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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 MisenkoProject ManagerExternal ReportingAccreditation and Certification Operations
Mark E. Schario MS, RN, FACHEField DirectorSurveyor Management and DevelopmentAccreditation and Certification Operations
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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
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The Basics
Application submitted in July 2010Application 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
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Deeming Authority
Accreditation is voluntary; free State Survey Agency (or Contractor) option
Federal requirements are in law and regulation
Defined application/renewal processesEstablished oversight processes
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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)
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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 hospitalsHospitals: largest number of validation
surveys FY 1999 (235), lowest number FY 2004 (44), last year 150
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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
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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
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Data Reporting Requirements
Facility specific demographic and deficiency information
Survey schedulesNotification letters (sent to both CMS
CO and appropriate RO) after a surveyAdverse decisions reported within 48
hours of the Committee’s decisionSurvey reports upon request
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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
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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
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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
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Standards and Elements of Performance
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Background:
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
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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.
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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
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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 Performance
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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
New Elements of Performance
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E-dition
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Condition of Participation
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Crosswalk
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Survey Process
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Survey process
Increase in survey time to address specificity
Survey activities impacted
New activities developed
Changes related to the special hospital Conditions of Participation:
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Survey Forms…a familiar place
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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)
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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
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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
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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
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CMS Forms (Hospital access)
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Follow up information can be obtained from:
Mark Schario, [email protected]
Steve Misenko, [email protected]
Trisha Kurtz, [email protected]