Intentional mistreatment that may cause either physical or psychological injury.

Determination by Joint Commission that an eligible organization complies with applicable Joint Commission accreditation requirements.

The primary document that establishes the terms of the relationship between the organization and Joint Commission.

Categories of accreditation that an organization can achieve based on a Joint Commission survey. These decision categories are as follows: - Limited, Temporary Accreditation - The organization demonstrates compliance with selected standards in surveys conducted under the Early Survey Policy. - Accredited - The organization is in compliance with all applicable standards at the time of the survey or has successfully addressed all Requirements for Improvement (RFIs) in an Evidence of Standards Compliance (ESC) within 60 days following the posting of the Final Accreditation Report and does not meet any other rules for other accreditation decisions. - Accreditation with Follow-up Survey - The organization is in compliance with all standards, as determined by an acceptable ESC submission. A follow-up survey is required within 6 months to assess sustained compliance. - Preliminary Denial of Accreditation - There is justification to deny accreditation to the organization as evidenced by - An Immediate Threat to Health or Safety to patients, residents, or the public, and/or - Submission of falsified documents or misrepresented information, and/or - Lack of a required license or similar issue at the time of survey, and/or - Significant noncompliance with Joint Commission standards, and/or - Patients and residents having been placed at risk for serious adverse outcomes due to significant and pervasive patterns/trends/repeat findings The decision is subject to review and appeal by the organization prior to the determination to deny accreditation. - Denial of Accreditation - The organization has been denied accreditation. All review and appeal opportunities have been exhausted.

A Joint Commission publication, either in print or online, consisting of policies, procedures, and accreditation requirements relating to ambulatory care, assisted living communities, behavioral health care and human services, critical access hospital, home care, hospital, nursing care centers, office-based surgery, rural health clinic, telehealth, and clinical laboratory and point-of-care testing. Organizations should use the manual that contains the set of accreditation requirements that is most appropriate to the primary focus or mission of the organization.

A continuous process whereby organizations are required to demonstrate to Joint Commission that they are providing safe, high-quality care, as determined by compliance with Joint Commission standards, National Performance Goals, and performance measurement requirements (as applicable). Key components of this process are an evaluation of the organization by a Joint Commission surveyor(s) and, where applicable, quarterly submission of performance measurement data to Joint Commission.

An evaluation of an organization to assess its level of compliance with applicable Joint Commission accreditation requirements and to make determinations regarding its accreditation status. The survey includes evaluation of documentation of compliance provided by organization staff, verbal information concerning the implementation of standards or examples of their implementation that enable a determination of compliance to be made, observations by the surveyor(s), and an opportunity for education regarding standards compliance and performance improvement.

Findings from an evaluation conducted by Joint Commission surveyors that result in an organization’s accreditation decision.

Care, treatment, or services provided to individuals with substance use disorders or other addictive behaviors.

The process by which an individual comes into a service or program, including screening and/or assessment by the organization or the licensed practitioner, in order to determine the capacity of the organization or licensed practitioner to provide the care, treatment, or services required to meet the individual’s needs.

Services provided by an agency whereby an adult(s) assumes the parenting for a child or youth and, in so doing, all rights and responsibilities are permanently transferred from the original parent or parents. Unlike guardianship or other systems designed for the care of the young, adoption is intended to effect a permanent change in status and as such requires societal recognition, either through legal or religious sanction.

An individual who has reached the age of legal majority.

Health care, recreation and diversion activities, social services, and other health maintenance activities offered to adults during daytime hours. These services can include health monitoring, occupational therapy, recreational therapy, personal care, meals, and transportation. This care is an ongoing program that typically meets two to five times a week for two to five hours per day.

A document or documentation allowing a person to give directions about future health care or to designate another person(s) to make health care decisions if the individual loses decision-making capacity. Advance directives may include living wills, durable powers of attorney, do-not-resuscitate (DNR) orders, right-to-die documents, or similar documents listed in the Patient Self-Determination Act that express the person’s preferences. See also psychiatric advance directive.

An injury resulting from a medical intervention related to a medication, including harm from an adverse drug reaction or a medication error. See also medication error.

A response to a medicinal product that is noxious and unintended and that occurs at doses normally used in humans for the prophylaxis, diagnosis, or treatment of disease or for the restoration, correction, or modification of physiological or psychological function.

A patient safety event that resulted in harm to a patient.

See adverse drug event (ADE).

See adverse drug reaction (ADR).

A person who represents the rights and interests of another individual as though those rights and interests were the person’s own in order to realize the rights to which the individual is entitled, obtain needed services, and remove barriers to meeting the individual’s needs.

An integrated approach to emergency preparedness that focuses on identifying hazards and developing emergency preparedness capacities and capabilities that can address a wide spectrum of emergencies or disasters. This approach includes preparedness for natural, human-made, and/or facility emergencies that may include but are not limited to care-related emergencies; equipment and power failures; interruptions in communications, including cyberattacks; loss of a portion or all of a facility; and interruptions in the normal supply of essentials, such as water and food. Planning for using an all-hazards approach should also include emerging infectious disease (EID) threats. Examples of EIDs include influenza, Ebola, and Zika viruses.

Health services provided to individuals who are not confined to institutional beds as inpatients during the time services are rendered. Ambulatory care services are provided in many settings ranging from freestanding ambulatory surgery facilities, to primary care settings, to diagnostic radiology; outpatient behavioral health services are not included.

A goal-directed intervention in which an animal meeting specific criteria is an integral part of the treatment process. Animal-assisted therapy is delivered and/or directed by staff working within the scope of their profession and training. This type of intervention is designed to promote improvement in the physical, emotional/behavioral, and/or cognitive functioning of the individual served. Animal-assisted therapy is provided in a variety of settings and includes group or individual interventions. This definition does not apply to pets.

One year from the date of the last event, plus or minus 30 days. Synonymous with every 12 months, once a year, or every year.

The process afforded to an organization that receives a Preliminary Denial of Accreditation decision, which includes the organization's right to make a presentation to the Review Hearing Panel before accreditation is denied.

An organization that is seeking either accreditation for the first time or re-accreditation.

See E-App.

Intensive case management services based on a team approach, designed to provide comprehensive community-based support to adult individuals served with the goal of maintaining an individual in a community setting.

The process established by an organization for obtaining appropriate and necessary information about each individual seeking entry into a health care setting or service. The information is used to match an individual's need with the appropriate setting, care level, and intervention.

Describes devices used by individuals with intellectual and/or developmental disabilities or brain injuries or other physical disabilities to help compensate for functional limitations and increase learning, independence, mobility, communication, environmental control, and choice.

Procedures in which the individual served is exposed to an unpleasant or noxious stimulus while engaging in the target behavior. Positive punishment is considered to be a type of aversive contingency in which target behavior is followed by the presentation of an unpleasant or noxious stimulus to decrease probability that the behavior will occur again. Negative punishment is not an aversive contingency. Negative punishment is a procedure in which the target behavior is followed by the removal of a desirable stimulus to decrease the probability that the behavior will occur again.

See psychiatric advance directive.

A broad array of care, treatment, or services for individuals with mental health issues, child welfare needs, addictive behaviors, chemical dependency issues, or intellectual/developmental disabilities. Care, treatment, or services can be provided in a wide variety of settings, such as inpatient crisis stabilization, residential, day program, outpatient, and community-based settings.

A model for the coordination and integration of behavioral and primary physical health care, treatment, or services provided to individuals served through an organization accredited under the CAMBHC. The behavioral health home may provide both the behavioral and primary physical health care, treatment, or services itself; work with another organization that will provide the primary physical health care, treatment, or services; or use a facilitated referral process to make certain the individual served receives the physical health care they require. Regardless of which operational model is used by the behavioral health home, it must make certain that all of the behavioral and physical health care, treatment, or services are delivered to the individual served as a coordinated and integrated whole with the goal of improving the individual’s health care outcomes over their lifespan.

Conduct by staff working in the organization that intimidates others to the extent that quality and safety could be compromised. These behaviors, as determined by the organization, may be verbal or nonverbal, may involve the use of rude language, may be threatening, or may involve physical contact.

A sample with known value tested by personnel who do not know the expected result.

Assistance provided to individuals or their authorized representatives aimed at assessing needs, linking community resources, coordinating services, and delivering flexible problem solving and crisis response.

An individualized plan for or provision of services that addresses the needs, safety, and well-being of an individual while in foster care.

An integrative behavioral health care model based on Substance Abuse and Mental Health Services Administration (SAMHSA) criteria that provides individuals served with coordinated, comprehensive access to a spectrum of behavioral health care services, as well as primary care screening, monitoring, and coordination. CCBHCs are required to serve anyone who requests care for mental health or substance use, regardless of their ability to pay, place of residence, or age. CCBHCs are designed to provide a comprehensive range of mental health and substance use disorder services to all individuals. CCBHCs are required to provide nine core services, either directly or through formal relationships with designated collaborating organizations (DCOs). A DCO is an entity that is not under the direct supervision of the CCBHC but is engaged in a formal relationship with the CCBHC and delivers services under the same requirements as the CCBHC. These services include but are not limited to the following: 1. Crisis services, including 24-hour mobile crisis teams, emergency crisis intervention services, crisis stabilization, suicide crisis response, withdrawal management, and coordination with law enforcement and hospitals 2. Treatment planning 3. Screening, assessment, diagnosis, and risk assessment 4. Outpatient mental health and substance use services 5. Targeted case management 6. Outpatient primary care screening and monitoring 7. Community-based mental health care for veterans 8. Peer counseling and peer, family, and caregiver support services 9. Psychiatric rehabilitation services. To become an accredited CCBHC, the clinic must comply with CCBHC–specific requirements in addition to the other applicable accreditation requirements found in the CAMBHC.

Services that are designed to address environmental, interpersonal, and intrapersonal factors for individuals with alcohol and/or drug dependencies in a designated program or track. An organization providing these services must have policies and procedures in place, must have trained staff to address the needs of the individual served, and may advertise or present its services to the public.

A person between 0 and 12 years of age, or as determined by applicable law and regulation.

Services designed to keep children safe and provide families with the support necessary to care for their children successfully.

Behavioral health care provided to children or youth for diagnosis and treatment or services for behavioral health problems.

Federal legislation that created uniform federal standards for regulating laboratory testing. CLIA '88 unified the disparate federal and state standards regulating clinical laboratories and extended government oversight to all testing facilities, including physician offices.

A behavioral health care professional with overall responsibility to plan, organize, and operate a clinical service or program (for example, a clinical director or a service or program director).

Tools that describe a specific procedure or processes found, through clinical trials or consensus opinion of experts, to be the most effective in evaluating and/or treating a mother and/or newborn, patient, resident, or individual served who has a specific symptom, condition, or diagnosis. Synonyms include practice parameter, protocol, clinical practice recommendation, preferred practice pattern, and guideline.

Authorization assigned by the appropriate authority to a physician or other licensed practitioner to provide specific care, treatment, or services in an organization within well-defined limits, based on the following factors, as applicable: license, education, training, experience, competence, health status, and judgment.

Staff members who provide or have provided clinical services (such as personal care or medical treatment) to the organization's patients, residents, or individuals served. See also staff.

Any information, oral or recorded, in any form or medium, that relates to an individual’s past, present, or future physical health, mental health, or social condition; the provision of health care and/or human services; or payment for the provision of health care and/or human services. This information is created by a health care provider, health plan, public health authority, social service agency, employer, life insurer, or school or university.

1. An account compiled by the behavioral health care or human services organization on a variety of clinical/case information, such as screening/assessment findings; care, treatment, or service details; and progress notes. 2. Data obtained from records or documentation maintained on an individual served in any behavioral health care or human services setting.

Used to describe any process variation that did not affect an outcome but for which a recurrence carries a significant chance of a serious adverse outcome. Such events fall within the scope of the definition of a sentinel event but outside the scope of those sentinel events that are subject to review by The Joint Commission under its Sentinel Event Policy.

Services that assist individuals in establishing or maintaining a life in the community.

Services provided to meet the identified needs of an individual who requires assistance in the maintenance and management of daily living activities.

The goal of this exercise is that health care organizations collaborate with state and local entities within their community to promote an integrated emergency response. Conducting integrated planning with state and local entities could identify potential gaps in their capabilities that can then be addressed in advance of an emergency.

Housing arranged as a required component of care, treatment, or services provided by the organization. Housing may include apartments, condominiums, or houses and must have three or fewer individuals served living in each unit. A community-based home may be owned or leased by the organization, and is either staffed up to 24 hours a day, 7 days a week, or not staffed. A community-based home may also be a private residence that is staffed by the organization up to 24 hours a day, 7 days a week.

The concept of using various building components (for example, fire walls and doors, smoke barriers, fire-rated floor slabs) to prevent the spread of fire and combustion and to provide a safe means of egress to an approved exit. The presence of these features varies depending on the building occupancy classification.

An organization accredited by Joint Commission under more than one accreditation manual.

A process for identifying basic or causal factors underlying variation in performance, including the occurrence or possible occurrence of a sentinel event. A root cause analysis is one type of comprehensive systematic analysis.

1. Restriction of access to data and information to individuals who have a need, a reason, and permission for such access. 2. An individual's right, within the law, to personal and informational privacy, including their health care records.

Care, treatment, or services provided over time in various settings, programs, or services and spanning the illness-to-wellness continuum.

The degree to which the care of individuals is coordinated among health care professionals, among organizations, and over time.

A formal agreement for care, treatment, or services with an organization, agency, or individual that specifies the services, personnel, products, or space provided by, to, or on behalf of the organization and specifies the consideration to be expended in exchange.

Services provided through a written agreement with another organization, agency, or person. The agreement specifies the services or personnel to be provided on behalf of the applicant organization and the fees to provide these services or personnel.

An agreement with any organization, group, agency, or individual for services or personnel to be provided by, to, or on behalf of the organization. Such agreements are defined in written form, such as in a contract, letter of agreement, or memorandum of understanding.

The process of coordinating care, treatment, or services provided by an organization, including referral to appropriate community resources and liaison with others involved in care, treatment, or services (such as an individual's physician or other licensed practitioner, primary care provider, or another health care organization/agency) to meet the ongoing identified needs of the individual served, to ensure implementation of the plan of care, treatment, or services, and to avoid unnecessary duplication of services.

Behavioral health care and human services provided in a correctional setting.

See maintenance.

Documented evidence of licensure, education, training, experience, or other qualifications.

Any entity that provides information on an individual's professional credentials. An organization that bases a decision in part on information obtained from a CVO should have confidence in the completeness, accuracy, and timeliness of information. To achieve this level of confidence, the organization should evaluate the entity providing the information initially and then periodically as appropriate. The 10 principles that guide such an evaluation include the following: 1. The entity makes known to the user the data and information it can provide. 2. The entity provides documentation to the user describing how its data collection, information development, and verification process(es) is performed. 3. The user is given sufficient, clear information on database functions, including any limitations of information available from the entity (such as individuals not included in the database), the time frame for entity responses to requests for information, and a summary overview of quality control processes related to data integrity, security, transmission accuracy, and technical specifications. 4. The user and entity agree on the format for transmitting credentials information about an individual from the CVO. 5. The user can easily discern what information transmitted by the CVO is from a primary source and what is not. 6. For information transmitted by the agency that can go out of date (for example, licensure, board certification), the CVO provides the date the information was last updated from the primary source. 7. The CVO certifies that the information transmitted to the user accurately represents the information obtained by it. 8. The user can discern whether the information transmitted by the CVO from a primary source is all the primary source information in the CVO’s possession pertinent to a given item or, if not, where additional information can be obtained. 9. The user can engage the CVO’s quality control processes when necessary to resolve concerns about transmission errors, inconsistencies, or other data issues that may be identified from time to time. 10. The user has a formal arrangement with the CVO for communicating changes in credentialing information.

The accuracy, consistency, and completeness of data that are protected in some way from corruption, misuse, or accidental exposure to unauthorized users.

A primary source used for data collection (for example, physical health and behavioral health information, personnel records, written agreements, safety incident log).

An environment offering an organized day or evening program that may include screening or assessment, treatment, care, services, and habilitation or rehabilitation for individuals not requiring 24-hour care. For behavioral health, this may be a structured, ongoing program that typically meets two to five times a week for two to five hours per day or evening.

Status conferred by the Department of Health and Human Services Substance Abuse and Mental Health Services Administration (SAMHSA) on an opioid treatment program (withdrawal management program) when it receives its own accreditation, regardless of whether the program is freestanding or a component of another organization (see also opioid treatment program).

An individual who has received either a doctor of dental surgery degree or a doctor of dental medicine degree and who is licensed to practice dentistry.

A type of emergency that, due to its complexity, scope, or duration, threatens the organization’s capabilities and requires outside assistance to sustain care, safety, or security functions.

A formalized process in a health care organization through which a program of continuing and follow-up care is planned and carried out for each patient or individual served.

Emergency management exercise that either familiarizes staff with existing plans, policies, or procedures or is used to develop new plans, policies, and procedures. Types of discussion-based exercises include the following: - Seminar: Orients participants to or provides an overview of authorities, strategies, plans, policies, procedures, protocols, resources, concepts, and ideas. - Workshop: Led by a facilitator/presenter with participant interaction. It is typically used to test new ideas, processes, or procedures; may include training on specific procedures. - Tabletop: Involves key personnel discussing simulated scenarios and is used to assess plans, policies, and procedures. It is a discussion-based exercise that familiarizes participants with current plans, policies, agreements, and procedures or may be used to develop new plans, policies, agreements, and procedures. (Refer to Homeland Security Exercise and Evaluation Program, January 2020)

See medication management.

See behaviors that undermine a culture of safety.

Recreational activities used in diversional therapy that are designed and implemented as part of person-centered, leisure-based activity programs. The aim of such activities is to improve the individual’s quality of life through ongoing support and development of psychological, emotional, spiritual, social, and physical needs, as well as overall well-being.

See prohibited abbreviations.

See medication.

See medication allergy.

An electronic form used for collecting information pertaining to the applicant organization. Information collected on this form will be used to determine the accreditation/certification requirements applicable to the organization, the types of surveyors/reviewers needed, the length of survey/review, and the survey fee.

A policy that permits an organization to achieve accreditation in a two-survey process. The first survey is limited in scope, and successful completion results in Preliminary Accreditation. The second survey addresses all accreditation requirements, and successful completion results in full accreditation.

A disorder characterized by eating habits that may involve either insufficient or excessive food intake to the detriment of an individual’s physical and emotional health.

Specific action(s), process(es), or structure(s) that must be implemented to achieve the goal of a standard. The scoring of EP compliance determines an organization’s overall compliance with a standard.

An unexpected or sudden event that significantly disrupts the organization’s ability to provide care, treatment, or services or the environment of care itself or that results in a sudden, significantly changed or increased demand for the organization's services. Emergencies can be either human-made or natural (such as an electrical system failure or a tornado), or a combination of both, and they exist on a continuum of severity.

The organization's written document that describes the process it would implement for managing the consequences of emergencies, including natural and human-made disasters, that could disrupt the organization's ability to provide care, treatment, or services.

A situation (for example, cardiac arrest, respiratory arrest) in which an individual may require resuscitation or other support to sustain life.

A formal or an informal process of assisting the individual served in considering or maintaining employment as part of general care, treatment, or services. This term is not synonymous with vocational rehabilitation.

Nutrition provided via the gastrointestinal tract. Enteral nutrition encompasses both oral (delivered through the mouth) and tube (provided through a tube or catheter that delivers distal to the mouth) nutrition.

A disease, such as influenza, that spreads rapidly, attacks many people in a geographic area, causes a high rate of morbidity or mortality, and then subsides. Epidemic applies especially to infectious diseases, as in an epidemic of cholera, but is also applied to any disease, injury, or other health-related event, such as an epidemic of teenage suicide.

The organized, phased, and supervised withdrawal, dispersal, or removal of patients, staff, and visitors from dangerous or potentially dangerous areas. Full (total) or partial evacuation occurs because conditions make it no longer safe to remain inside a building or in a specific area of a building. These levels of evacuation require persons to either move out and away from a building (full) or away from a specific area inside a building (partial).

Three years from the date of the last event, plus or minus 45 days.

A report submitted by a surveyed organization, that details the action(s) it took to bring itself into compliance with an accreditation requirement or clarifies why the organization believes that it was in compliance with the accreditation requirement for which it received a Requirement for Improvement. An ESC report must address compliance at the element of performance level.

Integrating the best research evidence with licensed practitioner expertise and other resources, and with the characteristics, needs, values, and preferences of the population(s) served, to make decisions about how to promote health or provide care, treatment, or services.

A procedure in which an individual served is excluded from the immediate environment by staff to help the individual regain behavioral/emotional control. This procedure involves the staff verbally directing the individual to remove themselves from the immediate environment and verbally restricting the individual to a quiet area or unlocked quiet room. This definition of time-out does not include instances in which an individual served is restricted to an unlocked room or area consistent with a program’s rules (such as restriction to the individual’s sleeping area for quiet time before bedtime or a room or area for homework time) nor does it include a self-calming strategy that the individual served may learn and use to remove themselves from an overly-stimulating environment.

Taking unjust advantage of another for one’s own advantage or benefit.

A process by which a behavioral health home refers individuals served to another organization for the individual’s primary physical health care, treatment, or service needs. This process includes taking the steps necessary to assist the individual in making an appointment and arriving at the scheduled time, accompanying the individual if necessary, following up with the primary physical health care provider to make certain that all relevant information is included in the individual’s clinical/case record, scheduling and keeping additional appointments, and any other activities needed to facilitate the provision of the primary physical health care, treatment, or services.

A person or persons who play a significant role in an individual’s life. A family is a group of two or more persons united by blood or adoptive, marital, domestic partnership, or other legal ties. The family may also be a person or persons not legally related to the individual (such as a significant other, friend, support person, or caregiver) whom the individual personally considers to be family. A family member may be the surrogate decision-maker if authorized to make care decisions for the individual should the individual lose decision-making capacity or choose to delegate decision-making to another.

Organizations providing and/or coordinating services for children, youth, and their families with the goal of maintaining the child or youth in their family or community.

Services that aid in the process of returning children from temporary, out-of-home care to their families of origin.

A service in which family members are assigned roles and responsibilities (for example, job coach) on the support team for the patient, resident, or individual served. This term is not synonymous with family therapy/counseling.

A type of therapy/counseling designed to identify and address family patterns that contribute to a behavior disorder or mental illness. Family therapy involves discussion and problem-solving sessions with the family. Some of these sessions may be as a group, in couples, or one on one. In family therapy, the established patterns of interpersonal relationships are examined and, ideally, communication is strengthened within the family.

Intentionally causing undue fear, fright, panic, or terror in order to obtain compliance by the individual.

Activities selected and implemented by the organization to assess and control the risks of fire, smoke, and other by-products of combustion that could occur during the organization’s provision of care, treatment, or services.

The assignment of a person or persons to an area for the express purpose of protecting occupants from fire or similar emergencies. Examples of this protection include: - Notifying the fire department, the building occupants, or both of an emergency - Preventing a fire from occurring - Extinguishing small fires

Material that has undergone a test and is fire protection rated or fire resistance rated. Two examples of the concept of fire-rated include the following: - fire resistance rating - The time, in minutes or hours, that materials or assemblies have withstood a fire exposure, as determined by tests, or methods based on tests, prescribed by the National Fire Protection Association (NFPA). - fire protection rating - A designation indicating the duration of fire test exposure to which a fire door assembly or fire window assembly was exposed and for which it met all the acceptance criteria, as determined in accordance with NFPA 252, Standard Methods of Fire Tests of Door Assemblies, or NFPA 257, Standard on Fire Test for Window and Glass Block Assemblies.

A unit of work done by a force of one pound acting through a distance of one foot in the direction of the force.

Behavioral health care and human services provided by an order issued by the criminal or juvenile justice system.

A living arrangement where an adult resides as a means of providing protection, shelter, and care. These living arrangements are in private, single residences.

A living arrangement where a child or youth resides outside their own home as a means of providing protection and care. These living arrangements are private, single residences that include relative, non-relative, or non-finalized adoptive homes.

Treatment services provided to a child or youth outside their own home, in a single, private residence. Services are delivered primarily by treatment foster parents who bear direct responsibility for implementing the select in-home aspects of the treatment plan.

A survey that assesses an organization’s compliance with all applicable Joint Commission accreditation requirements. See also accreditation survey.

An operations-based exercise that tests many facets of preparedness. The exercise involves planning and response partners (for example, state and local agencies) and takes place at the health care organization’s location using, as much as possible, the individuals and equipment that would be called upon in a real event. The emergency operations plan and integration of operational elements are tested in scripted emergency scenarios intended to mimic realistic situations. Through this exercise, participants utilize rapid problem solving in high-stress situations.

See operations-based exercise.

The individual(s), group, or agency that has ultimate authority and responsibility for establishing policy; maintaining quality of care, treatment, or services; and providing for organization management and planning. Governance may be a separate entity or it may fall within the medical advisory or executive committee. Other names for this group include the board, board of trustees, board of governors, board of commissioners, and partnership.

A community-based congregate living arrangement that is staffed when individuals served are present. Group homes may serve children, youth, or adults who are capable of self-preservation in the event of an emergency in the organization.

A parent, a trustee, a conservator, a committee, or another individual or agency empowered by law to act on behalf of or be responsible for the patient, resident, or individual served. See also family, surrogate decision-maker.

A systematic approach used to identify the hazards or risks that are most likely to have an impact on a health care facility and the surrounding community.

Materials whose handling, use, and storage are guided or defined by local, state, or federal regulation, such as the Occupational Safety and Health Administration’s Regulations for Bloodborne Pathogens regarding the disposal of blood and blood-soaked items and the Nuclear Regulatory Commission’s regulations for the handling and disposal of radioactive waste. This also includes hazardous vapors (for example, glutaraldehyde, ethylene oxide, nitrous oxide) and hazardous energy sources (for example, ionizing or nonionizing radiation, lasers, microwave, ultrasound). Although Joint Commission considers infectious waste as falling into this category of materials, federal regulations do not define infectious or medical waste as hazardous waste.

Any information, oral or recorded, in any form or medium, that is created by a health care provider, health plan, public health authority, employer, life insurer, school or university, or health care clearinghouse that relates to past, present, or future physical or mental health or condition, the provision of health care, or payment for the provision of health care to an individual.

A procedure or process that, if not planned and/or implemented correctly, has a significant potential for affecting the safety of a patient or an individual served.

Information gathered about an individual using a holistic approach for the purpose of establishing a diagnosis and developing a plan for care, treatment, or services to address physical health issues. The history may include information about previous illnesses; previous medical or surgical interventions and response to treatment; family health history; and social, cultural, economic, and lifestyle issues that may affect the individual’s health and well-being. The physical involves the physical examination of the individual’s body by the following means: inspection, palpation, percussion, and auscultation. When used in concert with behavioral health care and human services, the history and physical may be used to rule out physical causes for behavioral health conditions or to assess the impact of a medical diagnosis or treatment on a behavioral health condition or current situation.

A program model with the goal of placing individuals served who are homeless into private, permanent housing without any requirement to participate in behavioral or physical health care, treatment, or services of any kind, except to meet with the organization’s case management staff on a regular basis. Case management staff then actively work with the individual to engage the individual in other available behavioral or physical health care, treatment, or services in support of the individual's goals. See also permanent housing support.

Case management services based on a housing first program model for individuals served who are homeless. See also housing first.

The use of humans in the systematic study, observation, or evaluation of factors for preventing, assessing, treating, and understanding an illness. The term applies to all behavioral and medical experimental research that involves human beings as experimental subjects.

A threat that represents immediate risk and has or may potentially have serious adverse effects on the health or safety of the patient, resident, or individual served. These threats are identified by the surveyor.

Behavioral health care and human services provided in the residence of an individual served. In-home behavioral health care and human services may include individual and family counseling, mobile crisis evaluation service, parent training, early intervention, or support services.

An individual who receives care, treatment, or service; the individual can be a child, a youth, or an adult. When required for the well-being or age of the individual served, a legally responsible individual is also involved in the care, treatment, or service of the individual served.

An intervention based on behavioral and learning theory using operant conditioning, social learning, or rarely, classical conditioning. Techniques commonly used in the intervention include: - Positive reinforcement schedules for replacement behavior (acceptable, appropriate, desirable behavior). - Extinction techniques to extinguish or significantly reduce the target behaviors (unacceptable, inappropriate, or undesirable behaviors). Characteristics of an individualized behavioral contingency program include the following: - It is a written, planned program. - It is individualized. - It is distinct from routine interactions with the individual served. - It is applied at all times the individual served is supervised by staff. - Staff are trained in the application of the program.

The transmission of a pathogenic microorganism to a host, with subsequent invasion and multiplication, with or without resulting symptoms of disease.

See epidemic.

Agreement or permission accompanied by full notice about the care, treatment, or service that is the subject of the consent. A patient or resident must be apprised of the nature, risks, and alternatives of a medical procedure or treatment before the physician or other licensed practitioner begins any such course. After receiving this information, the patient or resident then either consents to or refuses such a procedure or treatment.

An accreditation survey of an organization that has not been accredited by Joint Commission for at least four months or an accreditation survey of an organization undergoing its first Joint Commission survey.

A highly structured environment for individuals who require 24-hour registered nursing supervision and who may be incapable of self-preservation in case of an emergency. Crisis stabilization is typically characterized by a short length of stay, with discharge or transfer to a hospital or inpatient psychiatric facility.

A highly structured environment that provides services to patients who require care that warrants 24-hour treatment or habilitation and who may be incapable of self-preservation in case of an emergency in the organization.

A waived testing device used for recording, measuring, or controlling. The levels of operation vary from manual steps to full automation, and specialized knowledge and skill are required.

Tests with analysis steps that rely on the use of an instrument to produce a test result of a patient, resident, or individual served.

Care, treatment, or services (including helping individuals to make healthy choices and lifestyle changes) provided or facilitated by the behavioral health home that address the behavioral health and physical health needs, strengths, preferences, and goals of the individual served. The care, treatment, or services are planned, delivered, and monitored as a coordinated and integrated whole in order to improve individuals’ behavioral and physical health outcomes. See also integrated care team.

The staff in the behavioral health home who provide or facilitate the provision of integrated care to the individual served. The team members include the behavioral and physical health care licensed practitioner providing care, treatment, or service. The team members work together and communicate closely with one another in order to provide or facilitate the provision of integrated, comprehensive, and coordinated care, treatment, or services to the individual served. The team members understand the individual’s needs, strengths, preferences, and goals regarding the individual's behavioral health and physical health and use that information to plan and deliver the individual’s integrated care. Depending on the structure of the behavioral health home, the integrated team members may all be members of the behavioral health care organization’s staff, or they may be split between the behavioral health care organization and another organization; regardless of the home’s structure and the location of the team members, they are expected to function as a single integrated team. See also integrated care.

The property that data or information have not been altered or destroyed in an unauthorized manner.

Intellectual and physical limitations affecting major life activities. These limitations arise before adulthood and usually last throughout the individual’s life.

An environment offering an organized day or evening program that may include screening or assessment, treatment, care, services, and habilitation or rehabilitation for individuals not requiring 24-hour care. For behavioral health, this may be a structured, ongoing program that typically meets two to five times a week for two to five hours per day or week.

An approach to care, treatment, or services that involves two or more disciplines or professions (for example, social work, nursing, spiritual support, psychology, psychiatry, music, or art therapy) collaborating to plan, treat, or provide care, treatment, or services to an individual served and/or that person's family.

A series of 14 administrative actions intended to temporarily compensate for significant hazards posed by existing National Fire Protection Association 101 - 2012 Life Safety Code deficiencies or construction activities.

A trans-language rendition of a spoken message in which the interpreter comprehends the source language and can speak comprehensively in the target language to convey the meaning intended in the source language. The interpreter knows health and health-related terminology and provides accurate interpretations by choosing equivalent expressions that convey the best matching and meaning to the source language and captures, to the greatest possible extent, all nuances intended in the source message.

See maintenance.

A process to help accredited organizations at various touch points in the triennial accreditation cycle with their continuous compliance efforts. The process involves access to an ICM Profile available on the organization’s Joint Commission Connect® extranet site. The ICM Profile identifies high-risk areas and related standards areas and displays them within a Focused Standards Assessment (FSA) tool, which allows organizations to conduct a self-assessment of standards to identify and manage risk in the organization. See also Focused Standards Assessment (FSA).

A medication used as part of a research protocol or clinical trial.

An independent, not-for-profit organization dedicated to improving the safety and quality of health care through standards development, public policy initiatives, accreditation, and certification. Joint Commission accredits and certifies more than 20,000 health care organizations and programs in the United States.

Foster care placement with relatives or fictive kin.

A collection of stored facts, models, and information that can be used for ongoing staff development, for designing and redesigning processes, and for solving problems. Knowledge-based information is found in the clinical, scientific, and management literature.

A facility that is equipped to examine material derived from the human body to provide information for use in the diagnosis, prevention, or treatment of disease; also called clinical laboratory or medical laboratory.

An individual who sets expectations, develops plans, and implements procedures to assess and improve the quality of the organization’s governance, management, and clinical and support functions and processes. At a minimum, leaders include members of the governing body and medical staff, the chief executive officer and other senior managers, the nurse executive, clinical leaders, and staff members in leadership positions within the organization.

A type of behavioral intervention that uses a methodology to group individuals served by their needs and behaviors. An individual served progresses through levels of systems that are associated with privileges and restrictions that are made known to staff, individuals served, and their families.

An individual who is licensed and qualified to direct or provide care, treatment, and services in accordance with state law and regulation, applicable federal law and regulation, and organizational policy.

A legal right that is granted by a government agency in compliance with a statute governing an occupation (such as medicine, nursing, psychiatry, or clinical social work) or the operation of an activity in a health care occupancy (for example, skilled nursing facility, residential treatment center, hospital).

A chronological record of a child’s life, usually in a photo album or binder, created by the child and/or the child's caregivers, that documents for the child in a concrete way the events and relationships important to the child. It may include photographs, mementos, descriptions, or other elements that help the child understand their biological origins and others who played significant roles in their life.

A set of standards for the construction and operation of buildings intended to provide a reasonable degree of safety during fires. These standards are prepared, published, and periodically revised by the National Fire Protection Association and adopted by The Joint Commission to evaluate health care organizations under its life safety management program.

Similar medication names, either written or spoken, which may lead to potentially harmful medication errors when confused with each other.

There are five types of maintenance — predictive, metered, corrective, interval-based, and reliability-centered: 1. Predictive maintenance: A type of maintenance strategy that provides the means to achieve reliability levels that exceed the performance of a piece of equipment or system. This strategy is designed to measure and track data significant to the piece of equipment or system. It confirms possible faults with the equipment, and specific repairs are completed before the equipment fails. Predictive analysis can be performed using advanced monitoring instruments and predictive software that collects data and performs an analysis. The data collected are analyzed, and corrective maintenance is performed when the equipment is performing outside the desired operating parameters. 2. Metered maintenance: Maintenance strategy based on the hours of run time or the number of times the equipment is used (for example, number of images processed). 3. Corrective maintenance: Maintenance strategy that restores a piece of equipment to operational status after equipment failure. 4. Interval-based maintenance: Maintenance done according to specific intervals (for example, calendar time, running hours). A number of periodic inspections or restoration tasks are completed, based on information/data obtained from the last equipment check. 5. Reliability-centered maintenance: A type of maintenance that begins with a failure mode and effects analysis to identify the critical equipment failure modes in a systematic and structured manner. The process then requires the examination of each critical failure mode to determine the optimum maintenance policy to reduce the severity of each failure. The chosen type of maintenance strategy must take into account cost, safety, and environmental and operational consequences. Some functions are not critical and may be allowed to "run to failure," while other functions must be preserved at all cost. Reliability-centered maintenance emphasizes the use of predictive maintenance techniques in addition to traditional preventive measures (metered, corrective, and interval based).

A continuous and unobstructed way of travel from any point in a building or other structure to a public way consisting of three separate and distinct parts: the exit access, the exit, and the exit discharge.

A way out of a building that does not conform to criteria for an approved means of egress but does provide an alternative way out (for example, an unenclosed interior stair).

An instrument, apparatus, implement, machine, contrivance, implant, in vitro reagent, or another similar or related article, including a component part or accessory that is (1) recognized in the official National Formulary or the United States Pharmacopeia or any supplement to them; (2) intended for use in the diagnosis of disease or other conditions or in the cure, mitigation, treatment, or prevention of disease in humans or other animals; or (3) intended to affect the structure or any function of the body of humans or other animals and that does not achieve any of its primary intended purposes through chemical action within or on the body of humans or other animals and that is not dependent on being metabolized for the achievement of any of its primary intended purposes.

For opioid treatment programs: A physician, licensed to practice medicine in the jurisdiction in which the opioid treatment program (OTP) is located, who assumes responsibility for all medical and behavioral health services provided by the program, including their administration. A medical director may delegate specific responsibilities to authorized program physicians, appropriately licensed nonphysician practitioners with prescriptive authority functioning under the medical director's supervision, or appropriately licensed and/or credentialed nonphysician health care professionals providing services in the OTP, in compliance with applicable federal and state laws. Such delegations will not eliminate the medical director's responsibility for all medical and behavioral health services provided by the OTP.

Fixed and portable equipment used for the diagnosis, treatment, monitoring, and direct care of individuals.

A component of the medical record consisting of an account of an individual’s physical health history, obtained whenever possible from the individual, and including at least the following information: chief complaint, details of the present illness or care needs, relevant past history, and relevant inventory by body systems.

Medical items, usually of a disposable nature, such as bandages, sterile drapes, and suture materials. These supplies differ from permanent or durable items, such as medical equipment and devices.

Interventions under the supervision of a physician or other licensed practitioner that may include the use of medications to manage withdrawal from alcohol, drugs, and/or other chemicals.

Any prescription medications, sample medications, herbal remedies, vitamins, nutraceuticals, vaccines, or over-the-counter drugs; diagnostic and contrast agents used on or administered to persons to diagnose, treat, or prevent disease or other abnormal conditions; radioactive medications, respiratory therapy treatments, parenteral nutrition, blood derivatives, and intravenous solutions (plain, with electrolytes and/or drugs); and any product designated by the Food and Drug Administration as a drug. This definition of medication does not include enteral nutrition solutions (which are considered food products), oxygen, and other medical gases.

A state of hypersensitivity induced by exposure to a particular drug antigen resulting in harmful immunologic reactions on subsequent drug exposures, such as a penicillin drug allergy. See also medication.

A preventable event that may cause or lead to inappropriate medication use or patient or resident harm while the medication is in the control of the health care professional, patient, resident, or consumer. Such events may be related to professional practice, health care products, procedures, and systems, including prescribing; order communication; product labeling, packaging, and nomenclature; compounding; dispensing; distribution; administration; education; monitoring; and use. See also significant medication error.

The last date that a medication or product is to be used or administered.

The process an organization uses to provide medication therapy to individuals served by the organization. The components of the medication management process include the following: - procurement - The task of obtaining selected medications from a source outside the organization. It does not include obtaining a medication from the organization’s own pharmacy, which is considered part of the ordering and dispensing processes. - storage - The task of appropriately maintaining a supply of medications on the organization’s premises. - secure - In locked containers, in a locked room, or under constant surveillance. - prescribing or ordering - The process of a physician or other licensed practitioner transmitting a legal order or prescription to an organization, directing the preparing, dispensing, and administration of a specific medication to a specific individual. It does not include requisitions for medication supplies. - transcribing - The process by which an order from a physician or other licensed practitioner is documented either in writing or electronically. - preparing - Compounding, manipulating, or in some way getting a medication ready for administration, exactly as ordered by the physician or other licensed practitioner. - dispensing - Providing, furnishing, or otherwise making available a supply of medications to the individual for whom it was ordered (their representative) by a licensed pharmacy according to a specific prescription or medication order, or by a physician or other licensed practitioner authorized by law to dispense. Dispensing does not involve providing an individual a dose of medication previously dispensed by the pharmacy. - administration - The provision of a prescribed and prepared dose of an identified medication to the individual for whom it was ordered to achieve its pharmacological effect. This includes directly introducing the medication into or onto the individual’s body.

The process of identifying the medications currently being taken by an individual. These medications are compared to newly ordered medications, and discrepancies are identified and resolved.

FDA-approved medications used to treat opioid use disorder (MOUD) and alcohol use disorder (MAUD). Examples of these medications are buprenorphine, naltrexone, disulfiram.

Medications that bear a heightened risk of causing significant harm to individuals when they are used in error.

Intentional mistreatment of an individual that may cause psychological injury. Examples include humiliation, harassment, exploitation, and threats of punishment or deprivation.

A professional who is certified and/or licensed and has the skills and knowledge to provide a range of behavioral health services to individuals. A mental health counselor provides services in areas such as psychotherapy, substance use, crisis management, psychoeducational, and prevention programs.

Care, treatment, or services provided to individuals with mental health issues, including dual diagnosis.

See maintenance.

Those activities an organization undertakes in attempting to reduce the severity and impact of a potential emergency. See also emergency.

See operations-based exercise.

A group of staff members composed of representatives from a range of professions, disciplines, or service areas.

See close call.

The absence of the minimal services or resources required to meet basic needs. Neglect includes withholding or inadequately providing medical care and, consistent with usual care, treatment, or services, food and hydration (without approval from the individual, physician or other licensed practitioner, or surrogate), clothing, or good hygiene. It may also include placing an individual in unsafe or unsupervised conditions. See also abuse.

The health profession dealing with nursing care and services as (1) defined by the Code of Ethics for Nurses with Interpretive Statements, Nursing’s Social Policy Statement, Nurses’ Bill of Rights, Scope and Standards of Nursing Practice of the American Nurses Association and specialty nursing organizations and (2) defined by relevant state, commonwealth, or territory nurse practice acts and other applicable laws and regulations.

The purpose for which a building or portion thereof is used or intended to be used. Depending on the organization, occupancies may include ambulatory health care occupancy, business occupancy, health care occupancy, and residential occupancy. - health care occupancy - An occupancy used for purposes such as medical or other treatment or care of persons suffering from physical or mental illness, disease, or infirmity; and for the care of infants, convalescents, or infirm aged persons. Health care occupancies provide sleeping facilities for four or more occupants and are occupied by persons who are mostly incapable of self-preservation because of age, physical or mental disability, or security measures not under the occupant’s control. Health care occupancies include hospitals, critical access hospitals, skilled nursing homes, and limited care facilities.

Emergency management exercise that includes real-time responses, such as initiating communications or mobilizing personnel and resources to validate plans, policies, procedures, and agreements; clarify roles and responsibilities; and identify resource gaps. Types of operations-based exercises include the following: - Full-scale exercise: An exercise that tests the emergency operations plan and integration of operational elements through scripted emergency scenarios intended to mimic realistic situations using real-time movement of resources (staff, space, and supplies) and often involving multiple agencies and jurisdictions/organizations. - Functional exercise: Designed to test and evaluate capabilities and functions while in a realistic, real-time environment; however, movement of resources is usually simulated. - Mock disaster drill: Used to validate a single operation or function within the organization. Mock disaster drills are commonly used to provide training on new equipment, validate procedures, or practice and maintain current skills. (Refer to Homeland Security Exercise and Evaluation Program, January 2020)

A program that provides medications for opioid use disorder as certified by the Center for Substance Abuse Treatment (CSAT); this treatment includes withdrawal management or maintenance.

The degree to which a component of an organization is overseen and managed by the applicant organization. Organizational integration exists when the applicant organization’s governing body, either directly or ultimately, controls budgetary and resource allocation decisions for the component or, where separate corporate entities are involved, there is greater than 50% common governing board membership on the board of the applicant organization and the board of the component. Functional integration exists when the entity meets at least three of the following eight criteria: 1. The applicant organization and the component use the same process for determining membership of physicians or other licensed practitioners in practitioner panels or medical or professional staff and/or use the same process for credentialing and assigning of privileges or clinical responsibilities to physicians or other licensed practitioners, and/or share a common organized medical or professional staff between the applicant organization and the component. 2. The applicant organization’s human resources function hires and assigns staff at the component and has the authority to terminate staff at the component, to transfer or rotate staff between the applicant organization and the component, and to conduct performance appraisals of the staff who work in the component. 3. The applicant organization’s policies and procedures are applicable to the component with few or no exceptions. 4. The applicant organization manages all operations of the component (that is, the component has little or no management authority or autonomy independent of the applicant organization). 5. The component’s clinical records are integrated into the applicant organization’s clinical record system. 6. The applicant organization applies its performance improvement program to the component and has authority to implement actions intended to improve performance at the component. 7. The applicant organization bills for services provided by the component under the name of the applicant organization. 8. The applicant organization and/or the component portrays to the public that the component is part of the organization through the use of common names or logos; references on letterheads, brochures, telephone book listings, or websites; or representations in other published materials.

A process used to provide initial training and information while assessing the competence of staff relative to job responsibilities and the organization’s mission and goals.

The occurrence of more than the expected number of cases of disease, injury, or other health conditions among a specific group during a specified time frame.

A measure that indicates the result of the performance or nonperformance of a function or process (that is, the results of a procedure).

A behavioral health care treatment or service that uses an outdoor experience as an alternative to conventional environments and as a clinically focused intervention; also called outdoor treatment/wilderness program.

Human services or behavioral health care, treatment, or services provided on an appointment system for each visit.

The entity that has ultimate control of resources and operation of the organization applying for accreditation.

An environment offering an organized day or evening program that may include screening or assessment, treatment, care, services, and habilitation or rehabilitation for individuals not requiring 24-hour care. For behavioral health, this may be a structured, ongoing program that typically meets two to five times a week for two to five hours per day or week.

An individual who receives care, treatment, or services. For hospice providers, the patient and family are considered a single unit of care. Synonyms used by various health care fields include client, resident, patient and family unit, consumer, health care consumer, customer, or beneficiary. When appropriate, the term patient may also refer to the “legally responsible individual.”

An event, incident, or condition that could have resulted or did result in harm to a patient. See also adverse event, close call, sentinel event.

Information submitted by a physician(s) or other licensed practitioner(s) in the same professional discipline as an applicant, reflecting their perception of the applicant's clinical practice, ability to work as part of a team, and ethical behavior; or the documented peer evaluation of practitioner-specific data collected from various sources for the purpose of evaluating current competence.

A service wherein trained consumers support other consumers in recovery.

Continuous study and adjustment of the health care staffing services firm's operations to increase the probability of achieving a desired outcome to better meet staff and customer needs.

An individual who has a degree in pharmacy and is licensed and registered to prepare, preserve, compound, and dispense drugs and other chemicals.

Pharmaceutical care and services involving the preparation and dispensing of medications and medication-related devices and supplies by a licensed pharmacy, with or without the provision of clinical or consultant pharmacist services.

Intentional mistreatment of an individual that may cause physical injury. Examples include hitting, slapping, pinching, or kicking, and may also include attempts to control behavior through corporal punishment.

As defined by the Centers for Medicare & Medicaid Services in Sec. 1861.[42 U.S.C.1395x] of the Social Security Act: The term “physician,” when used in connection with the performance of any function or action, means (1) A doctor of medicine or osteopathy legally authorized to practice medicine and surgery by the State in which he performs such function or action (including a physician within the meaning of section 1101(a)(7)), (2) A doctor of dental surgery or of dental medicine who is legally authorized to practice dentistry by the State in which he performs such function and who is acting within the scope of his license when he performs such functions, (3) A doctor of podiatric medicine for the purposes of subsections (k), (m), (p)(1), and (s) of this section and sections 1814(a), 1832(a)(2)(F)(ii), and 1835 but only with respect to functions which he is legally authorized to perform as such by the State in which he performs them, (4) A doctor of optometry, but only for purposes of subsection (p)(1) with respect to the provision of items or services described in subsection (s) which he is legally authorized to perform as a doctor of optometry by the State in which he performs them, or (5) A chiropractor who is licensed as such by the State (or in a State which does not license chiropractors as such, is legally authorized to perform the services of a chiropractor in the jurisdiction in which he performs such services), and who meets uniform minimum standards promulgated by the Secretary, but only for the purpose of sections 1861(s)(1) and 1861(s)(2)(A) and only with respect to treatment by means of manual manipulation of the spine (to correct a subluxation) which he is legally authorized to perform by the State or jurisdiction in which such treatment is provided. For the purposes of section 1862(a)(4) and subject to the limitations and conditions provided in the previous sentence, such term includes a doctor of one of the arts, specified in such previous sentence, legally authorized to practice such art in the country in which the inpatient hospital services (referred to in such section 1862(a)(4)) are furnished.

For purposes of Joint Commission accreditation, an organization’s written statement that details the procedures to be taken and time frames to correct existing Life Safety Code® deficiencies. See also Life Safety Code, Statement of Conditions™ (SOC).

A plan detailing the action(s) that an organization will take in order to come into compliance with a Joint Commission accreditation requirement. A POA must be completed for each element of performance associated with a non-compliant accreditation requirement.

A written plan, based on data gathered during screening or assessment, that identifies care, treatment, or service needs, strengths, preferences, and goals; describes the strategy for meeting those needs, preferences, and goals; builds on the strengths and considers the preferences of the individuals served; and documents progress toward meeting the plan's objectives. The plan may include care, treatment, habilitation, and rehabilitation.

Analytical testing performed at sites outside the traditional laboratory environment, usually at or near where care is delivered to individuals. Testing may be categorized as waived, moderate, or high complexity under the Clinical Laboratory Improvement Amendments of 1988 (CLIA ’88). Testing may range from simple waived procedures, such as fecal occult blood, to more sophisticated chemical analyzers. Guided by CLIA requirements this testing may be under the control of the main laboratory, another specialized laboratory (for example, for arterial blood gas), or the nursing service (for example, for glucose meters). Point-of-care testing may also be known as alternative site testing, decentralized laboratory testing, or distributed site testing.

See clinical practice guidelines.

See maintenance.

Activities an organization undertakes to build capacity and identify resources that may be used if an emergency occurs. See also emergency.

A physician or other licensed practitioner authorized by law and organizational policy to order medications for individuals served.

See medication management.

Prevention and wellness promotion services provide information and/or experiences that raise an individual’s awareness of, and help to support, healthy choices and life practices. These services are designed to assist individuals in coping with the stresses of life and establishing and maintaining healthy lifestyles. Prevention and wellness promotion services are community-based and therefore do not necessitate the opening of an individual or family clinical/case record, although members of the defined community or population may be receiving care, treatment, or services. Community-based prevention and wellness promotion services do not include similar types of services that are provided to an individual served in conjunction with, or as a result of, their needs and are addressed in the plan for care, treatment, or services. Prevention and wellness promotion services can either target the public (services directed toward any individual in the general population) or target a subgroup of the population whose members are at higher-than-average risk of experiencing a mental health or substance abuse issue. An example of community-based services is a program for junior high students on the dangers of alcohol and/or drug use. Such a program could include the use of a routine standardized screening tool which may result in a referral to a provider for follow-up. An example of services targeting a subgroup is a group-based intervention for children of parents with alcoholism, or development of a coalition to address increased alcohol and/or drug abuse in a community.

A basic level of physical health care that includes programs addressing the promotion of physical health, early diagnosis of disease or disability, treatment of acute and chronic illnesses, and prevention of disease. Primary physical health care includes health maintenance and education of the individual served, which can include wellness programs or education on diet, smoking cessation, the benefits of physical activity, and risk factors for cardiovascular disease. Examples of common acute health issues treated through primary physical health care include: - Flu symptoms - Sore throats - Minor lacerations - Sprains Examples of common chronic health issues treated through primary physical health care include: - Hypertension, heart failure, and angina - Diabetes - Asthma and COPD - Arthritis Examples of other care provided through primary physical health care include: - Medical history and physical examination - Screenings and diagnostic tests (such as blood pressure, blood sugar level, cholesterol, tuberculosis, sexually transmitted diseases, and HIV) - Vaccinations - Wellness or education programs - Family planning services

The original source or an approved agent of that source of a specific credential that can verify the accuracy of a qualification reported by an individual practitioner. Examples include medical schools, nursing schools, graduate education, state medical boards, federal and state licensing boards, universities, colleges, and community colleges.

The right of an individual to limit the disclosure of personal information.

For opioid treatment programs: The person named in the application for certification described in 42 CFR 8.11(b) as responsible for the operation of the opioid treatment program (OTP) and who assumes responsibility for all its employees, including any practitioners, agents, or other persons providing medical, behavioral health, or social services at the program or any of its medication units. The program sponsor need not be a licensed physician but shall ensure that an actively licensed physician occupies the position of medical director within an OTP.

A list of abbreviations, acronyms, symbols, and dose designations that are not to be used throughout the organization. For accreditation purposes, the prohibited list applies, at a minimum, to all orders and all medication-related documentation that is handwritten (including free-text computer entry) or on preprinted forms.

Health information that contains information such that an individual person can be identified as the subject of that information.

A range of socio-legal, assistive, and remedial services that facilitate the exercise of individual rights and provide certain supportive and surrogate services to help children and youth, elderly, and developmentally disabled individuals reach the maximum independence possible yet protect them from exploitation, neglect, or abuse. Depending on the nature and extent of individual needs, protective services may range from counseling to full guardianship.

A licensed individual or organization that provides health care services outside the accredited organization.

A type of advance directive used to record a competent individual’s specific instructions or preferences regarding future mental health treatment. Psychiatric advance directives can be used to plan for the possibility that the individual may lose capacity to give or withhold informed consent to treatment during acute episodes of psychiatric illness. See also advance directive.

See psychotropic medication.

Pertaining to the influence of social factors on an individual’s mind or behavior and to the interrelation of behavioral and social factors.

Any medication that affects the central nervous system and that is prescribed with the intention of affecting psychological processes such as perception, mental status, or behavior. Examples of classes of psychotropic medications include antipsychotics, antidepressants, anxiolytics, hypnotics, and sedatives.

A Joint Commission policy which specifies the information that Joint Commission may release about accredited organizations. By submitting a signed accreditation contract, the organization is acknowledging that Joint Commission may make available to the public the accreditation-related information in accordance with this policy.

Knowledge, education, training, experience, competency, licensure, registration, or certification related to specific responsibilities.

A residential treatment program that must meet specific federal requirements according to the Family First Preservation Services Act.

A set of activities or techniques whose purpose is to ensure that all quality requirements are being met. The organization monitors processes and solves performance problems to achieve this purpose.

The degree to which care, treatment, or services for individuals and populations increases the likelihood of desired health or behavioral health outcomes. Considerations include the appropriateness, efficacy, efficiency, timeliness, accessibility, and continuity of care; the safety of the care environment; and the individual’s personal values, practices, and beliefs.

A test result that is measured as a discrete number.

Every three months, plus or minus 10 days.

Orders in which the dose or dosing interval varies over a prescribed range, depending on the situation or the individual’s status.

A short paragraph that explains the justification for a standard; that is, why the standard is important or how it contributes to quality and/or safety. A rationale is not scored, and not every standard has a rationale.

A method used to ensure understanding of information being communicated, often used between members of a care, treatment, or service team. The process involves the receiver of a verbal or telephone order writing down the complete order or test result or entering it into a computer and then reading it back and receiving confirmation from the person who gave the order or test result.

Ongoing data collection, which begins on initial assessment, comparing the most recent data with the data collected at earlier assessments.

Coordinated clinical and support services focused on an individual's self development to meet the challenges of daily life and achieve their fullest potential of independence and social integration. Recovery or resilience can refer to any of the following services: peer support, employment services, family support, community integration, and care coordination/case management.

The final phase of emergency management, related to strategies, actions, and individual responsibilities necessary to restore the organization’s services after an emergency. See also emergency.

The potentially fatal shifts in fluids and electrolytes that may occur in malnourished individuals receiving artificial refeeding (whether enterally or parenterally). These shifts result from hormonal and metabolic changes and may cause serious clinical complications.

For home health agencies and hospices that elect to use The Joint Commission deemed status option: A graduate of an approved school of professional nursing, who is licensed as a registered nurse in the state where practicing.

See maintenance.

A recommendation that is required to be addressed in an organization’s Evidence of Standards Compliance in order for the organization to retain its accreditation. Failure to adequately address an RFI after two opportunities may result in a recommendation to place the organization in Accreditation with Follow-up Survey.

A program that provides 24-hour care, treatment, or services to individuals who need a less structured environment than that of an inpatient program and who are capable of self-preservation in the event of an emergency in the organization. A residential setting may serve children, youth, or adults.

A parent, other than the individual’s parent of origin, who is caring for the individual in the capacity of a primary parent. This could be a relative (kinship care), foster parent, respite caregiver, or adoptive parent.

A short term, temporary living arrangement used as a means of providing care while the primary caregiver(s) is unavailable. These living arrangements are provided in private, single residences, which include relative and non-relative respite homes.

Actions taken and procedures implemented by the organization when an emergency occurs. See also emergency.

Any method (chemical or physical) of restricting an individual’s freedom of movement to manage their behavior. This includes any manual method, physical or mechanical device, material, or equipment that immobilizes or reduces the ability of an individual to move their arms, legs, body, or head freely. It also includes any drug or medication when it is used as a restriction to manage the individual’s behavior or to restrict their freedom of movement and is not a standard treatment or dosage for their condition. Practices that meet the definition of a restraint include but are not limited to the following: - Using side rails that keep an individual from voluntarily getting out of bed - Tucking in or using Velcro to hold a sheet, fabric, or clothing tightly so that an individual’s movement is restricted - Using devices in conjunction with a chair, such as trays, tables, bars, or belts, that the individual cannot remove easily and that prevent them from rising - Placing an individual in a chair that prevents them from rising - Placing a chair or bed so close to a wall that the wall prevents the individual from rising out of the chair or voluntarily getting out of bed

A panel of three individuals, including one member of Joint Commission's Board of Commissioners, which evaluates the facts of an organization appealing a Preliminary Denial of Accreditation.

An assessment that examines a process in detail including sequencing of events, actual and potential risks, and failure or points of vulnerability and that prioritizes, through a logical process, areas for improvement based on the actual or potential impact (that is, criticality) of care, treatment, or services provided.

See comprehensive systematic analysis.

The Survey Analysis for Evaluating Risk® (SAFER™) Matrix gives a visual representation of the risk level of each Requirement for Improvement (RFI). Each observation reported by a reviewer is plotted on the SAFER Matrix according to the risk level of the finding. The risk level is determined according to two factors: (1) the likelihood of the finding to cause harm to patients, staff, and/or visitors, and (2) the scope at which the finding was observed.

Risks that may arise from the performance of tasks, from the structure of the physical environment, or from situations beyond the organization's control (such as weather). Safety refers to actions that mitigate such risk to individuals served and other persons including staff.

Activities selected and implemented by the organization to assess and control the impact of environmental risk, and to improve general environmental safety.

Selecting a subset from a larger group of units or observations that provides information that may be used to decide about the larger quantity.

The activities performed by governance, managerial, clinical, or support staff.

Process of determining whether individuals have certain risk factors associated with physical or behavioral health issues requiring assessment.

1. The involuntary confinement of an individual in a room alone, for any period of time, from which the individual is physically prevented from leaving. Seclusion does not include involuntary confinement for legally mandated but nonclinical purposes, such as the confinement of a person who is facing serious criminal charges or who is serving a criminal sentence. 2. For hospices that elect to use The Joint Commission deemed status option: The involuntary confinement of a patient alone in a room or an area from which the patient is physically prevented from leaving.

In a locked container, in a locked room, or under constant surveillance.

Protection of people and property against harm or loss (for example, workplace violence, theft, access to medications). Security incidents may be caused by persons from outside or inside the organization.

Administrative, physical, and technical safeguards to prevent unauthorized access, use, disclosure, modification, or destruction of information or interference with system operations in an information system.

Independent use of a medication by a patient or individual served, including medications that may be held by the organization for independent use.

Activities performed by patients with one or more chronic conditions that enable them to take an active role in the management of their health care and improve their clinical outcomes.

Results of tests that are more precise than qualitative tests (negative/positive results) but less precise than quantitative tests (numerical value), usually scored on a graded scale (for example, 1+, 2+, 3+).

A patient safety event (not primarily related to the natural course of the patient’s illness or underlying condition) that reaches a patient and results in death, severe harm (regardless of duration of harm), or permanent harm (regardless of severity of harm). Sentinel events are a subcategory of adverse events.

Intentional mistreatment of a sexual nature of an individual that may cause physical and/or psychological injury. Examples include sexual harassment, sexual coercion, and sexual assault.

A rapid and effective means of protecting residents, staff, and visitors from an external or internal threat. This may include the movement of persons to selected interior rooms and away from windows; self-preservation by hiding in a safe place; taking immediate actions to protect environment from chemical, biological, or radiological releases.

A non-treatment setting that provides emergency housing and, where needed, protection to individuals.

An adverse medication reaction experienced by an individual that required intervention to preclude or mitigate harm or that requires monitoring to confirm that it resulted in no harm to the individual.

See significant adverse drug reaction (ADR).

A medication error that reached an individual that required intervention to preclude or mitigate harm and/or that required monitoring to confirm that it resulted in no harm to the individual.

An individual who provides a range of counseling, case management, and advocacy services to individuals served in various settings. Social workers may work in or with community-based programs, schools, residential and foster care programs, or independently as private practice psychotherapists. A social worker has at least a bachelor's degree in social work plus documentation of any additional training, education, or experience commensurate with their responsibilities.

Any non-primary physical health care, treatment, or services required by an individual served that are not provided by the behavioral health home. Such needs are most often addressed through facilitated referrals.

All people who provide care, treatment, or services in the organization, including licensed practitioners; permanent, temporary, and part-time personnel; contract employees; volunteers; and health profession students.

A principle of safety of the individual served and quality of care, treatment, or services that a well-run organization meets. A standard defines the performance expectations, structures, or processes that must be substantially in place in an organization to enhance the quality of care, treatment, or services.

A proactive document that helps an organization do a critical self-assessment of its current level of compliance and describe how to resolve any Life Safety Code® deficiencies. The SOC was created to be a “living, ongoing” management tool that should be used in a management process that continually identifies, assesses, and resolves Life Safety Code deficiencies.

The use of a physical or chemical procedure to destroy all microbial life, including highly resistant bacterial endospores.

Systems that automatically supply illumination or power to critical areas and equipment essential for safety to human life. Included are systems that supply emergency power for such functions as illumination for safe exiting, ventilation where it is essential to maintain life, fire detection and alarm systems, public safety communications systems, and processes where the current interruption would produce serious life safety or health hazards to patients, residents, individuals served, the public, or staff. Note: Other non-SEPSS battery back-up emergency power systems that an organization has determined to be critical for operations during a power failure (for example, laboratory equipment, electronic health records) should be properly tested and maintained in accordance with manufacturer recommendations.

See transitional/supportive living.

Someone legally appointed to make decisions on behalf of another. This decision-maker can be a family member or someone not related to the individual served or patient. A surrogate decision-maker makes decisions when the individual served or patient is without decision-making capacity or when the individual served or patient has given permission to the surrogate to make decisions. Such a decision-maker is sometimes referred to as a legally responsible representative. See also family.

A systematic method of collecting, consolidating, and analyzing data concerning the frequency or pattern of, and causes or factors associated with, a given disease, injury, or other health condition. Data analysis is followed by the dissemination of the information yielded to those who can improve outcomes. Examples of surveillance data are data on hand hygiene, vaccinations, and staff immunization.

A key component in the accreditation process whereby a surveyor(s) conducts an evaluation of an organization’s compliance with Joint Commission accreditation requirements.

For purposes of Joint Commission accreditation, a health care professional who meets Joint Commission’s surveyor selection criteria, evaluates compliance with accreditation requirements, and provides education regarding compliance with accreditation requirements to surveyed organizations or systems. The type of surveyor(s) assigned is determined by the accreditation program and its services. A surveyor may be, but is not limited to, a licensed physician, surgeon, podiatrist, dentist, nurse, physician assistant, pharmacist, medical technologist, respiratory therapist, administrator, social worker, psychologist, or behavioral health care professional.

See discussion-based exercise.

Care, treatment, or services provided through interactive, live/real time audio and video-conferencing utilizing internet technology.

Either 24-hour residential or day programs that provide an integrated educational milieu with an appropriate level of structure and supervision of physical, emotional, behavioral, familial, social, intellectual, and academic development. Therapeutic schools either grant a diploma or award credit that leads to admission or return to a diploma-granting school. Therapeutic schools serve children and youth who have a history of failing to function at home or in less structured or traditional school settings in terms of academic, social, or emotional behavioral development.

A procedure used to help a patient or individual served to regain emotional control that involves removing them from the immediate environment and restricting them to a quiet area or an unlocked quiet room.

A process surveyors use during the survey to analyze an organization’s systems or processes for delivering safe, high-quality care by following an individual patient or resident through the organization’s care process in the sequence experienced by each individual. Depending on the setting, this process may require surveyors to visit multiple care programs and services within an organization or within a single program or service to “trace” the care rendered.

Services provided to an older youth or young adult to assist the individual in transitioning to a more independent life.

A 24-hour living arrangement provided to individuals in need of a supervised, supportive living environment. This level of care is typically intermittently staffed and provided as a community re-entry phase within a continuum of care, treatment, or services serving adults or older youth.

A trans-language rendition of a written document in which the translator comprehends the source language and can write comprehensively in the target language to convey the meaning intended in the source language. The translator knows health and health-related terminology and provides accurate translations by choosing equivalent expressions that convey the best matching and meaning to the source language and captures, to the greatest possible extent, all nuances intended in the source document.

Infection prevention and control measures to protect against exposure to a suspected or identified pathogen. These precautions are specific and based on the way the pathogen is transmitted. Categories include contact, droplet, airborne, and a combination of these.

An experience that creates a sense of fear, helplessness, or horror and overwhelms an individual's resources for coping. The impact of traumatic stress can be devastating and long-lasting, interfering with an individual’s sense of safety, ability to self-regulate, sense of self, perception of control and self-efficacy, and interpersonal relationships. Common experiences of trauma may include sexual abuse, physical abuse, severe neglect, loss, acts of violence, and/or the witnessing of violence, terrorism, and/or disasters.

An agreed-on and accepted set of terms and definitions constituting a core of data; a collection of related data items.

Building systems that provide support to the environment of care, including electrical distribution and emergency power; vertical and horizontal transport; heating, ventilating, and air conditioning (HVAC); plumbing, boiler, and steam; piped gases; vacuum systems; and communication systems, including data exchange systems.

A measure of the difference in a set of observations; statistically, the square of the standard deviation.

Formal services designed to attain, retain, or restore vocational usefulness of persons experiencing limited functioning. Vocational rehabilitation services may include vocational evaluation services, employment skills training, work activities, and supportive employment.

Tests that meet the Clinical Laboratory Improvement Amendments of 1988 (CLIA ’88) requirements for waived tests and are cleared by the Food and Drug Administration for home use. These tests employ methodologies that are so simple and accurate that the likelihood of erroneous results is negligible, or they pose no risk of harm to the patient, resident, or individual served if the test is performed incorrectly. See also Clinical Laboratory Improvement Amendments of 1988 (CLIA ’88).

See outdoor/wilderness experience.

An act or a threat occurring at the workplace that can include any of the following: verbal, written, or physical aggression; threatening, intimidating, harassing, or humiliating words or actions; bullying; sabotage; sexual harassment; or physical assaults involving staff, patients, or visitors.

See discussion-based exercise.

See family preservation.

A person 13 years of age or older who has not reached age of majority, or as identified by law and regulation.