Anticipate a for-cause, unannounced survey
The Joint Commission stands firm on ethics
What happens to accreditation status if your facility is suspected of upcoding or other unethical behavior? A surprise survey at the very least. The Joint Commission on Accreditation of Healthcare Organizations in Oakbrook Terrace, IL, has just come forward to say government fraud investigations may provoke a for-cause, unannounced survey. A broad interpretation of three provisions of the standards is being used to give them this power.
"There should be no negative impact on JCAHO accreditation," says Ernest L. Tsoules Jr., JD, a Wayne, PA, attorney, "merely because an institution has been investigated for fraud and abuse or if the institution has settled a false-claims investigation prior to litigation." That’s so, but even an allegation of fraud is grounds for an investigation, says Janet McIntyre, a Joint Com mis sion spokeswoman. The agency has issued a statement on the agency’s stance on financial fraud allegations in accredited organizations:
"If there are allegations of financial fraud that suggest that the quality of care may be affected, the Joint Commission will take quick action to investigate. Depending on the seriousness of the issue, the Joint Commission can perform a for-cause, unannounced survey.
"Furthermore, Joint Commission standards require accredited organizations to have and operate according to a code of ethical behavior, which addresses its business practices such as marketing and the relationship of its staff members to other health care providers. If an organization is convicted of financial fraud, the Joint Commission will conduct a special on-site evaluation to review the organization’s code of ethical behavior, its implementation, and related issues.
"Information provided at any time by accredited organizations and used by the Joint Com mis sion for accreditation purposes must be accurate and truthful. The Joint Commission may deny or remove accreditation from any organization failing to participate in good faith by falsifying information."
Paula Swain, RN, MSN, CPHQ, a health care consultant in St. Petersburg, FL, and a member of HPR’s editorial advisory board, comments: "Using the for cause’ justification to survey an organization is problematic. An allegation of financial fraud is just that an allegation. Coupling that with patient complaints or qui tam-type information [from whistleblowers to Office of the Inspector General] would give more focus to an unannounced survey." (See "A prudent CP" on p. 144.)
Three Joint Commission standards could be interpreted as referring to fraudulent behavior affecting patient care:
• Intake and access opportunities (CC.1) deals with decisions being made on behalf of the patient regarding types of care, locations of care, or care in itself.
• Patient complaint and advocacy systems (RI.1.3) discusses methods for complaint resolution. Essentials are thoroughness, follow-through, and reduction of complaint issues by demonstrated practices.
• Hospital plan for patient care delivery describes how the hospital delivers care, including every facet from the philosophy to how money is maintained to provide that philosophy. Every service has written "the patient comes first" in their scope of service including staffing issues for nights and weekend coverage. The document will probably begin to include the federal requirement for a CP, and its inclusion adds one thing not present now teeth. That incentive would outstrip a nonaccrediation verdict.
"Joint Commission surveyors will have to be specially trained to think critically in implementing these standards," says Swain. "They’ll be required to discover inconsistencies among philosophy, scope, and the plan of patient care delivery."
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