TJC's Medicare condition-level follow-up survey
The Joint Commission has acknowledged confusion in the field between its Medicare condition-level follow-up survey and conditional accreditation status and is considering changing the names to make the distinction clearer.
"They really are completely unrelated. I mean, you can be conditionally accredited with no CMS conditional deficiencies. You can have conditional deficiencies and be fully accredited. They're totally unrelated. Both of them do require a follow-up visit, but we're actually looking at the possibility of changing the terminology for conditional accreditation because we do realize it's confusing," saysJohn Herringer, associate director, standards interpretation group.
Pat Adamski, RN, MS, MBA, director, standards interpretation group and the Office of Quality Monitoring, explains the survey this way: "We would do this check of a follow-up survey if an organization was found to have any condition-level deficiencies during their survey. So if during the course of the survey, an organization was found to be not-complaint with a Condition of Participation or more Conditions of Participation and it rose to the condition-level deficiency, meaning it was of a serious nature, it was pervasive across the organization, or perhaps it was a deficiency that was directly related to the Condition of Participation as put forth by Medicare, they would require a follow-up survey in order to demonstrate that they were back in compliance with the condition to satisfy that requirement of Medicare.
"It could be more than one condition out of compliance. In Medicare regulations, if there were deficiencies identified, they would either be at the standard level or the condition level. And a standard level is considered less serious than a condition-level deficiency. So anything that rose to the condition level would tell CMS that the organization was out of compliance with the Condition of Participations required in order for an organization to be eligible for Medicare reimbursement. So if they are out of compliance at the condition level, then that is a very serious situation from a Medicare perspective. And if the organization is not able to demonstrate that they are back in compliance with that condition within a defined time frame, they could lose their ability to bill Medicare for services rendered to patients. So it's a pretty significant issue," she says.
An organization would be notified that they will have a follow-up survey in The Joint Commission survey report. Adamski explains the difference between conditional accreditation status and a Medicare conditional-level follow-up survey: "Conditional accreditation is a level of accreditation that The Joint Commission may give to an organization which has some issues that we want to make sure we can do further follow up with them, keep a little closer tabs on them. That is quite different and quite separate from an organization receiving condition-level deficiencies for Medicare reimbursement."
But whether it's an accreditation status question or a condition-level deficiency problem, The Joint Commission requires a hospital to correct the issue for its validation survey, not just have a corrective action plan. A conditional-level deficiency follow-up survey would take place about 90 days after the organization submits its evidence of standards compliance, says Kevin Hickey, MSA, director, survey scheduling and management support.
If an organization fails its Medicare condition-level deficiency follow-up survey, the Centers for Medicare & Medicaid Services "has the prerogative to do whatever they want," Hickey says. "They can defer to us and we may do a second survey or they can say the scope or the severity is so great that they want to then take over and they want to be involved. So with the majority, we expect we would do a second survey if they failed. They would have one more opportunity like they do with our process."
He also explains that if The Joint Commission does not find a condition-level deficiency in a survey, but CMS does as part of its validation survey, The Joint Commission would not conduct the follow-up survey. The state, on behalf of CMS, would do it.
The Joint Commission has acknowledged confusion in the field between its Medicare condition-level follow-up survey and conditional accreditation status and is considering changing the names to make the distinction clearer.You have reached your article limit for the month. Subscribe now to access this article plus other member-only content.
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