As we all know, The Joint Commission suspended regular survey activity effective March 16, 2020.
We covered questions from our readers on that topic in our post The Joint Commission Suspends Surveys. Since that announcement, TJC has not been conducting routine surveys. Understandably, they’ve wanted to allow healthcare organizations to focus on their response to the COVID-19 pandemic.
Joint Commission Recovery Plan
So now, two months later, organizations are asking when TJC will resume regular surveying. TJC is grappling with that complex issue right now and working on their Recovery Plan.
Joint Commission COO Mark Pelletier recently hosted a conference call for members of the Consultants Forum. He updated us on this topic and how TJC is planning to re-start surveys.
Admittedly, this is a complicated endeavor. TJC doesn’t want to unnecessarily disrupt operations in locations still in the throes of dealing with the pandemic. They also want to keep their surveyors safe and healthy.
Currently, TJC plans to resume approximately 25% of survey activity in June. Subsequently, they plan to phase in the remainder of survey activity over the next several months. Once normal operations resume, TJC will conduct all postponed surveys.
TJC leadership made it clear they will follow all federal, state, and local guidelines as they resume survey activity in various locations throughout the country. Clearly, this Recovery Plan is evolving and will be dependent on the path that the pandemic takes in the coming months.
Joint Commission Survey Priorities
As part of its Recovery Plan, TJC has identified certain priorities for resuming regular survey activity. First, they will prioritize based on program type. They plan to give top priority to the following types of facilities:
- Rehabilitation facilities
- Specialty hospitals: This includes psychiatric hospitals.
- Department of Defense facilities
- Veterans Administration facilities
- Ambulatory Care programs
- Ambulatory Surgery Centers
- Health Care Staffing Services
- Freestanding labs (unless doing COVID testing)
- Home care programs
They will then survey programs requiring more recovery time from COVID-19:
- Med/surg hospitals
- Critical access hospitals
- Disease Specific Care certified programs in hospitals
- Labs in hospitals
- Ambulatory Surgery Centers used for acute care overflow
- Nursing Care Centers
- Freestanding labs doing COVID-19 testing
Next, TJC will prioritize based on the type of survey they need to conduct. A top priority will be organizations with adverse decisions on their last survey.
Adverse decisions include findings such as Preliminary Denial of Accreditation or Immediate Threat to Health and Safety. TJC will also prioritize Medicare Deficiency surveys, and surveys in response to egregious complaints.
Virtual Joint Commission Surveys
During this national emergency, TJC has implemented a virtual survey process for initial surveys of organizations seeking CMS deemed status. Feedback is that these are going smoothly.
This is thanks in large part to the ability to conduct document review and electronic medical record reviews remotely. Once the federal government lifts the national emergency, TJC will conduct onsite surveys at these facilities.
Medical Record Documentation during National Emergency
Additionally, TJC shared important information during our conference call in regard to surveying medical records once surveys resume. TJC leadership indicated that surveyors will NOT review any medical record documentation completed during the time period from March 16th until the national emergency ends. This is welcome news for healthcare organizations that have been grappling with the challenges of COVID-19 over the past several months!
Continuous Readiness
As TJC plans to resume normal survey operations, continuous readiness becomes ever more important. Getting up to date on new standards and requirements will be critical. Be assured that our Mock Surveys and Continuous Readiness Consultations can help you get back up to speed and prepare for that next survey – whenever it occurs.
As always, we’ll be sure to keep you updated on further developments regarding TJC’s return to normal survey activity.