The Joint Commission:
Deeming Authority and the Integrated Survey
Process for Psychiatric Hospitals and the Special
Conditions
February 6, 2012
Mark E. Schario MS, RN, FACHE
Field Director
Surveyor Management and Development
Accreditation and Certification Operations
© Copyright, The Joint Commission
Steve Misenko
Project Manager
External Reporting
Accreditation and Certification Operations
Presentation Objectives
 Brief review of the federal
deeming process for
hospitals and the special
conditions
 New standards, crosswalk
and documents for special
conditions
 Survey process specific to
the special conditions of
participation
2
© Copyright, The Joint Commission
 Overview of framework for
Joint Commission approach
to deeming for the special
conditions
The Basics
Application submitted in July 2010
Application process is 210 days
Approval was published in the Federal
Register on Friday, February 25, 2011
Term of approval is four years
3
© Copyright, The Joint Commission
– Review of standards, survey process,
procedures, survey team composition, etc
Accreditation is voluntary; free State
Survey Agency (or Contractor) option
Federal requirements are in law and
regulation
Defined application/renewal processes
Established oversight processes
4
© Copyright, The Joint Commission
Deeming Authority
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
–Mid-cycle
–Complaint (allegation)
–Look-behind (traditional)
5
© Copyright, The Joint Commission
Types of validation surveys include:
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
6
© Copyright, The Joint Commission
Validation Surveys
Complaint Surveys
– 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
7
© Copyright, The Joint Commission
Complaint/Allegation Survey
Look-Behind Validation Surveys
8
© Copyright, The Joint Commission
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 Conditionlevel findings
Results provided to Congress
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
9
© Copyright, The Joint Commission
Data Reporting Requirements
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
10
© Copyright, The Joint Commission
Deemed Data to Date
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
11
© Copyright, The Joint Commission
- Must meet two special conditions for
psychiatric hospitals
Joint Commission Process
Psychiatric Hospital approach:
 Will use our existing hospital
survey process
 Will add survey process specific to
the special conditions
12
© Copyright, The Joint Commission
 Will add standards and crosswalk
specific to the special conditions
13
© Copyright, The Joint Commission
Standards
and Elements
of
Performance
Background:
 Existing hospital standards requirements were
crosswalked to the psychiatric hospital CoPs
(482.60, 482.61, and 482.62)
14
© Copyright, The Joint Commission
 As a result of this crosswalk, it was determined that
57 existing hospital EPs could be applied to these
psychiatric hospital CoPs

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.
15
© Copyright, The Joint Commission
Background for specific issues:
New Elements of Performance
 PC.01.02.13 EP7 –Psychiatric evaluation
completed within 60 hours
 RC.02.01.01 EP10 –who records progress
notes and how often
16
© Copyright, The Joint Commission
 PC.04.01.03 EP3 –New “note” regarding
social services staff responsibilities
New Elements of Performance
 MS.06.01.03 EP7 – Qualifications of director of
inpatient psychiatric services
 LD.04.03.01 EP14 – Requirement to provide
psychological, psychiatric nursing, social work,
and therapeutic activity services
17
© Copyright, The Joint Commission
 HR.01.02.05 EP16 – Qualifications of director of
psychiatric nursing
New Elements of Performance
HR.01.02.05 EP18 – Qualifications of
director of social work services
18
© Copyright, The Joint Commission
LD.04.01.01 EP16 – Administrative
requirement for special provisions for
psychiatric hospitals at 482.60
19
© Copyright, The Joint Commission
E-dition
20
© Copyright, The Joint Commission
Condition of Participation
21
© Copyright, The Joint Commission
Crosswalk
22
© Copyright, The Joint Commission
Survey Process
Survey process
Changes related to the special hospital
Conditions of Participation:
 Increase in survey time to
address specificity
 New activities developed
23
© Copyright, The Joint Commission
 Survey activities impacted
24
© Copyright, The Joint Commission
Survey Forms…a familiar place
 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)
25
© Copyright, The Joint Commission
Impact on Survey Activities
Survey activities
– 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
26
© Copyright, The Joint Commission
 Credentialing and Privileging
Session
New survey activities
– 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
27
© Copyright, The Joint Commission
 Staffing Review Session
 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
28
© Copyright, The Joint Commission
New survey activities
29
© Copyright, The Joint Commission
CMS Forms (Hospital access)
Follow up information can be obtained from:
Mark Schario, mschario@jointcommission.org
Trisha Kurtz, pkurtz@jointcommission.org
30
© Copyright, The Joint Commission
Steve Misenko, smisenko@jointcommission.org