Tips from TSE: New accreditation decision: How will this affect 2010 surveys?
Staff Development Weekly: Insight on Evidence-Based Practice in Education, November 20, 2009
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The Joint Commission has announced the adoption of a new accreditation decision for 2010, “Medicare Condition-Level Deficiency Follow-Up Survey,” which will be used when surveyors evaluate a facility with one or more condition-level deficiencies out of compliance.
These condition-level deficiencies refer to CMS’ Conditions of Participation (CoP). If a hospital receives this decision, it must address the deficient CoP, after which an on-site follow-up survey will be conducted.
This survey should not be confused with conditional accreditation decisions. According to Joe Cappiello, chair of Cappiello & Associates in Elmhurst, IL, this new accreditation decision is the result of continuing dialogue between The Joint Commission (formerly JCAHO) and CMS concerning The Joint Commission’s pending deeming application decision.
In addition to the news that an accreditation decision is coming, there will be new language in the conditional accreditation rules that indicate additional causes for this accreditation decision. Conditional accreditation occurs when an organization fails to resolve issues stemming from a provisional accreditation status or when the organization is in substantial noncompliance of mandated Joint Commission standards.
Editor’s note: This excerpt was adapted from the November issue of The Staff Educator. Discover all the benefits of subscribing to The Staff Educator!
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