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All Accreditation ProgramsSurvey Activity GuideJanuary 2021

Survey Activity GuideFor Health Care OrganizationsAll Accreditation ProgramsJanuary 2021Issue Date: January 20, 2021

What’s New for 2021New or revised content for 2021 is identified by underlined text.Changes effective: January 20, 2021Hospital Perinatal Survey Guide with Standards – Tool has been removed from the guide for editing andrefinement for health care organizations.Changes effective: January, 2021All Programs Surveyor Planning Initial – This activity has been eliminated for all programs. NOTE: Surveyorswill need as many documents as possible from the program-specific Document Lists availablefor the Surveyor Arrival and Preliminary Planning activity. Special Issue Resolution and Surveyor Planning/Team Meeting – Special Issue Resolution takesplace throughout the survey; that is, surveyors do not typically wait to address issues until a scheduledtime on the agenda. Therefore, these activities will now occupy the same 30-minute timeframe on thesurvey agenda and either one or the other activity will be conducted by the surveyor based on need.Surveyors will inform the organization which activity will take place.Ambulatory Health Care (Note: Please see the Ambulatory Health Care Organization Survey ActivityGuide for additional changes related to ambulatory surgery centers accredited under the Ambulatory HealthCare accreditation program.) Survey Activity List – Updated to clarify applicability of the Life Safety Code Building Assessmentactivity. Life Safety Code Building Assessment – Specified the NFPA editions that are being surveyed. Imaging Document Review Guide – Introducing a new tool to help organizations compile imagingservices documents and data needed for surveyor review, based on the imaging modalities provided bythe organization.Behavioral Health Care and Human Services Updated to reflect the revised accreditation program name.Home Health, Home Infusion Therapy, Hospice, Pharmacy, and Home MedicalEquipment/DMEPOS Document List – Updated with new items.Hospital Life Safety Code Building Assessment – Specified the NFPA editions being surveyed. Environment of Care Session – This survey activity has been eliminated from the agenda. The topicsthat were addressed during this session will now be covered throughout the survey by Life Safety Code surveyors and clinical surveyors during Individual Tracer, Facility Orientation, and Building Assessmentactivities. Life Safety & Environment of Care Document List and Review Tool – Tool has been expanded toinclude additional environment of care related documents for review.Copyright: 2021 The Joint Commission

Medical Staff-Related Standards Compliance Evaluation Guides – Introducing new tools thatsurveyors will be using to guide their evaluation of compliance with the hospital medical staff standards. Kitchen Tracer Survey Guide – This guide is the same as surveyors use when conducting theirevaluation of the kitchen environment and dietary services. Perinatal Survey Guide with Standards – Introducing a new tool to help organizations who offerperinatal services understand how surveyors will approach evaluating compliance with hospitalstandards relative to their services. Imaging Document Review Guide – Introducing a new tool to help organizations compile imagingservices documents and data needed for surveyor review, based on the imaging modalities provided bythe organization.Critical Access Hospital Life Safety Code Building Assessment – Specified the NFPA editions being surveyed. Environment of Care Session – This survey activity has been eliminated from the agenda. The topicsthat were addressed during this session will now be covered throughout the survey by Life Safety Code surveyors and clinical surveyors during Individual Tracer, Facility Orientation, and Building Assessmentactivities. Life Safety & Environment of Care Document List and Review Tool – Tool has been expanded toinclude additional environment of care related documents for review. Medical Staff-Related Standards Compliance Evaluation Guides – Introducing new tools thatsurveyors will be using to guide their evaluation of compliance with the hospital medical staff standards. Kitchen Tracer Survey Guide – This guide is the same as surveyors use when conducting theirevaluation of the kitchen environment and dietary services. Imaging Document Review Guide – Introducing a new tool to help organizations compile imagingservices documents and data needed for surveyor review, based on the imaging modalities provided bythe organization.Laboratory (Note: Please see the Survey Activity Guide for Laboratory Accreditation for additional surveyprocess changes related to the Laboratory accreditation program standards updates for 2021.) Regulatory Review – Updated to note that surveyors will be reviewing documentation of reportingSARS-CoV-2 test results. Laboratory Document List – New item added under Regulatory Review section requestingdocumentation of reporting SARS-CoV-2 test results.Nursing Care CenterNo changes except those noted under All ProgramsCopyright: 2021 The Joint Commission

How to Use this GuideThe Joint Commission’s Survey Activity Guide is available on your organization’s extranet site.This guide contains: Information to help you prepare for survey An abstract of each survey activity that includes logistical needs, session objectives, an overview of thesession, and suggested participants Sessions are listed in the general order that they are conducted.A template agenda and a list of survey activities that occur during an onsite visit are posted to yourorganization’s Joint Commission Connect extranet site in proximity to the time your application is received andreviewed. When the template agenda and survey activity list is available, please download and review theactivities and think about the people you might like to have involved. The activity list includes a column in whichyou can record participant names or positions next to each of the sessions. Identifying key participants (andtheir phone numbers) for each session, including back-ups, is important. Consider including possible meetinglocations and surveyor workspace in your planning documents. Reference the sessions in this Survey ActivityGuide and learn more about what you can expect to occur during the activity.The template agenda and activity list include suggested duration and scheduling guidelines for each of theactivities. On the first day of survey, there will be an opportunity for you to collaborate with the surveyor inpreparing an agenda for the visit that is considerate of your day-to-day operations.Please Note: Not all the activities described in this guide are included in the activity list or on the agendatemplate. Many of the accreditation program-specific activities are designed to take place during individualtracer activity. Surveyors will incorporate these into the onsite survey when they are applicable to yourorganization.For complex organizations (being surveyed under more than one accreditation manual or for more than oneservice under one accreditation manual), you will receive an activity list and agenda template for each of theprograms being surveyed (e.g., hospital, home care, long term care). Include an organization contact name andphone number for each program, as well as, names or positions and phone numbers of activity participants fromall of the programs on these activity lists. Identify when it would be most effective to conduct an activity with allprograms present (e.g., Leadership, Daily Briefing, and System Tracer--Data Management) and suggest this tothe surveyors when they arrive.For multiple services being surveyed under a single accreditation program, be sure to include contact namesand phone numbers from all your organization’s services. For example, Home Care might have the followingservices: Home Health, Hospice, Personal Care /Support Services, Home Medical Equipment, or Pharmacy.Finally, please recognize that this Survey Activity Guide is created for small and large organizations. Someorganizations will have one surveyor while others will have multiple surveyors. If you have any questions aboutthe number of surveyors who will arrive at your site, please contact your Account Executive. If you are unsure ofyour Account Executive’s name or phone number, call the Joint Commission switchboard operator at 630-7923007 for assistance.Copyright: 2021 The Joint Commission

Health Care OrganizationSurvey Activity Guide (SAG)Key: The following abbreviations are used throughout this Guide to identify specific accreditation programs and the survey activitiesapplicable to the program. All – All programs (All accreditation programs listed below) AHC – Ambulatory Health Care (surveyed from the Comprehensive Accreditation Manual for Ambulatory Health Care and not theHospital Accreditation Manual) BHC – Behavioral Health Care and Human Services CAH – Critical Access Hospitals HAP – Hospital LAB – Laboratory NCC – Nursing Care Centers (previously Long Term Care or Nursing and Rehabilitation Centers) OBS – Office-Based Surgery OME – Home Care - Home Health, Home Infusion Therapy, Pharmacy, Hospice HME – Home Medical EquipmentTable of ContentsSessionPre-surveyPreparing for Surveyor ArrivalReadiness GuideAmbulatory Care and Office-Based Surgery Accreditation ProgramsDocument List and Survey Activity ListBehavioral Health Care and Human Services Accreditation ProgramDocument List and Survey Activity ListHospital and Critical Access Hospital Accreditation Programs Document Listand Survey Activity ListLaboratory Accreditation Program Document List and Survey Activity ListNursing Care Centers Accreditation Program Document List and SurveyActivity ListHome Care Accreditation Program Document List and Survey Activity ListDuring survey – Sessions are generally in order of the survey agendaSurveyor ArrivalSurveyor Preliminary Planning SessionOpening ConferenceOrientation to Your OrganizationIndividual Tracer ActivityProgram-Specific Tracers: (conducted during Individual Tracer Activity) Continuity of Care Elopement Continuity of Foster/Therapeutic Foster Care Violence Suicide Prevention Laboratory Integration Patient Flow Staffing Equipment & Supply Management Fall Reduction Hospital ReadmissionSpecial Issue ResolutionSurveyor Planning/Team MeetingDaily BriefingCompetence Assessment and Credentialing/PrivilegingCompetence AssessmentEnvironment of Care and Emergency Management SessionFacility Orientation – Life Safety SurveyorLife Safety Code Building AssessmentEmergency ManagementCopyright: 2021 The Joint CommissionApplicableProgramAllPageNumber12AllAHC, OBS1415BHC19HAP, CBHCBHCBHC, HAPHAP, CAHHAP, CAHNCCHMEOMEOMEAllAllAllAHC, BHC, NCC,OBS, OMEHAP, CAH495051525354555657585960616263AHC, BHC, NCC,OBS, OMEHAP, CAHHAP, CAHHAP, CAH6564697072