The number of onsite Joint Commission surveys increases each month as we move out of the COVID-19 pandemic. In June 2021, TJC scheduled 784 onsite surveys. That’s the highest number since they resumed limited onsite survey activity in June 2020.
In March 2021, they began more routine survey activity. Since then, the number of onsite surveys has increased each month.
Scheduling Onsite Joint Commission Surveys
TJC Account Executives no longer contact organizations to determine their COVID status and readiness for survey. Now that the incidence of COVID-19 has decreased, they’ve returned to their usual procedure for scheduling surveys.
TJC does still track the counties that meet criteria for scheduling onsite surveys. That number peaked in June 2021.
Once TJC clears a county for an onsite survey, the Account Executive schedules the organization. Next, TJC posts the survey notification on the organization’s Joint Commission Connect site by 7:30 a.m. local time on the first morning of the survey.
Priorities for Scheduling Surveys
At a recent Consultants Forum meeting, TJC announced that by the end of 2021 they will conduct all triennial surveys due in 2020 but not conducted. They carried over 1000 surveys from 2020 into 2021.
As a result, TJC is moving approximately 500 – 600 hospital surveys from 2021 into 2022. Consequently, hospitals due for survey in Q4 2021 will likely be scheduled for 2022. TJC will be more definitive as Q4 2021 takes shape.
A top priority right now is scheduling all CMS deemed status surveys. This category includes psychiatric hospitals that use their Joint Commission accreditation for CMS deemed status.
Also, new hospitals are a priority. TJC works closely with newly opening hospitals to schedule their surveys as soon as possible after opening.
In addition, Medicare Deficiency Surveys are a priority. As usual, TJC will conduct these within 45 calendar days from the last day of a hospital’s Joint Commission survey if the hospital receives a Condition Level finding with a CMS Condition of Participation. This Accreditation Decision Rule applies to Medicare certified hospitals that use their TJC accreditation for CMS deemed status.
Hiring New Surveyors
TJC is ramping up its surveyor cadre to meet the demand. They’re hiring 150 new surveyors this year. Their typical yearly average is 80 new surveyors.
Intracycle Monitoring Process
TJC has redesigned the Intracycle Monitoring Process. However, given the priority of catching up on overdue surveys, they’ve postponed introducing that for now. More to come when that’s back on the radar.
CMS Validation Surveys
In March 2020, CMS suspended Validation Surveys in order to focus on the COVID-19 pandemic. Specifically, they communicated the following:
“In order to decrease burden on facilities so they can focus on infection control matters and ensure State Agency surveyors retain capacity to respond to any potentially emergent concerns, CMS is also temporarily suspending validation surveys of facilities participating in Medicare via accreditation until further notice.”
The most recent update is that CMS will not resume Validation Surveys until October 1, 2021 – at the earliest.
Continuation of Offsite Joint Commission Surveys
TJC continues to schedule offsite surveys. There were 288 scheduled for June 2021. That’s down from a peak of 647 in February 2021.
Of note, the Behavioral Health Care and Human Services Accreditation Program has had the most offsite surveys of all the accreditiaotn programs. Several of our clients had offsite surveys this past year. For an in-depth look at that process, see our post Virtual Joint Commission Surveys: Get Prepared
Barrins & Associates Consultation
Now that TJC is back to “business as usual” we’re, likewise, very busy conducting Mock Surveys and Continuous Readiness Consultations. We’ve incorporated all the new 2021 standards and surveyor tools. As always, we’re prepared to support your ongoing compliance and survey readiness even in these challenging times.