CMS’ notice on Joint Commission surveys could be eye-opener for MSPs

In the Federal Register last summer, the Centers for Medicare & Medicaid Services (CMS) made a significant move that impacts Joint Commission surveys.

On July 17, 2020, in Volume 85, Number 138 under the section “Medicare and Medicaid Programs; Application From the Joint Commission for Continued Approval of its Hospital Accreditation Program,” CMS indicated that The Joint Commission (TJC) has taken steps to “[clarify and provide] additional training to surveyors related to survey processes and procedures for review of credentialing and human resources and or personnel file reviews.”

And under Section B, “Term of Approval,” CMS approved The Joint Commission (TJC) as a national accreditation organization for hospitals that request participation in the Medicare program, but only for two years: through July 15, 2022. Approval is traditionally a longer term than two years.

“This shorter term of approval is based on our concerns related to the comparability of TJC's survey processes to those of CMS, as well as what CMS has observed of TJC's performance on the survey observation,” CMS officials wrote in the Federal Register. “Some of these concerns stem from the level of detail TJC provides in the daily briefings it provides to facilities, as well as TJC's processes surrounding its staff interview practices. Additionally, we are concerned about TJC's review of medical records and surveying off-site locations, in particular for the Physical Environment condition of participation.”

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