APR 01.01.01: Organization Submits Information to The Joint Commission as required

Revision Date:  October 13, 2020

TABLE OF CONTENTS

Written/Revised By: Ana Herrera, DNP, APRN, FNP-C

Approved By: Ana Herrera, DNP, APRN, FNP-C

Policy Description:  

Accurate and timely information is paramount to initiating and participating in the accreditation process of The Joint Commission. Therefore, the organization needs to prepare and have ready data and information that may be requested or required by The Joint Commission throughout the accreditation process and period of accreditation. This policy shall be applicable to Iris providers. The head of the department will review on a biennial basis.

 

PROCEDURES:

Iris Telehealth will prepare and maintain data and information required by The Joint Commission for accreditation and will submit materials upon request by The Joint Commission. Submissions will be made in a timely manner such that The Joint Commission’s accreditation decision may be reaffirmed without exercising consequences for non-compliance, including having to undergo an Accreditation with Follow-up Survey. 

Iris Telehealth will prepare and maintain data and information that is accurate and appropriate to the organization’s electronic application for accreditation (E-App) such that The Joint Commission is able to conduct a survey within the estimated length of time, the survey time is not extended and no additional costs are created, nor incurred by Iris Telehealth. 

Iris Telehealth will provide accurate information and will not provide information that is falsified or otherwise misrepresents the organization, its accreditation or any part of the accreditation process. 

 

 

APR 02.02.01: Organization Provides Accurate Information Throughout the Accreditation Process

Revision Date:  October 13, 2020 

Written/Revised By: Ana Herrera, DNP, APRN, FNP-C

Approved By: Ana Herrera, DNP, APRN, FNP-C

Policy Description:  

Accurate information is paramount to the accreditation process. Therefore, the organization will ensure information is accurate and consistently-so through the many forms in which information may be provided to The Joint Commission. This policy shall be applicable to Iris providers. The head of the department will review on a biennial basis.

 

PROCEDURES:

Iris Telehealth will provide accurate information and will not provide information that is falsified or otherwise misrepresents the organization, its accreditation or any part of the accreditation process. Iris Telehealth employees will provide information consistent with their role, responsibilities and scope of work and will provide such information accurately and in a factual manner. Iris Telehealth and all employees will provide The Joint Commission information that is factual and accurate and may do so in various ways, including: 

  • Verbally.
  • When working under direct observation by a Joint Commission employee. 
  • When being interviewed by a Joint Commission employee. 
  • When engaging in any (other) type of communication with a Joint Commission employee. 
  • When supplying documents to The Joint Commission or to a Joint Commission employee. 
  • When submitting information electronically to The Joint Commission. 

Iris Telehealth will provide only accurate information and will never provide information that is falsified or fabricated, in whole or in part or through commission or omission, to The Joint Commission. Iris Telehealth will not freely redraft, reformat, or delete document content of data or information provided to The Joint Commission.   When necessary, Iris Telehealth will submit supporting material that explains the original information submitted to The Joint Commission, as well as additional materials that are properly identified, dated, and accompanied by the original documents. The content of information will remain consistent such that accuracy does not waiver, diminish or is otherwise reflect evidence lacking fidelity to the organization, its function and materials. 

 

 

APR 01.03.01: Organization Reports Changes in Information Provided in the Application for Accreditation

Revision Date:  October 13, 2020

Written/Revised By: Ana Herrera, DNP, APRN, FNP-C

Approved By: Ana Herrera, DNP, APRN, FNP-C

Policy Description:  

Changes to information provided in the application for accreditation or made between surveys undoubtedly jeopardize the accuracy of information as held by The Joint Commission and the information upon which accreditation is granted by The Joint Commission. Therefore, the organization will report any changes in the information provided in the application for accreditation and any changes made between surveys in a timely manner as defined in this policy. This policy shall be applicable to Iris providers. The head of the department will review on a biennial basis.

 

PROCEDURES:

Timely manner is defined as a period of within 30 days. 

Iris Telehealth, namely the Iris Telehealth leadership team, will notify The Joint Commission in writing within 30 days of a change in ownership, control, location, capacity, or services offered. In notifying The Joint Commission of changes to ownership, control, location, capacity, or services offered, Iris Telehealth also acknowledges that it may be necessary for The Joint Commission to survey the organization again. 

The Iris Telehealth leadership team will comply with notification requirements in a timely manner and is aware that failing to notify The Joint Commission within 30 days, could result in the loss of accreditation. 

During proceedings that would cause for this policy to be enacted, the Iris Telehealth leadership team will determine and appoint the position(s) or individual(s) responsible for maintaining Iris Telehealth in compliance with this policy as an organization. 

 

 

APR 02.01.01: Organization Permits the Performance of a Survey at The Joint Commission’s Discretion

Revision Date:  October 13, 2020 

Written/Revised By: Ana Herrera, DNP, APRN, FNP-C

Approved By: Ana Herrera, DNP, APRN, FNP-C

Policy Description:  

Integral to seeking, obtaining and maintaining accreditation by The Joint Commission is complying with surveys, announced and unannounced, solely at The Joint Commission’s discretion. Therefore, the organization permits and welcomes The Joint Commission to perform surveys throughout the accredited and accreditation period. This policy shall be applicable to Iris providers. The head of the department will review on a biennial basis.

 

PROCEDURES:

Beginning with the first application for accreditation, Iris Telehealth, as an organization, its leadership team and all employees, will permit The Joint Commission to perform a survey of its facilities, infrastructure, data and information, for a period of days and times determined by and scheduled at the discretion of The Joint Commission. Surveys will be performed during normal operating hours and may be announced or unannounced; where announcement is defined as awareness of previously scheduled activities.  

Iris Telehealth leadership team and all employees will actively participate and cooperate in surveys performed by The Joint Commission and with survey activities performed by employees. Participation and cooperation may include: performing job duties and responsibilities as done on daily and ordinary basis, permitting The Joint Commission employees to observe and shadow through any and all job duties and responsibilities, and to provide The Joint Commission and The Joint Commission employees data and information as requested through interviews, documents, or other communication. 

 

 

APR 05.01.01: Organization Allows The Joint Commission to Review the Results of External Evaluations

Revision Date:  October 13, 2020 

Written/Revised By: Ana Herrera, DNP, APRN, FNP-C

Approved By: Ana Herrera, DNP, APRN, FNP-C

Policy Description:  

Evaluations and findings by publicly recognized bodies are part of an organization’s data and information. As such, the organization will allow The Joint Commission to review the results of external evaluations from publicly recognized bodies as part of data and information. This policy shall be applicable to Iris providers. The head of the department will review on a biennial basis.

 

PROCEDURES:

Beginning with the first application for accreditation and during all follow-up surveys, Iris Telehealth will make available any and all records and reports of evaluations conducted by external publicly recognized bodies including licensing, examining, reviewing or planning bodies, to The Joint Commission and to Joint Commission employees. 

 

 

Revision Date:  October 13, 2020

Written/Revised By: Ana Herrera, DNP, APRN, FNP-C

Approved By: Ana Herrera, DNP, APRN, FNP-C

 

Policy Description:  

Joint Commission employees function only within the purpose and scope of The Joint Commission. In acknowledgement of this and to comply, the organization will not use Joint Commission employees to provide accreditation-related consulting services. This policy shall be applicable to Iris providers. The head of the department will review on a biennial basis.

 

PROCEDURES:

Iris Telehealth does not, and will not under any circumstances, use Joint Commission employees to provide any accreditation-related consulting services. Consulting services include, but are not limited to:

  •  Helping the organization to meet Joint Commission standards
  • Helping the organization to complete its Focused Standards Assessment (FSA)
  • Assisting the organization in remedying areas identified in its FSA as needing improvement
  • Conducting mock surveys

The Iris Telehealth leadership team will not approach or otherwise use Joint Commission employees to provide consulting services or act in any capacity outside their intended purpose and scope as Joint Commission employees.