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The Centers for Medicare & Medicaid Services (CMS) recently issued crucial updates regarding accreditation processes for healthcare organizations. These updates, detailed in a memo dated September 15, 2023, have far-reaching implications for how Hospitals and Behavioral Health providers manage unannounced surveys, avoid dates, and handle complaint procedures. In this blog post, we will break down the key changes and what they mean for accredited organizations.

Unannounced Surveys: A Commitment to Compliance

One of the most significant changes introduced by CMS is the elimination of avoid dates for organizations selecting the Joint Commission deemed status survey option. More than ever, deemed status healthcare organizations are now expected to maintain compliance with accreditation and Medicare requirements, without specifying dates when surveys should be avoided. This change underscores the importance of continuous readiness and commitment to meeting healthcare standards.
Moreover, healthcare organizations need to communicate with accrediting bodies, such as The Joint Commission, about any circumstances that could affect the efficacy of an unannounced survey. For instance, if a sole practitioner is not available on a particular day to provide treatment, organizations can inform the accrediting body. But, the accrediting body will assess whether this information affects the timing of the unannounced survey.

Changes in Survey Notification

Per CMS requirements, The Joint Commission will enact changes starting October 7, 2023. To uphold the unannounced nature of surveys for organizations that select the deemed status survey option, they will discontinue the 7:30 am notification process on the first day of unannounced deemed status surveys. But, organizations that qualify for announced (30 calendar days) or short notice (7 business days) surveys (non-deemed status) will still receive notification within these specified time frames. Once the survey starts, organizations can verify surveyors’ identities and access survey agendas through the Joint Commission’s secure Connect extranet site.

Complaint Procedures Streamlined

CMS has also changed the way accrediting organizations manage complaints. The Joint Commission will no longer contact deemed status organizations for written responses to complaints. This change will also take effect October 7, 2023.

Instead, The Joint Commission will determine how to evaluate allegations made in complaints. This will occur either during an unannounced complaint survey, at an upcoming unannounced survey event, or during the next full onsite survey. If The Joint Commission requires more information, they will attempt to contact the individual who submitted the complaint.

Summary of Changes

In summary, these updates to accreditation processes signify a shift towards greater transparency, continuous readiness, and standardization in healthcare accreditation. Deemed status healthcare organizations must adapt to these changes and ensure they maintain compliance with CMS requirements.

It is essential for organizations to stay informed about these developments and to review their policies and procedures to align with the new expectations. These changes aim to enhance the quality and safety of healthcare services provided to patients and ensure that organizations are always prepared to meet the highest standards of care. 

Barrins & Associates Consultation

Our expert consultants are available to help organizations assess their compliance with Joint Commission standards. We can perform a TJC Focused Survey, Comprehensive Mock Survey, or  Continuous Readiness Consultation. We continue to be your partner in achieving and sustaining Joint Commission Accreditation and regulatory compliance.