Does TJC accredit your organization under more than one accreditation manual? If so, that means you get a Joint Commission “tailored survey.”
In a tailored survey, TJC applies standards from different accreditation manuals based on your services and settings. For example, they may use both the Hospital standards and the Behavioral Health Care & Human Services standards.
Behavioral Healthcare Tailored Surveys
Tailored surveys are common in the behavioral healthcare industry. There are many hospitals that operate both inpatient psychiatric services and partial hospitalization or intensive outpatient programs.
If these PHP/IOP programs have an average daily census of 11 or more, TJC applies both the Hospital standards and the Behavioral Health Care & Human Services standards. As a result, the survey report includes two SAFER matrices: one for the Hospital standards and one for the Behavioral Health Care & Human Services standards.
Clarification on Joint Commission Tailored Surveys
TJC recently published an important clarification on its tailored survey process in the August 2021 issue of Joint Commission Perspectives . Specifically, it stated: “For hospitals that use The Joint Commission for deemed status purposes, all services reported under the hospital’s US Centers for Medicare & Medicaid Services (CMS) Certification Number (CCN#) must be surveyed under the CAMH.”
So, that means TJC will survey your mental health/eating disorder PHP/IOPs (with ADC of 11 or more) under the applicable Hospital standards. And those PHP/IOP findings will go on your Hospital SAFER matrix. As a result, they can potentially contribute to a CMS Condition level deficiency on your Hospital report.
In addition, TJC will apply the Behavioral Health Care and Human Services to those PHP/IOP programs – as they’ve done in the past. One important exception: TJC always surveys alcohol and drug services under the Hospital manual.
Takeaways re Joint Commission Tailored Surveys
The most obvious takeaway is these tailored survey rules can get pretty complicated! Therefore, it’s critical you review your application very carefully with your TJC Account Executive.
First, make sure you understand and correctly identify your different settings and populations. Moreover, make sure you’re crystal clear on which accreditation manuals TJC will apply to your various programs.
If you don’t address this ahead of time, you risk confusion during your survey about which standards TJC is applying. Worse yet, you may get surprised when your survey report identifies deficiencies in a manual that you weren’t aware applied to your organization.
Barrins & Associates
When we conduct our mock surveys, we identify the different standards that TJC will use during a tailored survey. This helps your organization focus on the specific requirements for each setting and any potential deficiencies.
At Barrins & Associates, we’re now pretty much back to “business as usual.” We’re busy conducting Mock Surveys and Continuous Readiness Consultations across the country.
We’ve incorporated all the new standards that go into effect in 2022. As always, we’re prepared to support your ongoing survey readiness and best practices for regulatory compliance.