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The Joint Commission: Deeming Authority and the Integrated Survey Process for Psychiatric Hospitals and the Special Conditions February 6, 2012. Steve Misenko Project Manager External Reporting Accreditation and Certification Operations. Mark E. Schario MS, RN, FACHE Field Director

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Steve misenko project manager external reporting accreditation and certification operations

The Joint Commission: Deeming Authority and the Integrated Survey Process for Psychiatric Hospitals and the Special ConditionsFebruary 6, 2012

Steve Misenko

Project Manager

External Reporting

Accreditation and Certification Operations

Mark E. Schario MS, RN, FACHE

Field Director

Surveyor Management and Development

Accreditation and Certification Operations

Presentation objectives
Presentation Objectives

  • Brief review of the federal deeming process for hospitals and the special conditions

  • Overview of framework for Joint Commission approach to deeming for the special conditions

  • New standards, crosswalk and documents for special conditions

  • Survey process specific to the special conditions of participation

The basics
The Basics

  • Application submitted in July 2010

  • Application process is 210 days

    • Review of standards, survey process, procedures, survey team composition, etc

  • Approval was published in the Federal Register on Friday, February 25, 2011

  • Term of approval is four years

Deeming authority
Deeming Authority

  • Accreditation is voluntary; free State Survey Agency (or Contractor) option

  • Federal requirements are in law and regulation

  • Defined application/renewal processes

  • Established oversight processes

Cms deeming authority oversight
CMS’ Deeming Authority Oversight

  • Validation surveys

  • Generally performed by State Survey Agencies (SSA) on behalf of CMS

  • Task is to validate accreditation organization’s performance in assessing compliance with the CoPs/CfCs

  • Types of validation surveys include:

    • Mid-cycle

    • Complaint (allegation)

    • Look-behind (traditional)

  • Validation surveys
    Validation Surveys

    • Prior to MIPPA only hospitals and labs included in the Annual Report to Congress

    • Since 2009: hospitals, CAHs, hospice, ASCs, home Care, labs,

    • Starting in 2012 psychiatric hospitals

    • Hospitals: largest number of validation surveys FY 1999 (235), lowest number FY 2004 (44), last year 150

    Complaint surveys
    Complaint Surveys

    • Complaint/Allegation Survey

      • Response to an allegation of a significant deficiency

        • Narrow focus on the area(s) of complaint

        • For deemed organizations must be approved by CMS RO

        • About 5,000 complaint surveys conducted in TJC hospitals every year

          • Small percent (4 to 6) are substantiated with a condition-level finding

    Look behind validation surveys
    Look-Behind Validation Surveys

    • CMS’ CO selects “representative” sample

    • Conducted 60 days after an AO survey

      • Performed to determine a match between the AO’s findings and the SA’s Condition-level findings

  • Results provided to Congress

  • Data reporting requirements
    Data Reporting Requirements

    • Facility specific demographic and deficiency information

    • Survey schedules

    • Notification letters (sent to both CMS CO and appropriate RO) after a survey

    • Adverse decisions reported within 48 hours of the Committee’s decision

    • Survey reports upon request

    Deemed data to date
    Deemed Data to Date

    • 420 Medicare certified psychiatric hospitals accredited

    • 133 facilities have requested the psychiatric hospital deemed status option

    • 2012 due = 137

    • 2013 due = 164

    • 2014 due = 119

    Psychiatric hospitals
    Psychiatric Hospitals

    • What makes you different:

      • -primary purpose is for diagnosis and treatment of the mentally ill under the supervision of a physician

      • -must meet all the conditions of participation for Medicare hospitals

      • - Must meet two special conditions for psychiatric hospitals

    Joint commission process
    Joint Commission Process

    Psychiatric Hospital approach:

    • Will use our existing hospital survey process

    • Will add standards and crosswalk specific to the special conditions

    • Will add survey process specific to the special conditions


    • Existing hospital standards requirements were crosswalked to the psychiatric hospital CoPs (482.60, 482.61, and 482.62)

    • As a result of this crosswalk, it was determined that 57 existing hospital EPs could be applied to these psychiatric hospital CoPs

    Background for specific issues
    Background for specific issues:

    • Additional EPs were needed in order to better address the details in some of the CoPs

    • 7 new EPs and a “note” have been added to the existing hospital standards.

    New Elements of Performance

    • PC.01.02.13 EP7 –Psychiatric evaluation completed within 60 hours

    • PC.04.01.03 EP3 –New “note” regarding social services staff responsibilities

    • RC.02.01.01 EP10 –who records progress notes and how often

    New elements of performance
    New Elements of Performance

    • MS.06.01.03 EP7 – Qualifications of director of inpatient psychiatric services

    • HR.01.02.05 EP16 – Qualifications of director of psychiatric nursing

    • LD.04.03.01 EP14 – Requirement to provide psychological, psychiatric nursing, social work, and therapeutic activity services

    New elements of performance1
    New Elements of Performance

    • HR.01.02.05 EP18 – Qualifications of director of social work services

    • LD.04.01.01 EP16 – Administrative requirement for special provisions for psychiatric hospitals at 482.60

    E dition

    Survey process
    Survey process

    Changes related to the special hospital Conditions of Participation:

    • Increase in survey time to address specificity

    • Survey activities impacted

    • New activities developed

    Impact on survey activities
    Impact on Survey Activities

    • Individual Tracer Activity

      • Evaluate degree and intensity of treatment provided

      • Patient tracer selection guideline/sampling

      • Psychiatric evaluation complete within 60 hours

      • Progress notes are recorded

      • Review compliance with B-tags (B-105 through B126 and B132)

    Survey activities
    Survey activities

    • Credentialing and Privileging Session

      • Qualifications, roles, and responsibilities of the clinical director

      • Qualifications of physicians who provide psychiatric services

      • Discuss physician coverage on evenings, nights, and weekends

      • Review data on CMS Form 729 from hospital

    New survey activities
    New survey activities

    • Staffing Review Session

      • New 60 minute activity

      • Staffing based on qualifications and mix of staff

      • Confirm a registered nurse is available 24 hours a day

      • Review data on CMS Form 727 and 728 from hospital

    New survey activities1
    New survey activities

    • Discharge Planning/Death Record Review

      • New 60-90 minute activity

      • Review discharge records to evaluate compliance with discharge planning requirements

      • Death record review, when necessary, include review of conclusions and recommendations of the Mortality Review Board, determining if proper treatment was provided, and reviewing the autopsy report