In a recent email, The Centers for Medicare and Medicaid (CMS) released an important memo that outlines updates and guidelines for all Accrediting Organizations (AO). The memo, effective from July 14, 2023, includes several important points that will impact TJC’s operations. Here are 4 key takeaways from the memo and their potential implications.
1) Elimination of Extranet Posting
According to the CMS memo, TJC is expected to stop posting on the extranet at 7:30 am on the morning the survey team arrives for a survey. In fact, this change indicates a shift towards limiting the availability of information regarding the survey scheduling. It aims to reduce the possibility of prior awareness.
2) Communication about Survey Imminence
Another significant change outlined in the memo is the cessation of any communication within six months of the survey due date that may indicate an impending survey. This measure intends to eliminate any potential advance knowledge of an upcoming survey and level the playing field for all healthcare organizations.
3) Blackout Date Restrictions
The CMS memo states that all Accrediting Organizations should discontinue the practice of allowing deemed hospitals to identify black-out dates. Black-out dates typically refer to specific days during which organizations prefer not to undergo surveys due to various reasons such as vacation plans or major events. With the removal of this allowance, healthcare organizations may need to adapt their readiness plans.
4) Offsite Complaint Investigations
The memo highlights changes in offsite complaint investigations. It advised TJC to limit contact with the facility during the investigation process, except for gathering additional input from the complainant. If an Accreditation Organization (AO) classifies a complaint at a non-Immediate Jeopardy (non-IJ) medium or low level, the AO should investigate during the next scheduled onsite survey or earlier, if deemed necessary. This update aims to streamline the complaint investigation process while ensuring timely and appropriate responses to reported concerns.
Although awaiting confirmation and response from the Joint Commission, the CMS memo presents several significant changes that will impact TJC’s operations and how healthcare organizations manage surveys and the accreditation process. Stay tuned to the Patton Blog and Patton Post Newsletter to stay informed and prepared for the potential changes to the survey and accreditation process.
Patton Healthcare Consulting
Patton Healthcare Consulting provides a complete range of Joint Commission and CMS Compliance Assistance services.
We work with more than 350 hospitals, behavioral health care organizations, ambulatory clinics and home care companies nationwide—hospitals ranging from critical access hospitals to the largest health systems. Contact us at (888) PHC-INC1 for more information.