Compliance Status When looking at the Joint Commission accreditation requirements, we can see there are 18 required areas for accreditation. After reviewing the FSA, we have found that 8 of the areas are in compliance and 10 areas are not in compliance. We will review the importance of each area and where we have found issues with non-compliance.
Accreditation Participation Requirements is very important during an audit because this area shows Joint Commission we are complying with their standards. This includes letting them do audits, providing care in Immediate Threat situations and allowing for reporting of safety and quality concerns. The area of Emergency Management allows our hospital to be prepared for threats, hazards and adverse events that will affect the care we are...