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In a recent email, The Centers for Medicare and Medicaid (CMS) released an important memo that outlines updates and guidelines for all Accrediting Organizations (AO). The memo, effective from July 14, 2023, includes several important points that will impact TJC’s operations. Here are 4 key takeaways from the memo and their potential implications.

1) Elimination of Extranet Posting

According to the CMS memo, AO’s are not to notify facilities of the AO survey team arrival prior to arriving onsite. As a result,TJC is expected to stop posting on the extranet at 7:30 am on the morning the survey team arrives for a survey. In fact, this change indicates a shift towards limiting the availability of information about the survey scheduling. It aims to reduce the possibility of prior awareness.

2) Communication about Survey Imminence

Another significant change is ending AO communications with the healthcare organization within six months of the survey date, This measure intends to stop any potential advance knowledge of an upcoming survey and level the playing field for all healthcare organizations.

3) Blackout Date Restrictions

In addition, the CMS memo states that all Accrediting Organizations should discontinue the practice of allowing deemed hospitals to identify black-out dates. Black-out dates typically refer to specific days during which organizations prefer not to undergo surveys due to various reasons such as vacation plans or major events. With the removal of this allowance, healthcare organizations may need to adapt their readiness plans.

4) Offsite Complaint Investigations

For non-long-term care facilities, both deemed and non-deemed, the memo highlights changes in offsite complaint investigations. It advised AOs to not contact facilities before onsite investigations. But, contact with the complainant is appropriate if the purpose is to determine whether to expedite a survey. Off-site investigations are generally not permitted. If an Accreditation Organization (AO) classifies a complaint as non-immediate Jeopardy (IJ) medium or non-IJ low, the AO must investigate no-later than when the next onsite survey occurs. This update aims to align the AO complaint process with CMS’s survey process for SAs.

Next Steps

Although we are awaiting response from the Joint Commission and other AOs, the CMS memo presents several significant changes that will impact AO operations and how healthcare organizations manage surveys and the accreditation process. Use our blog and newsletter to stay informed and prepared for potential changes to the survey and accreditation process.

Barrins and Associates

Barrins & Associates has an expert team that provides a complete range of Joint Commission and CMS Compliance Assistance services. We continue to be your partner in achieving and sustaining Joint Commission Accreditation and regulatory compliance.