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News Flash: CMS recently granted The Joint Commission a two year approval for its authority to conduct deemed status surveys for hospitals. The previous approval was for six years. So, what’s behind this shorter approval period?

Background on Deemed Status

CMS grants deeming authority to certain Accrediting Organizations (AOs.) Essentially, that means if a healthcare organization meets the standards of the AO, that healthcare organization is “deemed” to meet  the CMS Conditions of Participation (CoPs) for Medicare or Medicaid. Currently, the AOs that have deeming authority from CMS for hospitals are:

Notably, TJC is the only AO that has deeming authority for psychiatric hospitals. DNV has applied but CMS has not yet granted them approval for psychiatric hospitals.

CMS conducts validation surveys of hospitals subsequent to the surveys by the AOs. The purpose is to evaluate how closely the AO’s findings match the findings of the State Survey Agencies that survey hospitals on behalf of CMS.

Annually, CMS issues a Report to Congress on these validation surveys. Additionally, they calculate a disparity rate between the survey findings of the AO and the survey findings of the State Survey Agency. The lower the disparity rate, the more closely the AO is determined by CMS to be following the CoPs.

CMS Concerns re TJC Survey Process

CMS’ stated reason for the shorter approval period is primarily concern about the comparability of the TJC survey processes and the CMS survey processes. Some of the changes CMS wants TJC to make include the following:

Review of Offsite Hospital Locations

CMS is requiring additional training for TJC surveyors and wants a more comprehensive review of offsite locations for compliance with the Life Safety Code and CMS Physical Environment standards

Comment: TJC has already expanded the role of its Life Safety Code surveyors to include this more extensive review of offsite locations.

Surveyor Interviews of Staff

CMS wants TJC to modify the way they interview staff during surveys. Specifically, CMS wants less interviewing of staff in the presence of their supervisors. CMS purports that less presence of supervisors promotes “ease of sharing information with surveyors during interviews.”

Comment: We’re not sure what’s behind this one… In our experience, when Joint Commission surveyors interview staff (even with a supervisor present) they purposely engage directly with the front line staff. They don’t allow supervisors to dominate interviews.

Daily Briefings

CMS apparently thinks TJC gives too much information and “level of detail” to hospitals during the Daily Briefings. They claim this allows the hospital to immediately implement corrective actions organization-wide. CMS feels this could “change the integrity of the survey process.”

Comment: Our experience with Daily Briefings is that the level of detail provided, particularly through the daily report on SAFER matrix findings, has significantly improved transparency. In addition, it’s made survey findings more understandable in real-time. We don’t come across many (any?) organizations that can go out and fix a systemic issue the same day.

Governing Body Deficiencies

CMS wants TJC to cite the Governing Body more often for deficiencies found throughout the hospital. Particularly, they want to see Governing body citations for deficiencies found in the physical environment.

TJC Response

Joint Commission President Mark Chassin was quick to note that TJC had already addressed all of these issues during the deeming application process. Indeed, CMS stated in the public notice that “TJC has completed revising its survey processes in order to demonstrate that it uses survey processes that are comparable to state survey agency processes…”  

Thus, CMS acknowledges TJC has modified its survey processes to address the issues they cited. Then why the shorter approval period?

The decision seems to fit with CMS’ broader initiative to increase oversight of all AOs that have deemed status authority. Regarding the current decision for a two year approval for TJC, CMS indicated they will conduct more frequent reviews of TJC’s surveying activities to ensure consistency of the two survey processes.

Impact on TJC Surveys

Importantly, TJC’s top leadership made it clear that the CMS decision has no impact on accredited organizations with deemed status. Nor does it have any impact on the Joint Commission survey process.

As our clients with deemed status undergo their upcoming Joint Commission surveys, we’ll provide feedback, as always, on survey findings and the 2020 survey process. We’ll keep you posted on how any of these developments impact your survey preparation efforts.

For more information on deemed status and psychiatric hospitals, see our previous posts: