Compliance News: Accreditation Survey Findings Report Includes TJC and CMS Findings

By Dean Samet, CHSP 


In July of 2009 The Joint Commission modified its Accreditation Survey Findings Report to include both TJC and Medicare requirements which were identified as being less than fully compliant at the time of survey. This is primarily for organizations that use The Joint Commission accreditation for deemed status purposes. TJC has developed crosswalks of their requirements to Medicare Conditions of Participation (CoPs) as reflected in a new report format.

The accreditation decision report now reflects a “Summary of CMS Findings” section which provides crosswalks of noncompliant Medicare requirements to corresponding TJC standards and elements of performance that were found to be less than fully compliant. The report also identifies the deficiency level for each noncompliant Medicare Condition or Standard.

The “Joint Commission Findings” section of the report also includes the Medicare Condition and Standard numbers, tags, and text for the Centers for Medicare & Medicaid Services (CMS) requirements that crosswalk to The Joint Commission elements of performance that are also identified as being less than fully compliant. This section also includes TJC’s level of criticality scoring for all EPs identified as partially compliant or insufficiently compliant, e.g., Situational Decision Rules (2); Direct Impact Requirements (3); and Indirect Impact Requirements (4).

 

One final change is that TJC now has a new designation for EPs that initially were identified as less-thankfully compliant but were corrected before the conclusion of the survey, “Observed but Corrected On Site” (OCO).

See the October 2009 The Joint Commission Perspectives® article “Changes in Content, Format, and Posting of the Accreditation Survey Findings Report” for the full story and Example Summary of CMS Findings Report and Example Joint Commission Findings Report.