Are you a psychiatric hospital that uses your Joint Commission accreditation for deemed status to satisfy Medicare certification requirements? If so, there’s an important new TJC Accreditation Participation Requirement for you to be aware of.
Effective July 1, 2018, any hospital that loses its deemed status following a CMS complaint survey or CMS validation survey must immediately notify The Joint Commission. The reason for this requirement is that when a hospital has its deemed status taken away by CMS, the hospital is then placed under the survey jurisdiction of the State Survey Agency (e.g., State Department of Health.)
During this period, The Joint Commission is prohibited from conducting Medicare survey activity until the hospital’s deemed status has been restored by CMS. However, during this time period, The Joint Commission will continue to conduct the following types of surveys:
- Complaint surveys
- Accreditation follow-up surveys
- Special surveys for validation of completed ligature-related corrective actions
- Intracycle Monitoring surveys
- Any survey for another program outside of the program for which the deemed status has been removed (e.g., a program accredited under the Behavioral Health standards.)
When a hospital receives a 90-day termination letter in follow-up to a CMS complaint survey or CMS validation survey, there is a process that CMS allows the hospital to follow before it terminates the hospital’s participation in the Medicare program. That process includes the hospital developing a plan of correction and (if the POC is accepted) the State Survey Agency conducting a resurvey of the hospital.
There is a clear path to follow in these situations, and Barrins & Associates has worked with many clients to help them maintain their deemed status and Medicare participation. Keep in mind, however, that if you lose your deemed status and are terminated from the Medicare program, you must now immediately notify The Joint Commission.