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SAFER, SMARTER, GREENERNATIONAL INTEGRATEDACCREDITATIONFOR HEALTHCAREORGANIZATIONS (NIAHO )Accreditation Requirements, Interpretive Guidelines and Surveyor Guidance forHospitals - Revision 20-1DNV GL Healthcare USA, Inc.400 Techne Center Drive, Suite 100Milford, OH 45150Phone 866-523-6842 Fax 513-947-1250 Copyright 2005-2020 DNV GL Healthcare USA, Inc.All Rights Reserved. No claim to U.S. Government work.
NIAHOAccreditation Requirements, Interpretive Guidelines and Surveyor GuidanceRevision 20-1, 09-21-2020Page ii of 253
NIAHOAccreditation Requirements, Interpretive Guidelines and Surveyor GuidanceRevision 20-1, 09-21-2020TABLE OF CONTENTSGLOSSARY . viiiQUALITY MANAGEMENT SYSTEM (QM) . 11QM.1 QUALITY MANAGEMENT SYSTEM . 11QM.2 ISO 9001 QUALITY MANAGEMENT SYSTEM . 11QM.3 QUALITY OUTLINE/PLAN. 12QM.4 MANAGEMENT REPRESENTATIVE . 13QM.5 DOCUMENTATION AND QUALITY MANAGEMENT OVERSIGHT . 13QM.6 SYSTEM REQUIREMENTS . 13QM.7 MEASUREMENT, MONITORING, ANALYSIS . 15QM.8 PATIENT SAFETY SYSTEM . 16GOVERNING BODY (GB) . 18GB.1 DEFINITION OF A HOSPITAL . 18GB.2 LEGAL RESPONSIBILITY. 22GB.3 INSTITUTIONAL PLAN AND BUDGET . 22GB.4 CONTRACTED SERVICES . 23CHIEF EXECUTIVE OFFICER (CE) . 25CE.1 QUALIFICATIONS . 25CE.2 RESPONSIBILITIES . 25MEDICAL STAFF (MS) . 26MS.1 ORGANIZED MEDICAL STAFF . 26MS.2 ELIGIBILITY . 26MS.3 ACCOUNTABILITY . 26MS.4 RESPONSIBILITY . 27MS.5 EXECUTIVE COMMITTEE . 29MS.6 MEDICAL STAFF PARTICIPATION . 29MS.7 MEDICAL STAFF BYLAWS . 30MS.8 APPOINTMENT . 30MS.9 PERFORMANCE DATA . 31MS.10 CONTINUING EDUCATION . 32MS.11 GOVERNING BODY ROLE. 32MS.12 CLINICAL PRIVILEGES . 33MS.13 TEMPORARY CLINICAL PRIVILEGES . 34MS.14 CORRECTIVE OR REHABILITATION ACTION . 35MS.15 ADMISSION REQUIREMENTS . 36MS.16 MEDICAL RECORD MAINTENANCE . 37MS.17 HISTORY AND PHYSICAL OR OUTPATIENT ASSESSMENT . 37MS.18 CONSULTATION . 38MS.19 RESERVED . 39MS.20 TELEMEDICINE . 39NURSING SERVICES (NS) . 41NS.1 NURSING SERVICE . 41NS.2 NURSE EXECUTIVE . 43NS.3 ASSESSMENT AND PLAN OF CARE . 44STAFFING MANAGEMENT (SM) . 47SM.1 LICENSURE OR CERTIFICATION. 47SM.2 PROFESSIONAL SCOPE . 47SM.3 DEPARTMENT SCOPE OF SERVICE. 47SM.4 DETERMINING AND MODIFYING STAFFING . 48SM.5 JOB DESCRIPTION . 48SM.6 ORIENTATION . 48SM.7 STAFF EVALUATIONS . 49MEDICATION MANAGEMENT (MM) . 52MM.1 MANAGEMENT PRACTICES . 52MM.2 FORMULARY . 62MM.3 SCHEDULED DRUGS . 63MM.4 MEDICATION ORDERS . 64MM.5 REVIEW OF MEDICATION ORDERS . 65MM.6 OVERSIGHT GROUP . 67MM.7 AVAILABLE INFORMATION . 68MM.8 ANTIMICROBIAL STEWARDSHIP . 69SURGICAL SERVICES (SS) . 71SS.1 ORGANIZATION . 71Page iii of 253
NIAHOAccreditation Requirements, Interpretive Guidelines and Surveyor GuidanceRevision 20-1, 09-21-2020SS.2 STAFFING AND SUPERVISION . 73SS.3 PRACTITIONER PRIVILEGES . 74SS.4 HISTORY AND PHYSICAL OR OUTPATIENT ASSESSMENT . 75SS.5 AVAILABLE EQUIPMENT . 78SS.6 OPERATING ROOM REGISTER . 79SS.7 POST-OPERATIVE CARE . 80SS.8 OPERATIVE REPORT . 80ANESTHESIA SERVICES (AS) . 84AS.1 ORGANIZATION . 84AS.2 ADMINISTRATION . 86AS.3 POLICIES AND PROCEDURES . 90LABORATORY SERVICES (LS) . 94LS.1 ORGANIZATION . 94LS.2 POTENTIALLY INFECTIOUS BLOOD AND PRODUCTS . 95LS.3 PATIENT NOTIFICATION . 97LS.4 GENERAL BLOOD SAFETY . 99RESPIRATORY CARE SERVICES (RC) . 101RC.1 ORGANIZATION . 101RC.2 ORDERS FOR TREATMENT AND INTERVENTIONS. 101RC.3 POLICIES OR PROTOCOLS . 102RC.4 TESTS OUTSIDE THE LABORATORY . 102MEDICAL IMAGING (MI) . 104MI.1 ORGANIZATION . 104MI.2 RADIATION PROTECTION . 104MI.3 EQUIPMENT . 105MI.4 ORDER . 106MI.5 SUPERVISION . 106MI.6 STAFF . 107MI.7 RECORDS . 107MI.8 INTERPRETATION AND RECORDS . 107NUCLEAR MEDICINE SERVICES (NM) . 109NM.1 ORGANIZATION . 109NM.2 RADIOACTIVE MATERIALS . 109NM.3 EQUIPMENT AND SUPPLIES . 110NM.4 INTERPRETATION . 111REHABILITATION SERVICES (RS) . 112RS.1 ORGANIZATION . 112RS.2 MANAGEMENT AND SUPPORT . 112RS.3 TREATMENT PLAN/ORDERS . 113EMERGENCY DEPARTMENT (ED) . 114ED.1 ORGANIZATION . 114ED.2 STAFFING . 114ED.3 EMERGENCY SERVICES NOT PROVIDED . 115ED.4 OFF-CAMPUS DEPARTMENTS . 116OUTPATIENT SERVICES (OS) . 117OS.1 ORGANIZATION . 117OS.2 STAFFING . 117OS.3 SCOPE OF SERVICE . 117OS.4 ORDERS . 118DIETARY SERVICES (DS) . 120DS.1 ORGANIZATION . 120DS.2 SERVICES AND DIETS . 121DS.3 DIET MANUAL . 122PATIENT RIGHTS (PR) . 124PR.1 NONDISCRIMINATION . 124PR.2 SPECIFIC RIGHTS . 124PR.3 ADVANCE DIRECTIVE . 131PR.4 LANGUAGE AND COMMUNICATION . 132PR.5 INFORMED CONSENT . 133PR.6 GRIEVANCE PROCEDURE . 134PR.7 RESTRAINT OR SECLUSION . 135PR.8 RESTRAINT OR SECLUSION: STAFF TRAINING REQUIREMENTS . 147PR.9 RESTRAINT OR SECLUSION: REPORT OF DEATH . 149Page iv of 253
NIAHOAccreditation Requirements, Interpretive Guidelines and Surveyor GuidanceRevision 20-1, 09-21-2020INFECTION PREVENTION AND CONTROL PROGRAM (IC) . 153IC.1 INFECTION PREVENTION AND CONTROL PROGRAM. 153IC.2 ANTIBIOTIC STEWARDSHIP PROGRAM . 154IC.3 LEADERSHIP RESPONSIBILITIES . 155IC.4 UNIFIED AND INTEGRATED INFECTION PREVENTION AND CONTROL AND ANTIBIOTIC STEWARDSHIP PROGRAMSFOR MULTI-HOSPITAL SYSTEMS . 156MEDICAL RECORDS SERVICE (MR) . 162MR.1 ORGANIZATION . 162MR.2 COMPLETE MEDICAL RECORD . 162MR.3 RETENTION . 163MR.4 CONFIDENTIALITY . 163MR.5 RECORD CONTENT . 164MR.6 IDENTIFICATION OF AUTHORS . 166MR.7 REQUIRED DOCUMENTATION . 167DISCHARGE PLANNING (DC) . 170DC.1 WRITTEN POLICIES . 170DC.2 DISCHARGE PLANNING EVALUATION . 170DC.3 PLAN IMPLEMENTATION . 170DC.4 EVALUATION . 171DC.5 POST ACUTE CARE SERVICES . 171UTILIZATION REVIEW (UR) . 173UR.1 DOCUMENTED PLAN . 173UR.2 SAMPLING. 174UR.3 MEDICAL NECESSITY DETERMINATION . 174UR.4 EXTENDED STAY REVIEW . 175PHYSICAL ENVIRONMENT (PE) . 176PE.1 FACILITY . 176PE.2 LIFE SAFETY MANAGEMENT SYSTEM . 179PE.3 SAFETY MANAGEMENT SYSTEM . 182PE.4 SECURITY MANAGEMENT SYSTEM . 183PE.5 HAZARDOUS MATERIAL (HAZMAT) MANAGEMENT SYSTEM . 184PE.6 EMERGENCY MANAGEMENT SYSTEM . 185PE.7 MEDICAL EQUIPMENT MANAGEMENT SYSTEM . 189PE.8 UTILITY MANAGEMENT SYSTEM. 197ORGAN, TISSUE AND EYE PROCUREMENT (TO) . 200TO.1 PROCESS . 200TO.2 ORGAN PROCUREMENT ORGANIZATION (OPO) WRITTEN AGREEMENT . 200TO.3 ALTERNATIVE AGREEMENT . 202TO.4 RESPECT FOR PATIENT RIGHTS . 202TO.5 DOCUMENTATION . 203TO.6 ORGAN TRANSPLANTATION . 203TO.7 TRANSPLANT CANDIDATES . 203SWING BEDS (SB) . 205SB.1 FACILTY ELIGIBILITY . 205ADMISSION, TRANSFER AND DISCHARGE (TD) . 206TD.1 TRANSFER AND DISCHARGE REQUIREMENTS . 206TD.2 DOCUMENTATION . 207TD.3 NOTIFICATION. 207TD.4 ORIENTATION FOR TRANSFER OR DISCHARGE . 208TD.5 CHANGE OF ROOM IN COMPOSITE DISTINCT PART . 208TD.6 DISCHARGE SUMMARY . 209PLAN OF CARE (PC) . 210PC.1 ASSESSMENT. 210PC.2 CARE PLAN . 211RESIDENTS RIGHTS (RR) . 213RR.1 EXERCISE OF RIGHTS . 213RR.2NOTICE OF RIGHTS AND SERVICES . 213RR.3 HEALTH CARE DECISIONS . 214RR.4ADVANCE DIRECTIVES . 215RR. 5 MEDICAID BENEFITS . 216RR.6 PERSONAL PRIVACY AND CONFIDENTIALITY . 216RR.7 RESTRAINTS . 218RR.8 FREEDOM FROM ABUSE, NEGLECT, AND EXPLOITATION . 218Page v of 253
NIAHOAccreditation Requirements, Interpretive Guidelines and Surveyor GuidanceRevision 20-1, 09-21-2020FACILITY SERVICES (FS) . 222FS.1 PATIENT ACTIVITIES . 222FS.2 SOCIAL SERVICES . 222FS.3 DENTAL SERVICES . 223FS.4 SPECIALIZED REHABILITATIVE SERVICES . 224RESIDENT NUTRITION (RN) . 227RN.1 NUTRITIONAL STATUS . 227APPENDIX B - PSYCHIATRIC SERVICES . 229GENERAL REQUIREMENTS (PH-GR) . 229MEDICAL RECORDS SERVICE (PH-MR) . 230PSYCHIATRIC EVALUATION (PH-E) . 231NEUROLOGICAL EXAMINATION (PH-NE) . 233TREATMENT PLAN (PH-TP) . 235PROGRESS NOTES (PH-PN) . 239DISCHARGE PLANNING (PH-DP) . 241PERSONNEL RESOURCES (PH-PR) . 242MEDICAL STAFF (PH-MS) . 244NURSING SERVICES (PH-NS) . 245PSYCHOLOGICAL SERVICES (PH-PS) . 247SOCIAL WORK SERVICES (PH-SS) . 248PSYCHOSOCIAL ASSESSMENT (PH-PA) . 250THERAPEUTIC ACTIVITIES (PH-TA) . 251Page vi of 253
NIAHOAccreditation Requirements, Interpretive Guidelines and Surveyor GuidanceRevision 20-1, 09-21-2020Use of NIAHO Accreditation Requirements, Interpretive Guidelines and Surveyor GuidanceEffective DateNIAHO Accreditation Requirements, Interpretive Guidelines and Surveyor Guidance, Revision 20-1Effective Date: 09-21-2020Supersedes NIAHO Revision 20-0 and all prior revisions (Revision numbers now align with year of publication).National Professional Organizations- Evidence-Based Professionally Recognized Standards of PracticeEvidence-based professionally recognized standards of practice of the national professional organizations referenced inthese NIAHO Accreditation Requirements, Interpretive Guidelines and Surveyor Guidance (NIAHO ) document areconsultative and considered in the accreditation decision.Federal Laws, Rules and RegulationsThe most current version of Federal law and the CFR referenced in this NIAHO document are incorporated herein byreference and constitute NIAHO accreditation requirements.This NIAHO document is based upon the Centers for Medicare and Medicaid Services (CMS) Conditions of Participation42 CFR Section 482 and State Operations Manual Regulations and Interpretive Guidelines for Hospitals. TheseInterpretive Guidelines also are periodically updated based on notices distributed from CMS. Hospitals participating inthe Medicare and Medicaid program are expected to comply with current Conditions of Participation (CoP). When newor revised requirements are published, hospitals are expected to demonstrate compliance in a time frame consistentwith the effective date published by CMS in the Federal Register.Life Safety Code The Life Safety Code of the National Fire Protection Association referenced in this NIAHO document is incorporatedherein by reference and constitute NIAHO accreditation requirementPage vii of 253
NIAHO Accreditation Requirements, Interpretive Guidelines and Surveyor GuidanceRevision 20-1, 09-21-2020GLOSSARYAANAAmerican Association of Nurse Anesthetists (AANA)ACSAmerican College of SurgeonsACIPCDC’s Advisory Committee on Immunization PracticesAMAAmerican Medical AssociationAOAccreditation OrganizationAOAAmerican Osteopathic AssociationAORNAssociation of periOperative Registered NursesAPICAssociation of Professionals in Infection Control and EpidemiologyASAAmerican Society of AnesthesiologistsASHPAmerican Society of Health-System PharmacistsCAHCritical Access HospitalCDCCenters for Disease Control and PreventionCNSClinical Nurse SpecialistCEOChief Executive OfficerCFRCode of Federal RegulationsCMSCenters for Medicare and Medicaid ServicesCRNACertified Registered Nurse AnesthetistDEADrug Enforcement AdministrationDirect ServicesUnless the context indicates otherwise, means services provided byemployed staff of the Organization, not servi
NATIONAL INTEGRATED ACCREDITATION FOR HEALTHCARE ORGANIZATIONS (NIAHO ) DNV GL Healthcare USA, Inc. 400 Techne Center Drive, Suite 100 Milford, OH 45150 Phone 866-523-6842 Fax 513-947-1250 Accreditation Requirements, Interpretive Guidelines and Surveyor Guidance for
