1.) If an organization has a service that receives patients for treatment, i.e., an outpatient infusion center, from community practitioners not on the hospital’s medical staff, TJC advises that the organization must minimally assure that the ordering LIP is licensed to practice. TJC also suggests consulting the specific state for any additional rules or regulations. (Courtesy of a response from the TJC Standards Interpretation Group)
2.) Organizations providing outpatient services in rented space determined to be Business Occupancy, are responsible for assuring the applicable Life Safety requirements (i.e., fire alarm and fire sprinkler maintenance) for the rented space. The property manager may maintain these documents, but it would be advisable for the outpatient service to request and maintain copies. Additionally, such renters are not required to maintain documentation related to adjacent space (i.e., fire extinguishers in common corridors), however, it would be best practice to report and document any concerns about such systems to the property manager. (Courtesy of a response from the TJC Standards Interpretation Group)
3.) Organizations risk Preliminary Denial of Accreditation if the hospital does not have a current license or certificate as required by its state, or if a component that performs laboratory services (waived or non-waived) does not have a CLIA certificate. Be sure that all surveyable components have current required licensure or certifications.
4.) Surgical and procedural documentation must evidence that the time-out was conducted prior to incision. (Courtesy of a response from the TJC Standards Interpretation Group)
5.) Joint Commission has eliminated the ORYX requirements for the behavioral health care, home care and long term care accreditation programs effective January 1, 2010. The requirements under APR.04.01.01 will be deleted – with the exception of APR.04.01.01, EP27, for hospices that elect TJC for deemed status. See the November edition of The Joint Commission Perspectives for more information.
6.) Organizations using contracted staff for the provision of care, treatment or services, must assure human resources functions and staff competencies in accordance with Leadership (LD) and Human Resources (HR) requirements. Following are some things specifically related to the HR requirements that healthcare organizations should be aware of. See the August 2009 edition of The Joint Commission Perspectives for additional information.
- Orientation and training for contracted staff may be limited to key areas such as applicable emergency management, infection control, organizational safety and security. Orientation need not exactly mirror that of employed staff.
- The organization may rely on the contractors human resources files once appropriate due diligence has been performed to assure the files meet TJC standards and the contracting organization’s requirements.
- The contracting organization may accept primary source verification conducted by the contracted service.
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