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Most Frequently Cited Joint Commission Standards – What They Are and How to Avoid Them

Updated: Jun 27, 2023

Here are some of the Joint Commission’s most frequently cited recommendations for nursing care centers. By highlighting common areas and providing practical suggestions, we can help your organization avoid these pitfalls.

In 2021, EC.02.02.01, managing risk related to hazardous materials and waste, was the most frequently cited recommendation. This standard addresses a variety of items including, but not limited to, Safety Data Sheets (SDS), eye wash stations and proper credentials for signing for hazardous waste pick-ups. To help avoid receiving a recommendation for this environment of care standard, ensure that you have Safety Data Sheets for every product used in the building and that staff are following the safety protocols within the SDS such as using proper PPE (Personal Protective Equipment) when in contact with that product. Educate your staff on the purpose and location of Safety Data Sheets and ensure the needed personal protective equipment is available for staff. Eye wash stations should be accessible where chemicals are used and/or stored. By accessible, we mean within 10 seconds or 50 feet and not behind a locked door. Eye wash stations should be inspected weekly for items such as water pressure, dust caps and mixing valves and solution bottles should be monitored for expiration dates. Another area that is frequently identified as non-compliant under this standard is that the individual signing manifests for the hazardous waste pick-ups is not certified through the Department of Transportation.

Credentialing recommendations are near the top of the most frequently cited list. Ensuring that each file complies not only requires that you have the required documents from each practitioner, but also that all information is current and that each step of the process is completed in the proper order. Frequent credentialing recommendations include not having a query from the National Practitioner Data Bank, expired DEA certifications, not conducting the primary source license verification in a timely manner and having more than 2 years between the credentialing re-appointments.

The next frequently cited recommendation makes it to the top five list every year. Two forms of competency testing are required both upon hire and annually for nurses for any waived test being conducted on site. The most common waived test in nursing care centers is blood glucose monitoring. Nurses must complete a written test and perform a return demonstration using the glucometers. If there are other waived tests occurring on-site (i.e., rapid antigen testing, PT/INR, urine dipstick, fecal occult), the need for two forms of competency testing applies as well. The best ways to avoid this recommendation is to ensure the written and observational tests are part of the new hire orientation process for nurses and part of the training calendar at least annually. Going together with this requirement is the need to conduct quality control checks for instrument-based waived testing per manufacturer guidelines. For glucometers, the best practice is to assign quality control checks to a particular shift on a set frequency (often this is done daily but could be less based on manufacturer guidelines and corresponding organization policy). It is essential to conduct random audits of employee files to ensure the competencies are completed on record as required and assign an individual to check the quality control logs at least weekly to avoid recommendations for these standards. When auditing the quality control logs, check for the following: the serial number or other device identifier is included on the log and updated if the device is taken out of use, no omissions in the documentation, ensure the acceptable range for results is written on the log, and verify if documented actions were taken when/if readings were out of range. Finally, look at the quality control solution to ensure it is labeled with the open date and the discard date.

The last standard is regarding the organization implementing its infection prevention and control plan. Annually, each organization should conduct an infection control risk assessment which will identify the highest risk areas to prioritize. Your infection control plan should outline the activities you will do to limit the risk of those areas for which you are most at risk. Hand hygiene is the basis for your infection prevention and control plan and should always be an area of focus. Conducting hand hygiene competency testing upon hire and annually for all staff should be the protocol for all nursing care centers. A job specific hand hygiene training is recommended as well. For example, a new cook should be provided with examples of when hand hygiene should occur specific to food preparation. Conducting ongoing surveillance audits of staff and contractors will provide knowledge of compliance with the hand hygiene protocols in place. Try to observe staff without them knowing as they perform their job duties to ensure they are washing or sanitizing their hands each time it is required, using proper techniques. Analyzing the data collected during these audits will help determine if additional education is needed or if there are other potential barriers to achieving compliance.

Focusing on these four frequently cited standards will help prepare an organization for their next Joint Commission survey!

Gerrianne Hartman, LNHA, MA, is a Senior Consultant 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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