Compliance News: Notifying TJC about Organization Changes

By Dean Samet, CHSP

If and when significant changes occur within a hospital, the hospital staff must notify The Joint Commission in writing or through its Joint Commission Connect site not more than 30 calendar days after such a change is made. The staff must also notify TJC in writing or in its electronic application (e-APP) if it opens or closes any units or services.

There are three change categories addressed in the 2011 Hospital Accreditation Standards manual’s The Accreditation Process (ACC) chapter:

• Changes affecting e-APP Information

• Changes to the Site of Care, Treatment, or Services

• Mergers, Consolidations, and Acquisitions

 

45 Day Deficiencies Time Line

What is the time frame that the Joint Commission permits before a deficiency to a life safety feature must be entered in the SOC? In other words, does The Joint Commission allow an organization to manage the resolution to a life safety deficiency through a work order system if it can be resolved quickly?

SOC Schedule

How often should a hospital have an SOC completed?