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As we know, regular Joint Commission surveys resumed in June. So, how’s that going? TJC recently provided an update to our Consultants Forum group. Here’s some important info they shared.

Surveys Targeted to Low Risk Areas

Currently, TJC is scheduling surveys in counties identified as low risk for COVID-19. They use two key data points to determine a low risk county:

  1. The 2 week trend of COVID-19 cases
  2. The number of cases per 1,000 people

TJC is using the New York Times database to inform decisions about where to schedule surveys.

Priorities for Joint Commission Surveys

As we reported in a recent post, a top priority will be organizations overdue for their triennial surveys. Another priority will be deemed status organizations with Condition Level deficiencies on their previous survey. In these instances, TJC must conduct a 45 day follow-up Medicare Deficiency Survey.

Joint Commission account executives will contact organizations if TJC is considering scheduling their survey. The account executive will review the following factors to determine if the organization is survey-ready:

  • The organization is no longer under emergency operations
  • Is the organization using any CMS waivers?
  • No new staff COVID-19 cases for 14+ days
  • Are there any visitor restrictions?
  • Are any sites located outside of your state?

Scope of Joint Commission Survey

TJC has emphasized that the focus of surveys will be on the organization’s current practices. Specifically, surveys “will not include a retroactive review of compliance between March 1, 2020 through the end of the emergency declaration.”

The current Public Health Emergency Declaration expires July 25th.  However, the Department of Health & Human Services has announced they will  extend the declaration for another 90 days.

Important Note: During a recent conference call with TJC, we clarified that this timeframe for review of compliance is between March 1, 2020 through the end of the emergency declaration OR the Ready Date the organization communicates to TJC – whichever comes first. Thus, if you tell TJC you’re ready for them to survey you, they will review your compliance from that date forward. They can also review compliance prior to March 1st.

Virtual Joint Commission Surveys

As of June 23rd, TJC had conducted 14 virtual surveys in the Hospital Accreditation Program (including psychiatric hospitals.) These virtual surveys are only for initial, deemed status surveys – not for triennial surveys. In addition, TJC will complete on onsite survey in follow-up to these virtual surveys once the Public Health Emergency expires.

One new approach for virtual surveys which will likely find its way into routine onsite surveys is having the organization upload the required documents to SharePoint prior to the virtual survey. Surveyors report this gives them much more time to thoroughly review the documents and plan tracers accordingly.

So, Heads Up: Be prepared for much closer scrutiny of your documents than when surveyors had about 1.5 hours to rush through them the first morning of survey!

Tracer Focus

The tracers done on virtual surveys reflect the same priorities we saw for 2020 prior to the pandemic. These topics will likely continue as priorities for routine triennial surveys and include:

  • Ligature risks
  • High risk suicide patient
  • Patient treated for infection
  • Seclusion/restraint
  • Medically compromised patient
  • Acute detox patient
  • Patient on high risk medications (Clozaril, anticoagulants, insulin)
  • Admission/triage – staff interview

Additionally, surveyors conduct a Kitchen/Dietary Tracer. For more info on that, see our post TJC Tracer Update: Focus on Dietary Services.

In addition to these tracers, there’s, understandably, a focus on the organization’s COVID-19 response. Specifically, what policies and procedures did they develop and how did they train staff to deal with COVID-19? For guidance on this topic, see our recent post Joint Commission Surveys: Infection Control Focus.

Ramping Up Your Continuous Readiness

Now that TJC has resumed regular surveys, continuous readiness is once again critical. Our Mock Surveys and Continuous Readiness Consultations will help you get back up to speed and prepare for that next survey – whenever it happens.

Also, be sure to check out the COVID-19 resources on the Joint Commission website. There’s a wealth of information there to help you meet the challenges of the COVID-19 pandemic. For example, see their recent Quick Safety Issue 54: Promoting Psychosocial Well-being of Health Care Staff during Crisis.