TABLE OF CONTENTS

APR 07.01.01: Organization Accepts the Presence of Joint Commission Surveyor Management Staff

Revision Date:  October 13, 2020

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

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

Policy Description:  

Both, Joint Commission surveyor management staff and members of the Board of Commissioners, may observer on-site surveys in their capacity as employees and/or representatives of The Joint Commission. On-site surveys require physical access to facilities and sites. Therefore, the organization will accept the presence of Joint Commission surveyor management staff or a Board of Commissioners member in the role of observer of an on-site survey. This policy shall be applicable to Iris providers. The head of the department will review on a biennial basis.

 

PROCEDURES:

Iris Telehealth defines and clarifies “observer of an on-site survey” as: 

Observer: a person who attends but does not participate, such that they may note event proceedings. 

Observers of an on-site survey may attend an on-site survey, but do not and should not participate in survey proceedings. 

 

Iris Telehealth will allow Joint Commission surveyor management staff or a member of the Board of Commissioners to observe the on-site survey; that is to attend to survey proceedings so long as observers do not participate in the survey process. Iris Telehealth will not incur any additional survey fees because an observer(s) is present.

Iris Telehealth does not permit Joint Commission surveyor management staff and members of the Board of Commissioners acting as observers to:

  • Score Iris Telehealth’s compliance to standards 
  • Pass on any costs associated to or incurred as a result of their attendance to Iris Telehealth 

 

Iris Telehealth acknowledges and concedes participation is extended to surveyor management staff, only if: Surveyor management staff feels it is necessary to bring any potential findings or observations to the attention of the surveyor and the Iris Telehealth leadership team (organization).

 

 

APR 08.01.01: Organization Accurately Represents its Accreditation Status

Revision Date:  October 13, 2020

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

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

Policy Description:  

Both, Joint Commission surveyor management staff and members of the Board of Commissioners, may observer on-site surveys in their capacity as employees and/or representatives of The Joint Commission. On-site surveys require physical access to facilities and sites. Therefore, the organization will accept the presence of Joint Commission surveyor management staff or a Board of Commissioners member in the role of observer of an on-site survey. This policy shall be applicable to Iris providers. The head of the department will review on a biennial basis.

 

PROCEDURES:

Iris Telehealth will represent its accreditation status and the programs and services to which Joint Commission accreditation applies accurately. Iris Telehealth will reflect the scope of programs and services accredited by The Joint Commission accurately in any and all advertisements. Iris Telehealth will not engage in any false or misleading advertising about its accreditation award. 

 

 

APR 09.01.01: Organization Informs Public it Serves About How to Contact Leadership and The Joint Commission

Revision Date:  October 13, 2020

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

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

Policy Description:  

Conveying the significance of accreditation status requires context and information about what accreditation certifies and the accrediting body. The organization’s management (leadership team) is ultimately responsible for accreditation. Therefore, it is important the organization notify the public it serves about its management, The Joint Commission and how to contact both entities for matters related to accreditation standards, including safety and quality of care. This policy shall be applicable to Iris providers. The head of the department will review on a biennial basis.

 

PROCEDURES:

Iris Telehealth will notify the public it serves about how to contact the Iris Telehealth leadership team to report concerns about safety of the individual and quality of care. Iris Telehealth will notify the public it serves about how to contact The Joint Commission to report concerns about safety of the individual served and quality of care. To notify the public it serves, Iris Telehealth may: 

  • Distribute information about The Joint Commission on published materials, including its website
  • Include contact information for Iris Telehealth, its leadership team, and The Joint Commission in published materials such as brochures, fact sheets, reports and other advertisement materials.
  • Post contact information for Iris Telehealth, its leadership team, and The Joint Commission on the Iris Telehealth website.

 

 

APR 09.02.01: Any person who provides care, treatment, or services can report concerns about safety or the quality of care to The Joint Commission without retaliatory action from the organization.

Revision Date:  October 13, 2020

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

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

Policy Description:  

Intertwined with the responsibility to provide safe and quality care, treatment and services is the responsibility to report concerns about safety or quality. Therefore, the organization enables any person bearing such responsibilities to report concerns without retaliation. This policy shall be applicable to Iris providers. The head of the department will review on a biennial basis.

 

PROCEDURES:

Iris Telehealth educates its staff and other persons who provide care, treatment, or services that concerns about the safety or quality of care provided in the organization may be reported to The Joint Commission. Iris Telehealth informs its staff that it will take no disciplinary or punitive action because an employee or other person who provides care, treatment, or services reports safety or quality-of-care concerns to The Joint Commission. To educate and inform staff, Iris Telehealth may: 

  • Distribute information about The Joint Commission, including information about this policy 
  • Hold meetings and trainings about The Joint Commission, about providing safe and quality care and about this policy 
  • Provide information about how to contact The Joint Commission

Iris Telehealth takes no disciplinary or punitive action against employees or other persons who provide care, treatment, or services when they report safety or quality-of-care concerns to The Joint Commission.

 

 

 

APR 09.03.01: Organization is truthful and accurate when describing its Quality Report to the Public

Revision Date:  October 13, 2020

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

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

Policy Description:  

Truthful and accurate communication is paramount when presenting to the public information about accreditation, including the Quality Report. Therefore, the organization will communicate truthfully and accurately when describing the Quality Report to the public it serves. This policy shall be applicable to Iris providers. The head of the department will review this policy on a biennial basis.

 

PROCEDURES:

Iris Telehealth adheres to The Joint Commission’s published guidelines when describing information contained in its Quality Report. Guidelines include: 

  • To describe information in the Quality Report truthfully, defined as, in a manner consistent with reality.
  • To describe information in the Quality Report accurately, defined as, in a manner that is free from error, defect and is precise, exact and consistent with standards, rules and models. 

 

 

 

APR 09.04.01 Organization Provides Care, Treatment, Services, and an Environment that Pose no Risk of an “Immediate Threat to Health or Safety”

Revision Date:  October 13, 2020

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

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

Policy Description:  

The organization provides a safe environment for patients and employees. This policy shall be applicable to Iris providers. The head of the department will review this policy on a biennial basis.

 

PROCEDURES:

Iris Telehealth provides care, treatment, services, and an environment that pose no risk of an “Immediate Threat to Health or Safety,” also known as “Immediate Threat to Life” or ITL situation. In the event of a threat to health, safety or life, Iris Telehealth immediately suspends care, treatment, services and enacts emergency procedures and actions to return to an environment and state free of threats and risk.