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Joint Commission's New Follow-up Survey: What Answers Still Remain?

Matt Phillion, for HealthLeaders Media, August 7, 2009

The Joint Commission recently announced a new type of follow-up survey, "Medicare Condition-Level Deficiency Follow-Up Survey," which will go into effect in 2010. This is intended when surveyors assess a facility with one or more condition-level deficiencies out of compliance.

These condition-level deficiencies refer specifically to the Centers for Medicare and Medicaid Services' Conditions of Participation (CoP). This new accreditation decision is based in part on The Joint Commission's application for hospital deeming authority through CMS.

"I'm sure this is the result of continuing dialog between The Joint Commission and CMS regarding the Joint Commission's pending deeming application decision," says Joe Cappiello, chairman of Cappiello & Associates, Elmhurst, IL. "What CMS probably said was, 'If you have a condition out, it has to be fixed right away, and you'll have to go back in there and validate that it was fixed.'"

What wasn't addressed in this initial announcement—likely forthcoming before year's end— is what scenarios will cause this type of follow up.

Something The Joint Commission has not yet specified which the field is curious about, says Cappiello, is the time frame. Historically, CMS requires correction and verification by on-site follow-up within 90 days.

"I would imagine that CMS will require The Joint Commission to follow that timeline," says Cappiello.

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