Accreditation Basics
Basic Eligibility
The Application Process
Standards/Accreditation Requirements
On-Site Survey
Contracted Services
After You’re Accredited
Quality Check Directory of Providers
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Accreditation Basics
What are the requirements to become accredited?
Our requirements for accreditation fall into 3 primary categories:
- Accreditation Participation Requirements (APRs)
- The Standards
- National Patient Safety Goals
All of these requirements can be found in the Comprehensive Standards Manual for Home Care that you will receive free-of-charge upon receipt of your deposit. You will receive both a hard copy print version and new e-dition of the manual approximately 3 weeks after your deposit is processed.
You can also access our requirements on our website at should you wish to view them prior to making an application request. Click here.
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What are your accreditation fees?
Joint Commission fees consist of a minimum $1000 annual fee and a minimum on-site fee of $2,050 (payable once every three years). If you have more than one location (than is not simply a warehouse location), additional branch fees would also apply.
Our annual and on-site fees are based upon an average daily census (ADC) ranges for each eligible home care service your organization provides. An ADC represents those that have been admitted to your organization, but not discharged, for which you have ongoing care or service responsibilities. If your organization has had a relatively stable population, then a sample from a few representative days should be sufficient in determining ADC.
Current pricing sheets are listed on our website. Additionally, we encourage organizations to contact our pricing unit for a free quote at 630.792.5115.
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Can we have only part of our organization accredited?
Joint Commission accreditation is for your entire organization, not individual services.
We will survey all services for which we have applicable standards and make one accreditation decision for your organization. If, for example, you provide both home health and home medical equipment services, we must include both of these services in your survey.
At the request of an organization, we will evaluate whether a related organization may be excluded from the scope of an accreditation survey. If this is acceptable, your organization must make it clear to the public that the related organization is not included in the scope of its accreditation.
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My home health agency is considering the deemed status survey option. How does this process work?
If your home health agency is eligible for Medicare certification, you may choose to participate in a modified Joint Commission accreditation survey that can be used for both accreditation and for Medicare certification (called deemed status.)
If you choose this option, The Joint Commission will conduct an unannounced survey that will replace the Medicare survey usually conducted by your state agency. CMS additionally requires two consecutive interim surveys to be conducted with no condition-level deficiencies. Once we accredit you through this process, CMS will deem your organization to be in compliance with federal standards, the Conditions of Participation for home health agencies. CMS retains the authority to conduct random validation surveys and complaint investigations for Medicare-certified organizations.
The deemed status option applies only to organizations that meet the Medicare definition of a home health agency and are eligible for certification as determined by federal regulations. To participate, CMS requires organizations seeking home health deemed status provide skilled nursing services and at least one other therapeutic service to a minimum of 10 patients in the last 12 months with 7 receiving care at the time of survey.
Organizations selecting this option should have completed and verified their CMS 885a form prior to completing a Joint Commission application.
Separate accreditation fees apply for this special survey option. Please contact our pricing unit to discuss fees at 630.792.5115. Please contact your Account Representative at 630.792.3007 if you are a currently accredited organization interested in pursuing this survey option.
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My hospice organization is considering the deemed status survey option. How does this process work?
Hospice deemed status surveys, like home health deemed status surveys, must be unannounced. The deemed status option is open to organizations seeking Medicare funding for hospice services as well as those already Medicare certified. Organizations choosing that option will be evaluated against both Joint Commission standards and Hospice Medicare Conditions of Participation. Accreditation remains voluntary and seeking deemed status through accreditation is not a requirement for Medicare certification.
The deemed status option applies only to organizations that meet the Medicare definition of a hospice agency and are eligible for certification as determined by federal regulations. To participate, CMS requires organizations seeking hospice deemed status have served minimum of 5 patients in the last 12 months with 3 active patients at the time of survey.
Organizations selecting this option should have completed and verified their CMS 885b form prior to completing a Joint Commission application.
Separate accreditation fees apply for this special survey option. Please contact our pricing unit to discuss fees at 630.792.5115. Please contact your Account Representative at 630.792.3007 if you are a currently accredited organization interested in pursuing this survey option.
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Basic Eligibility
What types of services are eligible for home care accreditation?
For a brief overview of the types of services we accredited within the home care program Click here.
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How many patients do I need to have to be accredited?
For a particular service to be accredited it must be considered “active.” Active is defined as having provided one or more services to 10 or more patients in the last 12 months.
Second, a minimum of 2 active patients are required at the time of your on-site survey.
There are instances where we required a larger number of active patients. For example:
- For home health deemed status surveys, 7 active patients are required.
- For hospice deemed status service, 3 active patients are required.
If you do not have an eligible patient on service at the time of survey or do not meet the criteria for an active service, you may apply for provisional accreditation. However you must be providing services to an eligible patient at the time of your next survey (six months later).
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I am a start up and/or don’t have any patients yet. What are my options for accreditation?
The early survey option is just for you. You are not required to have any active patients to be surveyed under this option. However, it is only available to organizations accredited for the first time.
If you are to undergo a resurvey, and have not had 10 patients in the past year, you are not eligible to be reaccredited. If you met this requirement, but do not have an active patient at the time of survey, we will reschedule the survey at a point in which you have an active patient.
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If we have sites and patients in another country (i.e., Mexico, Canada, Puerto Rico), can we still be accredited?
We cannot survey sites located in other countries that are not part of the United States and its territories, unless it is owned by the United States Government. Hence, we could not survey sites located in Canada and Mexico (unless they were a US military base), but can survey sites in Puerto Rico, Guam, etc. We can survey patients located in other countries, if they are serviced from a site in the United States.
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The Application Process
How do I apply for accreditation?
To request access to our online application please email your complete information (name, title, organization name, address, phone, fax and email) to jjuric@jointcommission.org.
Within 3-5 business days, you will receive an email containing a special password to complete the application online at the Joint Commission website via Joint Commission Connect.
In that email will also be the name of your assigned Account Representative who can assist you if you have questions while completing the application.
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How soon after I apply can/will I be surveyed?
Your organization can normally be surveyed within three to four months after we receive your application. However, the key issue is whether you are ready to be surveyed. If your organization is just beginning to prepare for survey at the time of application, it should request to be surveyed at least four to six months later. Your application for survey is valid for 12 months from the date it is submitted.
On the application, under “Initial Surveys” section, you can note a month by which you will be ready to have your on site survey conducted. This means, the Joint Commission will not send a surveyor to your organization prior to then; however they can arrive anytime thereafter.
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How will I know that my completed application was successfully received?
You will receive a confirmation email with 24 hours of submitting your completed online noting it was successfully received. If you do not receive one, please call your account representative directly or at 630-792.3007.
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When do I need to pay my application deposit?
A deposit of $1700 is required in order to fully process your completed application. Please call 630.792.5665 to make a deposit payment by credit card. We suggest a deposit be made after you receive your email confirmation that your application was successfully received. Please be sure to have your HCO ID number handy when you call.
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Standards/Accreditation Requirements
How soon after I submit my application and deposit can I expect to receive my free standards manual?
You will receive your free hard copy and e-dition of the most recent Comprehensive Standards Manual for Home Care approximately 3 weeks after receipt of your deposit.
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Who can I call if I have a question about a standard?
Click here to access our Standards FAQs. If you don't find your answer there, you can complete our Online Standards Form or call 630-792-5900.
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How do I know if the services my respiratory therapists provide require that I comply with the additional Clinical Respiratory Standards?
It is the services provided, not the category of personnel that determines if clinical respiratory services are provided by an organization. For example, a respiratory therapist or nurse can deliver, set-up equipment and educate the patient on the use of the equipment without providing clinical respiratory services.
Click here for a helpful decision tree and detailed examples you can use to determine if the services your therapists provide fall into our definition of clinical respiratory services.
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Who determines if my organization must “monitor” a patient?
Generally, the determination of whether monitoring should be included within the scope of services provided by an organization is the responsibility of the leadership of the organization.
We would expect the organization to identify on their application if they provide clinical monitoring service (i.e., clinical/consultant pharmacy services). However, the Joint Commission will also consider the organization as providing these services under the following circumstances:
- When clinical monitoring is required by contract or written agreement.
- When clinical monitoring is being advertised as being provided by the applicant organization.
- When clinical monitoring or other clinical pharmacist functions were provided to 10 or more patients in the past 12 months.
- When Home Health Services or Clinical Respiratory Services are also provided to the patient (since our standards require these services to monitor the patient's drug therapy, and require that drug therapy monitoring be interdisciplinary and collaborative).
- When no other health care professional is monitoring the patient's drug therapy and patient is at high risk of a sentinel event as a result (i.e., receiving high dose gentamicin therapy).
Clinical monitoring is not required:
- • When physician or contract so indicates.
• When monitoring would be duplicative. Such as when monitoring performed by another pharmacist or the physician during outpatient visits.
• When the drug and patient situation is considered low-risk and requires no monitoring
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On-site Survey
How will I know when my on-site survey will be conducted?
Applicant organizations are advised to check their secure extranet site at 7:30 am each morning on and after the noted “ready date” on their application to determine if a surveyor will be arriving that day.
The day the surveyor arrives, he/she will arrive at the start of the normal business hours noted on the application; their name, photograph and survey agenda will be posted on the secure extranet at 7:30 am.
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How long does the on-site survey last?
The length of your survey will depend on the number of home care services you provided, your patient volume (average daily census) for each service, the number of your sites and their distance from the main site.
On average, most home care surveys are 2 days in length. Deemed status surveys for home health and/or hospice organizations are typically 3 days in length.
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How do we know which affiliated companies or joint ventures will be included in our survey?
Home care services provided through an affiliated company or a joint venture may be included in the scope of your survey if there is an organizational and functional relationship between the companies or public representation of the affiliated home care services you provide. This rule may also apply to hospitals affiliated with home care organizations as well as two home care or hospice organizations that are affiliates of each other.
Each organization's situation is considered individually. We encourage organizations offering home care or hospice services through a joint venture or an affiliated company to contact Home Care Accreditation Services to determine if these services should be surveyed. You may also refer to the "Official Accreditation Policies and Procedures" chapter of the Comprehensive Accreditation Manual for Home Care, under "Scope of Accreditation Surveys" for a detailed description of organizational and functional relatedness.
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What is a corporate system survey?
A home care corporate system is a multi-office national or regional organization with six or more eligible applicant or accredited locations sharing common governance and leadership. If your organization meets these criteria and intends to submit at least six applications for survey, you must participate in the Joint Commission's corporate survey process.
The survey scope for your organization may include multiple sites but may not exceed one span of administrative control (your organization's structure and the manner in which responsibility and authority are delegated to your locations and staff). You may group locations which share a common administrative, management, or supervisory component, but you are limited to one level of your administrative hierarchy.
This multi-office organization survey (corporate survey) begins with a one day survey at your corporate office. The survey is conducted by a survey team assigned specifically to your organization, led by a Joint Commission central office representative. The same team will survey all your applicant organizations. The corporate survey will focus on applicable leadership, governance and management standards, corporate policies and procedures, and organization-wide performance improvement activities.
The home care program works with your organization to plan the sequence of surveys for your offices or regions. For further information about survey fees and the corporate survey process, contact the Joint Commission.
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What if patients are serviced by a department of a hospital? Is this part of the hospital survey or the home care survey?
It does not matter whether home care services (as defined by the Joint Commission) are provided by a particular department of a hospital. Survey eligibility is based on all patients within the organization. Thus, if both the home health and respiratory care departments of a hospital separately provide eligible home care services, then both groups of patients are included in the survey process for home care.
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When will we get our report?
Upon conclusion of your survey, you will receive a summary of findings. If your organiztion received any Requirements for Improvement (RFIs), you will need to submit Evidence of Standards Compliance within 45 days. After that time, a final report will be issued. Your organization is retroactively accredited to the day after survey, but you may not market your accreditation until you receive the final written report.
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Contracted Services
How do we know which service agreements and contracted services will be included in our survey?
For the purposes of home care accreditation, applicable services provided by organizations or individuals through written agreements or contracts are surveyed for compliance with Joint Commission standards. On the application for survey, make sure you list all contractual arrangements for services provided on your behalf.
For example, if you contract for home medical equipment (HME) services, your organization's survey will also include the contracted HME company or individual. Any recommendations resulting from the contracted organization's service delivery on your behalf become part of your organization's accreditation report and influence your organization's accreditation decision.
If you provide services on behalf of another organization, these patients will also be included in the scope of your organization's survey, but you do not need to identify these contracts on your application.
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What if these services are provided for us, but we don't have a contract or written agreement?
These services are still included in the scope of the survey and our standards require a written agreement for such services.
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What if our organization has a contract with an accredited organization?
If the provider of your contracted service is already accredited or has applied for accreditation at least 120 days in advance of your survey date, we will waive the on-site survey of your contracted service. If the contracted organization is awaiting survey, this organization must be accredited within six months of your survey. If the organization is currently accredited by the Joint Commission, we will not visit the contracted organization's offices, unless there are extenuating circumstances.
However, even though we may waive the on-site survey, we will evaluate how well you manage your contracted services and the coordination of care and service between your organizations. For example, we may conduct a home visit for a patient who receives services from the contracted organization. These elements of the survey process are based on the relationship between your organization and the contracted organization.
The Joint Commission retains the right to visit the contracted provider's sites if an event during the survey indicates that this is advisable. For example, if during a home visit to a patient receiving HME services from a contracted provider, the patient complains that equipment was not operational when it was delivered, the surveyor may choose to visit the contracted organization's warehouse to review how the HME service maintains patient-ready equipment.
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Do contracted services have to be accredited?
No. Although all eligible contracted services provided on behalf of the applicant organization are included in the scope of the survey process, only unaccredited contracted services will be visited on site. Because recommendations made during site visits to contracted providers appear on the applicant organization's final report, many organizations prefer to deal exclusively with accredited providers, but this is not a Joint Commission requirement.
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After You’re Accredited
How will you notify us when our next three-year survey is due?
The Joint Commission requires accredited organizations to reapply for accreditation every three years. The Joint Commission pre-populates the resurvey application with your organization’s previously submitted data.
You can expect to receive an email indicating your pre-populated resurvey application is ready for you to review and submit via your secure extranet site 9 months before your next anticipated survey date.
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What happens to my accreditation when I sell my organization or am acquired by another organization or move? If I add a new service, is it automatically accredited until the time of my next survey?
We do not automatically transfer accreditation to new owners who acquire an accredited health care organization. Accreditation will not continue if significant changes occur from those existing at the time of the previous survey.
An accredited organization must notify us no more than 30 days after it merges, is acquired, or undergoes any major change in services, location, capacity, or corporate structure. We will extend accreditation until we can determine if a special survey is necessary. Failure to notify us of ownership and service changes can result in a loss of accreditation.
Click here to access the online Organizational Update Form.
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Does The Joint Commission have any tools I can use to publicize my accreditation achievement?
Yes! Click here to view the contents of our online publicity kit.
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Quality Check Directory of Providers
How do I find out how other health care facilities rate with the Joint Commission?
With our online Quality Check™ , you can "check up" on the performance of health care facilities, by reviewing their latest Quality Report.
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How do I register a complaint about a health care organization?
You can complete our online Quality Incident Report Form. For more information, please call 800-994-6610.
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