aft Task 1 1 
AFT Task 1
AFT2 Accreditation Audit
July 5, 2015
Western Governor’s University
Table of Contents
Compliance Status……...…………………………………………………………………..…….3
Plan for Compliance………………………..………………………………………………….....3
Justification…………………………………………………………………………..…………...4
Source………………………………………………………………………………………..……5
Compliance Status
PC .01.01.07 Pain is assessed in all patients (The Joint Commission, 2013)
Finding: In outpatient rehabilitation, the initial assessment of pain does not indicate the severity of the pain, making assessment of the relief of pain as a result of treatment difficult. To accurately capture the efficacy of treatment, the patient’s pain level should be assessed and reassessed throughout the patient’s outpatient rehabilitation. By failing to comply with the Joint Commission’s standard of pain assessment, the facility is unable to properly assess the appropriateness of treatment specific to each patient on an individual basis.
Plan for Compliance To ensure compliance of the Joint Commission’s standard of pain assessment, a pain management policy will be adopted effective immediately to educate staff. The pain management policy will expect staff to consider pain imperative as a fifth vital sign. To begin this process, a patient’s pain must be evaluated prior to treatment. By using a pain scale of 0-10 (zero being consider painless to 10 being the worst pain a patient has ever experienced), an accurate assessment of a patient’s individual pain level can be properly monitored. Next a patient’s pain level should be assessed during treatment. At the very least, a patient’s pain level should be assessed every two hours utilizing the 0-10 pain scale. Upon assessment, if the patient’s pain level is at an unacceptable level, pain medications may be provided upon physician approval and order. In consideration that this is an outpatient rehabilitation program, oral pain medication will likely be the proper choice for
AFT2 Accreditation Audit
July 5, 2015
Western Governor’s University
Table of Contents
Compliance Status……...…………………………………………………………………..…….3
Plan for Compliance………………………..………………………………………………….....3
Justification…………………………………………………………………………..…………...4
Source………………………………………………………………………………………..……5
Compliance Status
PC .01.01.07 Pain is assessed in all patients (The Joint Commission, 2013)
Finding: In outpatient rehabilitation, the initial assessment of pain does not indicate the severity of the pain, making assessment of the relief of pain as a result of treatment difficult. To accurately capture the efficacy of treatment, the patient’s pain level should be assessed and reassessed throughout the patient’s outpatient rehabilitation. By failing to comply with the Joint Commission’s standard of pain assessment, the facility is unable to properly assess the appropriateness of treatment specific to each patient on an individual basis.
Plan for Compliance To ensure compliance of the Joint Commission’s standard of pain assessment, a pain management policy will be adopted effective immediately to educate staff. The pain management policy will expect staff to consider pain imperative as a fifth vital sign. To begin this process, a patient’s pain must be evaluated prior to treatment. By using a pain scale of 0-10 (zero being consider painless to 10 being the worst pain a patient has ever experienced), an accurate assessment of a patient’s individual pain level can be properly monitored. Next a patient’s pain level should be assessed during treatment. At the very least, a patient’s pain level should be assessed every two hours utilizing the 0-10 pain scale. Upon assessment, if the patient’s pain level is at an unacceptable level, pain medications may be provided upon physician approval and order. In consideration that this is an outpatient rehabilitation program, oral pain medication will likely be the proper choice for