At the Consultants Forum meeting in Chicago, Joint Commission COO Mark Pelletier announced an interesting new approach TJC and CMS are piloting. It’s a concurrent validation survey process. This means CMS surveyors conduct their CMS validation survey at the same time TJC surveyors conduct their triennial survey.
The purpose of the CMS validation survey is to confirm that the TJC survey accurately evaluates compliance with the CMS Conditions of Participation. Currently, CMS conducts validation surveys on a retrospective basis. They survey 5% of accredited hospitals within 60 days of the hospital’s triennial Joint Commission survey.
Conflicting Survey Results
With the current process, there is sometimes a discrepancy between the TJC and CMS survey findings. As a result, we sometimes see our clients caught in this bind.
Two areas ripe for differing survey findings are ligature risks and medical records. We had one client who had fixed all the ligature risks cited on their Joint Commission survey. They passed their follow-up TJC survey with flying colors. The engineer surveyor cleared everything in under two hours. The following day, a CMS validation survey started. They cited different ligature risks and put the hospital on a 90 day Medicare termination track.
Furthermore, we’ve seen the same situation occur for compliance with the B Tags (Special Medical Record Requirements for Hospitals.) We had a client clear their TJC follow-up survey for treatment planning issues only to be put on a termination track by CMS four weeks later for the same issues.
Goal for the New CMS Validation Survey Process
What we heard at the Consultants Forum was promising. The pilot is showing better consistency when CMS and TJC surveyors concurrently evaluate the hospital. That would be good news for the industry! So we’ll keep our eye on this initiative. Hopefully, it will lead to a more aligned, consistent survey process and outcome.
Information on CMS Validation Surveys
For more information on the CMS validation survey process, see our June 2018 post – Psychiatric Hospitals: Be Prepared for CMS Validation Surveys. Also, check out the recent CMS communication to the field – CMS to Strengthen Oversight of Medicare’s Accreditation Organizations. For additional background, see the Advisory Board article Inside CMS’ New Pilot to Evaluate Hospital Accrediting Organizations.