The Joint Commission has made additions to their 2010 Conditional Accreditation decision rules. Unchanged is where Conditional Accreditation will still result when a health care organization fails to resolve the requirements of a Provisional Accreditation status, or was in substantial noncompliance with applicable TJC standards. As always, the organization must remedy the identified problem area(s) through an Evidence of Standards Compliance (ESC) submission and subsequently undergo an on-site follow-up survey.
New for 2010, “Conditional Accreditation may result when an organization fails to meet requirements for the timely submission of data and information to The Joint Commission; or survey findings demonstrate systematic patterns, trends or repeat findings from previous surveys; or there is credible evidence indicating that possible fraud or abuse has occurred at a health care organization.” (Refer to The Joint Commission Online August 5, 2009.) The new language related to survey findings has been made to bring the decision in line with TJC’s Standards Improvement Initiative (SII). The new wording related to possible fraud or abuse has been created to meet Centers for Medicare and Medicaid Services (CMS) requirements.
Also new for 2010 and related to TJC’s application to CMS for continued hospital-deeming authority, TJC has adopted a new type of follow-up survey called “Medicare Condition-Level Deficiency Follow-Up Survey.” This new survey will be required after an organization has one or more Medicare Conditions of Participation (CoPs) assessed by CMS as a “Condition-Level Deficiency.” This new regulation requires that an organization remedy the identified CoPs and then undergo an on-site follow-up survey by TJC. This follow-up survey is in addition to the above mentioned TJC Conditional Accreditation decision rules.
No comments:
Post a Comment