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.
Another question from the field: multiple follow-up surveys. For example, you've exceeded your bandwidth, you have gone to conditional accreditation, and you have a CoP out. This means you'll get a follow-up Conditional survey by The Joint Commission following your acceptable submission of ESC, and you'll have a follow up by The Joint Commission based on the CoPs.
"We don't know if those two are combined," says Cappiello. "Would they do them at the same time? Come back and take a look at direct impact standards and CoPs in the same visit? But what if the timelines are not compatible? I would hope that if the timelines match, The Joint Commission would combine the two into a single visit."
If, however, the timelines turn out to be incompatible, this could result in two visits—both of which the hospital pays for.
This may also have an effect on the size of the team sent for the follow-up survey. A follow-up survey is frequently one surveyor, one day. If there are a number of standards out, and a number of CoPs, this may result in a larger review team.
"I would think that The Joint Commission would review the timeline and the size/composition of the survey team on an individual basis," says Cappiello.