Behavioral Health Care

Last updated 11/17/09, 4:15 p.m. CT


Comprehensive Accreditation Manual for Behavioral Health Care (CAMBHC)
Standards Improvement Initiative (SII): Changes to 2010 CAMBHC
Changes Made to 2009 CAMBHC


Standards Improvement Initiative (SII): Changes to 2010 CAMBHC
The Updates
Requirements for Accreditation
Accreditation Participation Requirements (APR)
Environment of Care (EC)
Emergency Management (EM)
Human Resources (HR)
Infection Prevention and Control (IC)
Information Management (IM)
Leadership (LD)
Life Safety (LS)
Medication Management (MM)
National Patient Safety Goals (NPSG)
Provision of Care, Treatment, and Services (PC)
Performance Improvement (PI)
Record of Care, Treatment, and Services (RC)
Rights and Responsibilities of the Individual (RI)
Waived Testing (WT)
Policies, Procedures, and Other Information
The Accreditation Process (ACC)
Standards Applicability Process (SAP)
Sentinel Events (SE)
The Joint Commission Quality Report (QR)
Simplifying Compliance Activities (SCA)
Required Written Documentation (RWD)
Early Survey Policy Option (ESP)


The Updates

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Accreditation Participation Requirements (APR)

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Environment of Care (EC)

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Emergency Management (EM)

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Human Resources (HR)

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Infection Prevention and Control (IC)

Clarification on Reducing Infection Risks Associated with Medical Equipment, Devices, and Supplies (IC) (10/09)

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Information Management (IM)

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Leadership (LD)

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Life Safety (LS)

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Medication Management (MM)

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National Patient Safety Goals (NPSG)

2010 National Patient Safety Goals (10/09)

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Provision of Care, Treatment, and Services (PC)

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Performance Improvement (PI)

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Record of Care, Treatment, and Services (RC)

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Rights and Responsibilities of the Individual (RI)

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Waived Testing (WT)

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The Accreditation Process (ACC)

2010 Updates to Accreditation and Certification Decision Rules (8/09)

Shorter Time Frame for Second Survey Under the Early Survey Policy (9/09)

Correction to New Fraud and Abuse Accreditation Decision Rule (9/09)

Clarification on Conducting Extension Surveys (10/09)

Revision to the ESC Tool on Secure Extranet (10/09)

Decision Rule for Preliminary Denial of Accreditation Eliminated (12/09)

New Preliminary Denial of Accreditation Process (12/09)

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Standards Applicability Process (SAP)

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Sentinel Events (SE)

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The Joint Commission Quality Report (QR)

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Simplifying Compliance Activities (SCA)

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Required Written Documentation (RWD)

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Early Survey Policy Option (ESP)

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Changes Made to the 2009 CAMBHC (see above for changes made after implementation of the 2010 manual)
The Updates
The Accreditation Process
Sentinel Events
National Patient Safety Goals
The Joint Commission Quality Report
Accreditation Participation Requirements (APRs)
Standards Applicability Process
Standards, Rationales, Elements of Performance, and Scoring
 Section 1: Client-Focused Functions
  Ethics, Rights, and Responsibilities (RI)
  Provision of Care, Treatment, and Services (PC)
  Medication Management (MM)
  Surveillance, Prevention, and Control of Infection (IC)
 Section 2: Organization Functions
  Improving Organization Performance (PI)
  Leadership (LD)
  Management of the Environment of Care (EC)
  Life Safety (LS)
  Management of Human Resources (HR)
  Management of Information (IM)
  Opioid Treatment Programs (OTP)
  Foster Care (FC)
Performance Measurement and the ORYX Initiative
Simplifying Compliance Activities
Appendix: Introduction to Standards for Services That Support Recovery and Resiliency


The Updates

2006 Update 1 Table of Changes

2006 Update 2 Table of Changes

2007 Update 1 Table of Changes

2007 Update 2 Table of Changes

2008 Update 2 Table of Changes

Revised 2009 Standards Applicability Process Chapter (5/09)

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The Accreditation Process

2008 Accreditation Decision Rules for All Programs (8/07)

2008 Thresholds for Conditional Accreditation/Certification and Preliminary Denial of Accreditation/Certification (12/07)

Clarification on Details of Elimination of Four-Month Track Record Requirements Decision (1/08)

Methodology for Conducting Unannounced Surveys Within an 18-39 Month Window (4/08)

Inclusion of a Clarification Validation Survey as Part of the Appeal Process (5/08)

Time Limits Approved for Organizations to Eliminate an Immediate Threat to Life Situation (5/08)

TRICARE Requirements for Behavioral Health Care (7/08)

Improvements to the Decision Process (8/08)

10-Day Clarification Time Frame (8/08)

2009 Accreditation Decision Rules (8/08)

Correction to Accreditation Decision Rule CON02 (9/08)

How SII May Affect Your PPR (10/08)

Modifications to the Electronic Statement of Conditions™ for States Requiring Suspension of Testing Activities (10/08)

Corrections to a Few Accreditation Decision Rule 'Links' (11/08)

Remaining Component to the 2009 Accreditation Decision Methodology, Including Thresholds (12/08)

Clarification for Pediatric Emergency Medications and Immediate Threat to Life (1/09)

Update on the 2009 Decision Process (2/09)

Updated Deposit and Fee Policies (2/09)

Additional Unannounced Survey Exceptions and Advance Notice Provision (3/09)

Approved: Revisions to the Public Information Policy (4/09)

Approved: An Extension for Extension Surveys (5/09)

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Sentinel Events

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National Patient Safety Goals

The 2008 National Patient Safety Goals (7/07)

The Joint Commission Announces the 2009 National Patient Safety Goals and Requirements (7/08)

Errata to 2009 Requirements for LS, MM, and NPSG (2/09)

NPSG 8 (Medication Reconciliation) Will Not Be Scored in 2009 (3/09)

Errata for 2009 Accreditation Manuals for EC and NPSG (8/09)

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The Joint Commission Quality Report

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Accreditation Participation Requirements (APRs)

The Joint Commission Suspends Standard MS.1.20 Implementation Date; Implementation Task Force to Continue Work on Medical Staff Standard Revision (7/08)

Errata for All 2009 Accreditation and Certification Manuals (APR, EC, LS) (5/09)

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Standards Applicability Process

Correction to Standards Applicability Chapter (4/08)

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Standards, Rationales, Elements of Performance, and Scoring

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Section 1: Patient-Focused Functions

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Ethics, Rights, and Responsibilities (RI)

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Provision of Care, Treatment, and Services (PC)

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Medication Management (MM)

Errata to 2009 Requirements for LS, MM, and NPSG (2/09)

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Surveillance, Prevention, and Control of Infection (IC)

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Section 2: Organization Functions

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Improving Organization Performance (PI)

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Leadership (LD)

Revisions to Contracted Services Standard LD.3.50 (7/07)

Revised Scoring for All 2009 Accreditation Manuals (LD) (5/09)

Additional Scoring Changes for All 2009 Accreditation Manuals (LD, LS) (6/09)

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Environmental Safety and Equipment Management (EC)

Revisions to Fire-Safety Equipment Maintenance Standard EC.5.40, EP 14 (1/08)

Modifications to the Electronic Statement of Conditions™ for States Requiring Suspension of Testing Activities (10/08)

Errata for All 2009 Accreditation and Certification Manuals (APR, EC, LS) (5/09)

Errata for 2009 Accreditation Manuals for EC and NPSG (8/09)

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Life Safety (LS)

Errata to 2009 Requirements for LS, MM, and NPSG (2/09)

Errata for All 2009 Accreditation and Certification Manuals (APR, EC, LS) (5/09)

Additional Scoring Changes for All 2009 Accreditation Manuals (LD, LS) (6/09)

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Management of Human Resources (HR)

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Management of Information (IM)

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Opioid Treatment Programs (OTP)

Revisions to Behavioral Health Care Requirements for Opioid Treatment Programs (9/08)

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Foster Care (FC)

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Performance Measurement and the ORYX Initiative

ORYX Requirements for Three Programs Rescinded for 2010 (11/09)

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Simplifying Compliance Activities

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Appendix: Introduction to Standards for Services That Support Recovery and Resiliency

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