseling.

3IC.02.03.01

Current EP Text:

EP:

Revision Type:

When licensed independent practitioners or staff have, are suspected of having, or have been occupationally exposed to an infectious disease that puts others at risk, the hospital provides them with or refers them for assessment and potential testing, prophylaxis/treatment, or counseling.

2IC.02.03.01

New EP Text:

EP:

Consolidated

The hospital evaluates the effectiveness of its infection prevention and control plan.


The hospital evaluates the effectiveness of its infection prevention and control plan annually and whenever risks significantly change.

1IC.03.01.01

Current EP Text:

EP:

Revision Type:

The hospital evaluates the effectiveness of its infection prevention and control plan annually and whenever risks significantly change. The evaluation includes a review of the following:- The infection prevention and control plan's prioritized risks- The infection prevention and control plan's goals. (See also NPSG.07.01.01, EP 2)- Implementation of the infection prevention and control plan’s activities.

1IC.03.01.01

New EP Text:

EP:

Consolidated




The evaluation includes a review of the following: The infection prevention and control plan's prioritized risks.

2IC.03.01.01

Current EP Text:

EP:

Revision Type:


1IC.03.01.01

New EP Text:

EP:

Consolidated

The evaluation includes a review of the following: The infection prevention and control plan's goals. (See also NPSG.07.01.01, EP 2)

3IC.03.01.01

Current EP Text:

EP:

Revision Type:


1IC.03.01.01

New EP Text:

EP:

Consolidated

The evaluation includes a review of the following: Implementation of the infection prevention and control plan’s activities.

4IC.03.01.01

Current EP Text:

EP:

Revision Type:


1IC.03.01.01

New EP Text:

EP:

Consolidated




Rights and Responsibilities of the Individual (RI) Chapter

The hospital respects, protects, and promotes patient rights.

Standard RI.01.01.01Requirement Text:

The hospital respects the patient’s right to pain management. (See also HR.01.04.01, EP 4; PC.01.02.07, EP 1; MS.03.01.03, EP 2)

8RI.01.01.01

Current EP Text:

EP:

Revision Type:

The hospital respects the patient’s right to pain management. (See also LD.04.03.13, EP 3)

8RI.01.01.01

New EP Text:

EP:

Revised

The hospital respects the patient's right to receive information in a manner he or she understands.


The hospital provides language interpreting and translation services. (See also HR.01.02.01, EP 1; PC.02.01.21, EP 2; RI.01.01.01, EPs 2 and 5)Note: Language interpreting options may include hospital-employed language interpreters, contract interpreting services, or trained bilingual staff. These options may be provided in person or via telephone or video. The hospital determines which translated documents and languages are needed based on its patient population.

2RI.01.01.03

Current EP Text:

EP:

Revision Type:

The hospital provides language interpreting and translation services. (See also HR.01.01.01, EP 1; PC.02.01.21, EP 2; RI.01.01.01, EPs 2 and 5)Note: Language interpreting options may include hospital-employed language interpreters, contract interpreting services, or trained bilingual staff. These options may be provided in person or via telephone or video. The hospital determines which translated documents and languages are needed based on its patient population.

2RI.01.01.03

New EP Text:

EP:

Revised




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.


When a patient is unable to make decisions about his or her care, treatment, and services, the hospital involves a surrogate decision-maker in making these decisions. (See also RI.01.03.01, EP 6)

6RI.01.02.01

Current EP Text:

EP:

Revision Type:

When a patient is unable to make decisions about his or her care, treatment, and services, the hospital involves a surrogate decision-maker in making these decisions. (See also PC.01.02.07, EP 5; RI.01.03.01, EP 1)

2RI.01.02.01

New EP Text:

EP:

Moved and Revised

The hospital provides the patient with written information about the right to refuse care, treatment, and services.

2RI.01.02.01

Current EP Text:

EP:

Revision Type:

The hospital provides the patient or surrogate decision-maker with written information about the right to refuse care, treatment, and services. (See also PC.01.02.07, EP 5)

3RI.01.02.01

New EP Text:

EP:

Consolidated

When a surrogate decision-maker is responsible for making care, treatment, and services decisions, the hospital respects the surrogate decision-maker’s right to refuse care, treatment, and services on the patient’s behalf, in accordance with law and regulation.

7RI.01.02.01

Current EP Text:

EP:

Revision Type:

The hospital provides the patient or surrogate decision-maker with written information about the right to refuse care, treatment, and services. (See also PC.01.02.07, EP 5)

3RI.01.02.01

New EP Text:

EP:

Split

The hospital respects the patient’s right to refuse care, treatment, and services, in accordance with law and regulation.

3RI.01.02.01

Current EP Text:

EP:

Revision Type:

The hospital respects the patient’s or surrogate decision-maker's right to refuse care, treatment, and services, in accordance with law and regulation. (See also PC.01.02.07, EP 5)

4RI.01.02.01

New EP Text:

EP:

Consolidated




When a surrogate decision-maker is responsible for making care, treatment, and services decisions, the hospital respects the surrogate decision-maker’s right to refuse care, treatment, and services on the patient’s behalf, in accordance with law and regulation.

7RI.01.02.01

Current EP Text:

EP:

Revision Type:

The hospital respects the patient’s or surrogate decision-maker's right to refuse care, treatment, and services, in accordance with law and regulation. (See also PC.01.02.07, EP 5)

4RI.01.02.01

New EP Text:

EP:

Split

The hospital involves the patient’s family in care, treatment, and services decisions to the extent permitted by the patient or surrogate decision-maker, in accordance with law and regulation.

8RI.01.02.01

Current EP Text:

EP:

Revision Type:

The hospital involves the patient’s family in care, treatment, and services decisions to the extent permitted by the patient or surrogate decision-maker, in accordance with law and regulation. (See also PC.01.02.07, EP 5)

8RI.01.02.01

New EP Text:

EP:

Revised

The hospital provides the patient or surrogate decision-maker with the information about the outcomes of care, treatment, and services that the patient needs in order to participate in current and future health care decisions.

20RI.01.02.01

Current EP Text:

EP:

Revision Type:

The hospital provides the patient or surrogate decision-maker with the information about the following:- Outcomes of care, treatment, and services that the patient needs in order to participate in current and future health care decisions.- Unanticipated outcomes of the patient’s care, treatment, and services that are sentinel events as defined by The Joint Commission. This information is provided by the licensed independent practitioner responsible for managing the patient's care, treatment, and services, or his or her designee. (Refer to the Glossary for a definition of sentinel event.Note: In settings where there is no licensed independent practitioner, the staff member responsible for managing the care of the patient is responsible for sharing information about such outcomes.

20RI.01.02.01

New EP Text:

EP:

Consolidated




The hospital informs the patient or surrogate decision-maker about unanticipated outcomes of care, treatment, and services that relate to sentinel events as defined by The Joint Commission. (Refer to the Glossary for a definition of sentinel event.)

21RI.01.02.01

Current EP Text:

EP:

Revision Type:


20RI.01.02.01

New EP Text:

EP:

Consolidated

The licensed independent practitioner responsible for managing the patient's care, treatment, and services, or his or her designee, informs the patient about unanticipated outcomes of care, treatment, and services related to sentinel events when the patient is not already aware of the occurrence or when further discussion is needed. Note: In settings where there is no licensed independent practitioner, the staff member responsible for managing the care of the patient is responsible for sharing information about such outcomes.

22RI.01.02.01

Current EP Text:

EP:

Revision Type:


20RI.01.02.01

New EP Text:

EP:

Consolidated




The hospital honors the patient's right to give or withhold informed consent.


The hospital has a written policy on informed consent.

1RI.01.03.01

Current EP Text:

EP:

Revision Type:

The hospital follows a written policy on informed consent that describes the following:- The specific care, treatment, and services that require informed consent.- Circumstances that would allow for exceptions to obtaining informed consent.- The process used to obtain informed consent.- How informed consent is documented in the patient record.Note: Documentation may be recorded in a form, in progress notes, or elsewhere in the record.- When a surrogate decision-maker may give informed consent. (See also PC.01.02.07, EP 5; RI.01.02.01, EP 2)

1RI.01.03.01

New EP Text:

EP:

Consolidated

The hospital's written policy identifies the specific care, treatment, and services that require informed consent, in accordance with law and regulation.

2RI.01.03.01

Current EP Text:

EP:

Revision Type:


1RI.01.03.01

New EP Text:

EP:

Consolidated




The hospital's written policy describes circumstances that would allow for exceptions to obtaining informed consent.

3RI.01.03.01

Current EP Text:

EP:

Revision Type:


1RI.01.03.01

New EP Text:

EP:

Consolidated

The hospital’s written policy describes the process used to obtain informed consent.

4RI.01.03.01

Current EP Text:

EP:

Revision Type:


1RI.01.03.01

New EP Text:

EP:

Consolidated

The hospital’s written policy describes how informed consent is documented in the patient record. Note: Documentation may be recorded in a form, in progress notes, or elsewhere in the record.

5RI.01.03.01

Current EP Text:

EP:

Revision Type:


1RI.01.03.01

New EP Text:

EP:

Consolidated




The hospital’s written policy describes when a surrogate decision-maker may give informed consent. (See also RI.01.02.01, EP 6)

6RI.01.03.01

Current EP Text:

EP:

Revision Type:


1RI.01.03.01

New EP Text:

EP:

Consolidated

Informed consent is obtained in accordance with the hospital's policy and processes and, except in emergencies, prior to surgery. (See also RC.02.01.01, EP 4)

13RI.01.03.01

Current EP Text:

EP:

Revision Type:


1RI.01.03.01

New EP Text:

EP:

Consolidated

The informed consent process includes a discussion about the patient's proposed care, treatment, and services.

7RI.01.03.01

Current EP Text:

EP:

Revision Type:

The informed consent process includes a discussion about the following:- The patient's proposed care, treatment, and services.- Potential benefits, risks, and side effects of the patient's proposed care, treatment, and services; the likelihood of the patient achieving his or her goals; and any potential problems that might occur during recuperation.- Reasonable alternatives to the patient's proposed care, treatment, and services. The discussion encompasses risks, benefits, and side effects related to the alternatives and the risks related to not receiving the proposed care, treatment, and services.

2RI.01.03.01

New EP Text:

EP:

Consolidated




The informed consent process includes a discussion about potential benefits, risks, and side effects of the patient's proposed care, treatment, and services; the likelihood of the patient achieving his or her goals; and any potential problems that might occur during recuperation.

9RI.01.03.01

Current EP Text:

EP:

Revision Type:


2RI.01.03.01

New EP Text:

EP:

Consolidated

The informed consent process includes a discussion about reasonable alternatives to the patient's proposed care, treatment, and services. The discussion encompasses risks, benefits, and side effects related to the alternatives and the risks related to not receiving the proposed care, treatment, and services.

11RI.01.03.01

Current EP Text:

EP:

Revision Type:


2RI.01.03.01

New EP Text:

EP:

Consolidated

Occasionally, hospitals make and use recordings, films, or other images of patients for internal use other than the identification, diagnosis, or treatment of the patient (for example, performance improvement and education). When this occurs, and the patient is able to give consent, the hospital obtains and documents informed consent prior to producing the recordings, films, or other images. Note: The term "recordings, films, or other images" refers to photographic, video, electronic, or audio media.

1RI.01.03.03

Current EP Text:

EP:

Revision Type:

The hospital obtains and documents informed consent in advance when it makes and uses recordings, films, or other images of patients for internal use other than the identification, diagnosis, or treatment of the patient (for example, performance improvement and education).Note 1: The term "recordings, films, or other images" refers to photographic, video, digital, electronic, or audio media.Note 2: This element of performance does not apply to the use of security cameras.

3RI.01.03.01

New EP Text:

EP:

Moved and Revised




The hospital protects the patient and respects his or her rights during research, investigation, and clinical trials.


The hospital documents the following in the research consent form: That the patient received information to help determine whether or not to participate in the research, investigation, or clinical trials.

4RI.01.03.05

Current EP Text:

EP:

Revision Type:

The hospital documents the following in the research consent form:- That the patient received information to help determine whether or not to participate in the research, investigation, or clinical trials.- That the patient was informed that refusing to participate in research, investigation, or clinical trials or discontinuing participation at any time will not jeopardize his or her access to care, treatment, and services unrelated to the research.- The name of the person who provided the information and the date the form was signed.- The patient's right to privacy, confidentiality, and safety.

4RI.01.03.05

New EP Text:

EP:

Consolidated

The hospital documents the following in the research consent form: That the patient was informed that refusing to participate in research, investigation, or clinical trials or discontinuing participation at any time will not jeopardize his or her access to care, treatment, and services unrelated to the research.

5RI.01.03.05

Current EP Text:

EP:

Revision Type:


4RI.01.03.05

New EP Text:

EP:

Consolidated




The hospital documents the following in the research consent form: The name of the person who provided the information and the date the form was signed.

6RI.01.03.05

Current EP Text:

EP:

Revision Type:


4RI.01.03.05

New EP Text:

EP:

Consolidated

The research consent form describes the patient's right to privacy, confidentiality, and safety.

7RI.01.03.05

Current EP Text:

EP:

Revision Type:


4RI.01.03.05

New EP Text:

EP:

Consolidated




The hospital respects the patient's right to receive information about the individual(s) responsible for, as well as those providing, his or her care, treatment, and services.


The hospital informs the patient of the name of the physician, clinical psychologist, or other practitioner who has primary responsibility for his or her care, treatment, or services.Note: The definition of “physician” is the same as that used by the Centers for Medicare & Medicaid Services (CMS) (refer to the Glossary).

1RI.01.04.01

Current EP Text:

EP:

Revision Type:

The hospital informs the patient of the following:- The name of the physician, clinical psychologist, or other practitioner who has primary responsibility for his or her care, treatment, or services.- The name of the physician(s), clinical psychologist(s), or other practitioner(s) who will provide his or her care, treatment, and services.Note: The definition of “physician” is the same as that used by the Centers for Medicare & Medicaid Services (CMS) (refer to the Glossary).

1RI.01.04.01

New EP Text:

EP:

Consolidated

The hospital informs the patient of the name of the physician(s), clinical psychologist(s), or other practitioner(s) who will provide his or her care, treatment, and services.Note: The definition of “physician” is the same as that used by the Centers for Medicare & Medicaid Services (CMS) (refer to the Glossary).

2RI.01.04.01

Current EP Text:

EP:

Revision Type:

The hospital informs the patient of the following:- The name of the physician, clinical psychologist, or other practitioner who has primary responsibility for his or her care, treatment, or services.- The name of the physician(s), clinical psychologist(s), or other practitioner(s) who will provide his or her care, treatment, and services.Note: The definition of “physician” is the same as that used by the Centers for Medicare & Medicaid Services (CMS) (refer to the Glossary).

1RI.01.04.01

New EP Text:

EP:

Consolidated




The hospital addresses patient decisions about care, treatment, and services received at the end of life.


The hospital has written policies on advance directives, forgoing or withdrawing life-sustaining treatment, and withholding resuscitative services, in accordance with law and regulation.

1RI.01.05.01

Current EP Text:

EP:

Revision Type:

The hospital follows written policies on advance directives, forgoing or withdrawing life-sustaining treatment, and withholding resuscitative services that address the following:- Providing patients and residents with written information about advance directives, forgoing or withdrawing life-sustaining treatment, and withholding resuscitative services.- Providing the patient upon admission with information on the extent to which the hospital is able, unable, or unwilling to honor advance directives.- For outpatient hospital settings: communicating its policy on advance directives upon request or when warranted by the care, treatment, and services provided.- Whether the hospital will honor advance directives in its outpatient settings.- That the hospital will honor the patient’s right to formulate or review and revise his or her advance directives.- Informing staff and licensed independent practitioners who are involved in the patient's care, treatment, and services whether or not the patient has an advance directive.

1RI.01.05.01

New EP Text:

EP:

Consolidated




For outpatient hospital settings: The hospital’s written advance directive policies specify whether the hospital will honor advance directives. Note: It is up to the hospital to determine in which of its outpatient settings, if any, it will honor advance directives.

4RI.01.05.01

Current EP Text:

EP:

Revision Type:


1RI.01.05.01

New EP Text:

EP:

Consolidated

The hospital implements its advance directive policies.

5RI.01.05.01

Current EP Text:

EP:

Revision Type:


1RI.01.05.01

New EP Text:

EP:

Consolidated




The hospital provides patients with written information about advance directives, forgoing or withdrawing life-sustaining treatment, and withholding resuscitative services.

6RI.01.05.01

Current EP Text:

EP:

Revision Type:


1RI.01.05.01

New EP Text:

EP:

Consolidated

Upon admission, the hospital provides the patient with information on the extent to which the hospital is able, unable, or unwilling to honor advance directives.

8RI.01.05.01

Current EP Text:

EP:

Revision Type:


1RI.01.05.01

New EP Text:

EP:

Consolidated




Staff and licensed independent practitioners who are involved in the patient's care, treatment, and services are aware of whether or not the patient has an advance directive. (See also RC.02.01.01, EP 4)

11RI.01.05.01

Current EP Text:

EP:

Revision Type:


1RI.01.05.01

New EP Text:

EP:

Consolidated

The hospital honors the patient’s right to formulate or review and revise his or her advance directives.

12RI.01.05.01

Current EP Text:

EP:

Revision Type:


1RI.01.05.01

New EP Text:

EP:

Consolidated




The hospital honors advance directives, in accordance with law and regulation and the hospital’s capabilities.

13RI.01.05.01

Current EP Text:

EP:

Revision Type:


1RI.01.05.01

New EP Text:

EP:

Consolidated

For outpatient hospital settings: The hospital communicates its policy on advance directives upon request or when warranted by the care, treatment, and services provided.

19RI.01.05.01

Current EP Text:

EP:

Revision Type:


1RI.01.05.01

New EP Text:

EP:

Consolidated




The hospital documents the patient’s wishes concerning organ donation when he or she makes such wishes known to the hospital or when required by the hospital's policy, in accordance with law and regulation.

15RI.01.05.01

Current EP Text:

EP:

Revision Type:

When required by policy or upon patient request, the hospital documents the patient’s wishes concerning organ donation and honors the wishes within the limits of its capability, policy, and law and regulation.

15RI.01.05.01

New EP Text:

EP:

Consolidated

The hospital honors the patient's wishes concerning organ donation within the limits of the hospital’s capability and in accordance with law and regulation.

16RI.01.05.01

Current EP Text:

EP:

Revision Type:

When required by policy or upon patient request, the hospital documents the patient’s wishes concerning organ donation and honors the wishes within the limits of its capability, policy, and law and regulation.

15RI.01.05.01

New EP Text:

EP:

Consolidated

For outpatient hospital settings: Upon request, the hospital refers patients to resources for assistance with formulating advance directives.

20RI.01.05.01

Current EP Text:

EP:

Revision Type: Deleted

The patient and his or her family have the right to have complaints reviewed by the hospital.


The hospital establishes a complaint resolution process. (See also LD.04.01.07, EP 1; MS.09.01.01, EP 1)Note: The governing body is responsible for the effective operation of the complaint resolution process unless it delegates this responsibility in writing to a complaint resolution committee.

1RI.01.07.01

Current EP Text:

EP:

Revision Type:

The hospital establishes a complaint resolution process and informs the patient and his or her family about it. (See also LD.04.01.07, EP 1; MS.09.01.01, EP 1) Note: The governing body is responsible for the effective operation of the complaint resolution process unless it delegates this responsibility in writing to a complaint resolution committee.

1RI.01.07.01

New EP Text:

EP:

Consolidated




The hospital informs the patient and his or her family about the complaint resolution process. (See also MS.09.01.01, EP 1)

2RI.01.07.01

Current EP Text:

EP:

Revision Type:

The hospital establishes a complaint resolution process and informs the patient and his or her family about it. (See also LD.04.01.07, EP 1; MS.09.01.01, EP 1) Note: The governing body is responsible for the effective operation of the complaint resolution process unless it delegates this responsibility in writing to a complaint resolution committee.

1RI.01.07.01

New EP Text:

EP:

Consolidated

For psychiatric hospital settings that provide longer term care (more than 30 days) and for hospitals that use Joint Commission accreditation for deemed status purposes and have swing beds: The hospital protects the rights of patients and residents who work for or on behalf of the hospital.


For psychiatric hospital settings that provide longer term care (more than 30 days) and for hospitals that use Joint Commission accreditation for deemed status purposes and have swing beds: The hospital has a written policy that addresses situations in which patients and residents work for or on behalf of the hospital.

1RI.01.07.07

Current EP Text:

EP:

Revision Type:

For psychiatric hospital settings that provide longer term care (more than 30 days) and for hospitals that use Joint Commission accreditation for deemed status purposes and have swing beds: The hospital follows a written policy that addresses situations in which patients and residents work for or on behalf of the hospital.

1RI.01.07.07

New EP Text:

EP:

Consolidated

For psychiatric hospital settings that provide longer term care (more than 30 days) and for hospitals that use Joint Commission accreditation for deemed status purposes and have swing beds: The hospital implements its policy regarding patients and residents who work for or on behalf of the hospital.

2RI.01.07.07

Current EP Text:

EP:

Revision Type:

For psychiatric hospital settings that provide longer term care (more than 30 days) and for hospitals that use Joint Commission accreditation for deemed status purposes and have swing beds: The hospital follows a written policy that addresses situations in which patients and residents work for or on behalf of the hospital.

1RI.01.07.07

New EP Text:

EP:

Consolidated



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