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New accreditation decision: What will this mean for your facility in 2010 surveys?


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After reading this article, you will be able to:

  • Discuss what deficiencies are addressed by a “Medicare Condition-Level Deficiency Follow-Up Survey”
  • Identify differences between the new accreditation decision and existing decisions

The Joint Commission has announced it will adopt a new accreditation decision for 2010. This decision, “Medicare Condition-Level Deficiency Follow-Up Survey,” is intended when surveyors assess a facility with one or more condition-level deficiencies out of compliance.

These condition-level deficiencies refer specifically to CMS’ Conditions of Participation (CoP). This new accreditation decision is based in part on The Joint Commission’s application for hospital deeming authority through CMS.

According to The Joint Commission, if and when an organization has received this decision following a survey, the organization must then address the identified deficient CoPs. After this, a follow-up survey will be conducted on-site.

The Joint Commission has specifically stated that this accreditation decision is not to be confused with conditional accreditation decisions.

“I’m sure this is the result of continuing dialog between The Joint Commission and CMS regarding The Joint Commission’s pending deeming application decision,” says Joe Cappiello, chair of Cappiello & Associates in Elmhurst, IL. “What CMS probably said was, ‘If you have a condition out, it has to be fixed right away, and you’ll have to go back in there and validate that it was fixed.’ ”

What wasn’t addressed in this initial announcement is which scenarios will cause this type of accreditation decision.

What will trigger a visit?

There are several events that could potentially trigger a postsurvey on-site visit, says Cappiello, such as:

  • Postsurvey random unannounced survey. “This is the 5% random sample pool that everyone is put in,” says Cappiello. “If you require submission of a [measure of success (MOS)], you are out of the pool until your MOS is submitted.”
  • Postsubmission of clarifying data. “If the initial decision was conditional or preliminary denial of accreditation, on-site clarification validation survey will be scheduled if clarification changed the accreditation decision,” says Cappiello.

Other hypothetical causes for this survey include:

  • Conditional decision follow-up survey
  • Evidence of Standards Compliance (ESC) survey
  • MOS survey
  • Sentinel event follow-up survey
  • CoP follow-up survey

“With the exception of the CoP follow-up survey, these are just part of the previously published accreditation process,” says Cappiello.

Another example is if your hospital does not exceed the bandwidth but receives a few RFIs. But if you’ve got a CoP out, that is going to require a follow-up visit.

What the Joint Commission didn’t reveal was the time frame, says Cappiello. Historically, CMS requires correction and verification by on-site follow-up within 90 days.

“I would imagine that CMS will require The Joint Commission to follow that timeline,” says Cappiello.

And if you’ve exceeded your bandwidth, you have gone to conditional accreditation, and you have a CoP out, you’ll get a follow-up conditional survey by The Joint Commission following your acceptable submission of ESC, and you’ll have a follow up by The Joint Commission based on the CoP. “We don’t know if those two are combined,” says Cappiello. “Would they do them at the same time? Come back and take a look at direct impact standards and CoPs in the same visit? But what if the timelines are not compatible? I would hope that if the timelines match, The Joint Commission would combine the two into a single visit.”

If, however, the timelines turn out to be incompatible, this could result in two visits—both of which the hospital pays for.

This may also have an effect on the size of the team sent for the follow-up survey. A follow-up survey is frequently one surveyor, one day. If there are several standards out and many CoPs, this may result in a larger review team.

“I would think that The Joint Commission would review the timeline and the size/composition of the survey team on an individual basis,” says Cappiello.

Also unclear at this point are various postsurvey processes.

“Let’s say the report has been issued and the decision has been rendered,” says Cappiello. “How soon after the organization receives the report is this new condition-level deficiency follow-up done? Do they need to submit to The Joint Commission just like they do to [CMS] a plan of correction? What are they requiring to be submitted prior to the follow-up, and how far out will that be scheduled?”

Conditional accreditation update

Included in the news that a new accreditation decision is on the way are additions to the existing conditional accreditation decision.

By definition, conditional accreditation is the result of an organization failing to resolve issues stemming from a provisional accreditation status or when the organization is in substantial noncompliance of required Joint Commission standards.

In cases of conditional accreditation, the organization must submit ESC and receive a follow-up survey.

New language has been added to conditional accreditation rules that indicate additional causes for this accreditation decision. Hospitals can now receive conditional accreditation when:

  • The organization fails to provide required timely submission of information/data to The Joint Commission
  • Systemic patterns or repeat findings arise from previous surveys
  • Legitimate evidence is found that fraud and abuse occurs within the healthcare organization

These changes have been brought about as part of the Standards Improvement Initiative, and the “fraud and abuse” language brings The Joint Commission’s language in line with requirements from CMS.

Questions remaining

Several questions remain regarding The Joint Commission’s new accreditation decision, “Medicare Condition-Level Deficiency Follow-Up Survey.” Among them:

  • Do one or more COPs out of compliance drive an accreditation decision?
  • Is the accreditation decision still driven by the band range number of direct impact standards out of compliance despite COPs that may be out of compliance?
  • Under current policy, accreditation reports that do not exceed the band range are not reviewed by central office staff members.Will that change if one or more COPs are found out of compliance?
  • If one or more COPs are found out of compliance but the band range is not exceeded, can the central office hold the accreditation decision and refer the report to the Accreditation Committee for an adverse decision?