New Accreditation Decision for Joint Commission in 2010

A new accreditation decision will be added for hospitals in 2010, The Joint Commission reports. This new decision, "Medicare Condition-Level Deficiency Follow-Up Survey," will result when a facility is assessed with a condition-level deficiency in one or more Medicare Conditions of Participation (CoP).

According to the official Joint Commission announcement, this additional accreditation decision is the result of ongoing discussions between the accrediting body and CMS regarding The Joint Commission's deeming authority application.

When a hospital receives a "Medicare Condition-Level Deficiency Follow-Up Survey" decision, the organization must then address the deficient CoPs. An on-site follow-up survey will also be required. (Note: "Medicare Condition-Level Deficiency Follow-Up Surveys" are not to be confused with conditional accreditation.)

A number of factors regarding this new accreditation decision have not been officially announced, including:

• What follow-up documentation will be required of organizations receiving this decision?


• What is the timeframe for the follow-up survey when a facility receives this decision?


• Is a corrective plan of action required by The Joint Commission similar to what is required by CMS for deficient CoPs found during a CMS survey?


• In the event the hospital triggers a follow-up survey from The Joint Commission based on both Joint Commission standards and CMS CoPs, will this result in two follow-up surveys, or will the two be coordinated?

Changes were also made to the conditional accreditation decision. New language has been added to this decision addressing failure to submit data and information to The Joint Commission on a timely basis, as well as issues concerning patterns, trends, or repeat findings from previous surveys, and situations of fraud and abuse in the facility or health system.

These changes were made to align scoring decisions with changes that came about as part of the Standards Improvement Initiative.