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January 2023 Nursing Care Center Standards Updates

Updated: Jun 27, 2023



The Joint Commission eliminated 12 Nursing Care Center standards and revised one standard effective January 1, 2023. In September 2022, The Joint Commission announced its plan to review all leading standards to increase efficiency and influence on patient/resident safety and quality.


According to The Joint Commission, the organization reviewed each standard to answer the questions:

  • Does the requirement still address an important quality and safety issue?

  • Is the requirement redundant?

  • Are the time and resources needed to comply with the requirement commensurate with the estimated benefit to patient/resident care and health outcomes?

Below are the retired elements of performance:

Standard LS.02.01.40 The organization provides and maintains special features to protect individuals from the hazards of fire and smoke.

LS.02.01.40, EP 2 The organization meets all other Life Safety Code automatic extinguishing requirements related to NFPA 101-2012: 18/19.4.2.


Standard MM.03.01.01 The organization safely stores medications.

MM.03.01.01, EP 9 The organization keeps concentrated electrolytes present in patient and resident care areas only when patient or resident safety necessitates their immediate use, and precautions are used to prevent inadvertent administration.


Standard MM.06.01.05 The organization safely manages investigational medications.

MM.06.01.05, EP 1 The organization follows a written process addressing the use of investigational medications that includes review, approval, supervision, and monitoring.

MM.06.01.05, EP 3 When a patient or resident is involved in an investigational protocol that is independent of the organization, the organization evaluates and, if no contraindication exists, accommodates the patient's or resident’s continued participation in the protocol.


Standard NPSG.03.05.01 Reduce the likelihood of harm to patients and residents associated with the use of anticoagulant therapy.

NPSG.03.05.01, EP 1 The organization uses approved protocols and evidence-based practice guidelines for the initiation and maintenance of anticoagulant therapy that address medication selection; dosing, including adjustments for age and renal or liver function; drug–drug and drug–food interactions; and other risk factors as applicable.


NPSG.03.05.01, EP 4 The organization has a written policy addressing the need for baseline and ongoing laboratory tests to monitor and adjust anticoagulant therapy. Note: For all patients or residents receiving warfarin therapy, use a current international normalized ratio (INR) to monitor and adjust dosage. For patients or residents on a direct oral anticoagulant (DOAC), follow evidence-based practice guidelines regarding the need for laboratory testing.


NPSG.03.05.01, EP 5 The organization addresses anticoagulation safety practices through the following: -Establishing a process to identify, respond to, and report adverse drug events, including adverse drug event outcomes-Evaluating anticoagulation safety practices, taking actions to improve safety practices, and measuring the effectiveness of those actions in a time frame determined by the organization.


Standard PC.02.02.13 The patient's or resident’s comfort and dignity receive priority during end-of-life care.

PC.02.02.13, EP 1 To the extent possible, the organization provides care and services that accommodate the patient's or resident's and their family’s comfort; dignity; and psychosocial, emotional, and spiritual end-of-life needs.


PC.02.02.13, EP 2 The organization provides staff with education about the unique needs of dying patients and residents and their families.


Standard PI.03.01.01 The organization compiles and analyzes data.


PI.03.01.01, EP 19 The organization monitors the use of opioids to determine if they are being used safely (for example, tracking of adverse events such as over-sedation).


PI.03.01.01, EP 21 The organization provides incidence data to key stakeholders, including leaders, licensed independent practitioners, nursing staff, and other clinicians on multidrug-resistant organisms (MDRO).


Standard WT.05.01.01 The organization maintains records for waived testing.

WT.05.01.01, EP 2 Test results for waived testing are documented in the patient’s or resident’s clinical record.


Achieve Accreditation has updated our resources and provided tools to all initial accreditation and accreditation maintenance client partners in order to adjust to the updated requirements. Resources provided to client partners include but are not limited to: competency testing tools, vaccination tracking, educational materials, and hands-on training guides. Watch for additional information in our ongoing blog series.



Jessica Prucha, BAJ is the Operations Manager at Achieve Accreditation. Achieve Accreditation has helped skilled nursing providers and assisted living organizations to obtain and maintain their Joint Commission Accreditation for over 30 years.

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