Updated 12/31/05
General FAQs
Standards FAQs
Survey Process FAQs
General FAQs
Organizations choosing the new LTC accreditation option can notify the Joint Commission by noting their choice on the Request for Application. For currently accredited organizations, the Request for Application is automatically sent to the organization approximately six months before the triennial survey is due. Organizations that are currently due for survey and/or have already submitted their Request for Application, may contact their account representative at (630) 792-3007 to amend their Request for Application.
If a complex organization has multiple SNF/NF provider numbers for their LTC facilities, how will the Joint Commission survey it under the new Medicare/Medicaid Certification-Based accreditation option?
Since the LTC accreditation award under the new LTC option is based substantially on the findings of the current SNF/NF provider certification survey, each provider site would be surveyed independently but all recommendations will roll up to the organization level report.
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In 2006, subscription billing went into effect for all Joint Commission accreditation programs. The Joint Commission evaluates its fees annually.
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The basis of the options for Long Term Care Accreditation is reliance on the annual Medicare/Medicaid (SNF/NF) state agency survey. Most Home Care market segments do not have an annual survey with some segments having no on-site evaluation ever conducted. Additionally, not all Home Health and Hospice organizations are Medicare-certified and for those that are not licensed by their state, no on-site survey is ever done. Medicare-certified Hospices are visited for a survey on a schedule determined by the state, some are visited annually, but the majority of Hospices are surveyed once every three to five years or more. Medicare-certified Home Health Agencies can be visited for an on-site survey by the state on a variable schedule from one to three years. However, as with Medicare-certified Hospices, depending on the state, regardless of the requirement, some Medicare-certified Home Health Agencies have not been surveyed for five years or more. Thus, without the annual CMS survey, there are no results upon which to substantially base Home Care accreditation awards.
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Yes Hospital based SNF/NF providers with an ADC <20 can request to be surveyed under the traditional LTC accreditation program, the Medicare/Medicaid Certification-Based accreditation option, opt out of accreditation survey or continue to be surveyed under the hospital standards. If the latter option is chosen, the award certificate will not exclude LTC services from the accreditation award and the LTC volume fee will be folded into the complex organization fee.
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No.
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See Accreditation Options for Long Term Care at a Glance. A matrix detailing each option is listed. Accredited organizations may also call their account representative for more information. If the organization does not know who the account representative is, a call to 630.792.3007 will put you in touch with the assigned person.
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Standards FAQs
A 30% subset of Joint Commission LTC accreditation standards has been identified for on-site review under the Medicare/Medicaid certification based LTC accreditation option. These standards go beyond the Conditions of Participation for Skilled Nursing Facilities/Nursing Facilities and address areas that are typically not evaluated during the state agency certification survey. This path to LTC accreditation focuses on systems and processes that support organization safety, performance improvement, resident and family education, credentialing and privileging of licensed independent practitioners, pain management and point of care testing. The standards for this LTC accreditation option are included in the 2005-2006 Comprehensive Accreditation Manual Long Term Care (CAMLTC).
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Since the standards for the new LTC accreditation option are a subset of the current LTC standards, currently accredited organizations seeking continuing accreditation under the new LTC option are expected to be in compliance with these standards, so the track record for demonstrating compliance is twelve months. Those LTC organizations NEW to LTC accreditation are expected to have a four-month track record of compliance.
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Many Joint Commission policies will apply to Medicare/Medicaid Certification-Based LTC accreditation, including the Sentinel Event Policy, the National Patient Safety Goals, and Public Information Policy. However, organizations choosing this option will not need to submit ORYX performance measures to either a performance measurement system or directly to the Joint Commission. For this accreditation option, surveyors will review the Facility MDS QI Profile and/or Post-Acute QM Report during the survey to determine how the organization has used this information to establish their PI priorities.
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Survey Process FAQs
No. The standards identified for Medicare/Medicaid Certification-Based LTC accreditation are not inclusive of the standards that contain the ten subacute elements of performance. If an organization needs to demonstrate compliance with subacute EPs, then it must choose the traditional LTC accreditation option.
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Yes, the surveyor will review these documents to determine your Medicare/Medicaid provider certification status as well as identify how your organization uses these reports in establishing performance improvement priorities. Accreditation Participation Requirements (APRs) and decision rules address an organization that receives a Termination of Provider Agreement from CMS (decertified from Medicare/Medicaid participation)
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While the Joint Commission surveyor will not be duplicating the state agency survey process by reviewing compliance with and implementation of the facility's Plan of Correction (POC) identified on the 2567, he or she will spend time exploring how the LTC organization has incorporated the state agency identified deficiencies into their performance improvement plans. Organizations will be expected to share with the Joint Commission surveyor their performance improvement initiatives related to their POC noted on CMS form 2567 and state licensure reports along with performance improvement initiatives resulting from the Facility Quality Indicator (QI) Profile and/or Quality Measure (QM) report. The Joint Commission does not require that state agency identified certification and licensure deficiencies or flagged QIs/QMs be included in performance improvement priorities, but that these findings are considered when they are doing their PI planning. If the deficiencies and/or QIs fall into a high-risk, high-volume, problem prone area, it would be the Joint Commission's expectation that such deficiencies be included in the organization's performance improvement plan. It is not Joint Commission's intention to re-survey for certification or licensure related deficiencies that have already been addressed in the organization's POC to the state agency and CMS. However, for this accreditation option, it is a Condition of Participation that the SNF maintain its SNF provider agreement and that deficiencies noted on the 2567 are corrected.
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Yes, the award letter and certificate will state that the LTC survey relied substantially on the State Agency Certification survey.
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Yes through 2007, as the random unannounced mid-cycle survey will be eliminated once the organization has received its first unannounced full survey starting in 2006.
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