What’s the latest on Joint Commission survey activity? Well, we may soon be seeing a return to business as usual for onsite Joint Commission surveys.

As we know, The Joint Commission resumed onsite survey activity on a limited basis in June. Their approach to date has been to conduct onsite surveys in counties that are low risk for COVID-19. Effective March 15th, that approach is changing.

Onsite Joint Commission Surveys

On March 2nd, TJC sent an email to all accredited organizations updating them on the plan for onsite surveys. It indicated that TJC Account Executives will no longer contact organizations to determine their readiness for survey. (This was the procedure for the past several months.) Now that the incidence of COVID-19 is decreasing, TJC will return to its usual procedure for scheduling surveys.

First, TJC will determine if the geographic area is low risk for COVID-19. They use the New York Times COVID-19 Database as their guide.

Next, TJC will proceed to schedule the organization for survey. They will notify the organization of the upcoming survey via the Joint Commission Connect site in the Notification of Scheduled Events section.

For unannounced surveys, TJC will post that notification of the first day of the survey.  Also, they will send an email notification that day to the CEO and the Primary Accreditation Contact.

TJC Chief Operating Officer Mark Pelletier noted in the March 2nd communication that “All available resources will be utilized to conduct onsite, unannounced accreditation surveys.” Thus, the emerging theme of a return to business as usual.

Priorities for Onsite Joint Commission Surveys

A top priority for onsite surveys will be Medicare surveys for deemed status hospitals with accreditation due dates that are past due.  TJC is working closely with CMS to get these done.

As a result of the pandemic, TJC had to carry over more than 4,000 surveys into 2021. Therefore, their goal is to complete all of these in 2021.

At the same time, TJC has stated that if an organization is experiencing a surge in COVID-19 cases and due for survey, they should contact their Account Executive. They can discuss possibly delaying the onsite survey or doing it virtually.

Protocols for Onsite Joint Commission Surveys

As onsite surveys pick up, TJC surveyors will continue to adhere to CDC COVID-19 guidance during surveys including the following:

• Physical Distancing: Limiting the number of attendees at sessions, minimizing staff escorts during tracers, and driving in separate vehicles to offsite locations
• PPE: Surveyors will wear masks and follow the organization’s protocols regarding use of PPE.
• Enhanced Technology: Using screen sharing to review electronic medical records and interview staff or patients as well as videoconferencing to expand the number of attendees at meetings.

Continuation of Virtual Joint Commission Surveys

If an onsite Joint Commission survey is not feasible due to high risk for COVID-19, TJC will schedule a virtual survey. These surveys are now officially called offsite surveys.

We’ve had several clients undergo offsite surveys including psychiatric hospitals and behavioral health organizations. Of note, the Behavioral Health Care and Human Services Program has done approximately 600 offsite surveys to date. That’s second only to the Home Care Program for the number of offsite surveys.

For an in-depth look at the offsite survey process, see our recent post Virtual Joint Commission Surveys: Get Prepared.

Barrins & Associates Consultation

We’re now conducting our Mock Surveys and Continuous Readiness Consultations both virtually and onsite. 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.