General FAQs
Standards FAQs
Survey Process FAQs
General FAQs
The following chart shows the differences between accreditation and licensure/certification:
|
|
Accreditation Surveys |
State Surveys |
|
Purpose |
Performance improvement; deemed status in some states |
licensure and/or Medicare/Medicaid provider certification |
|
Oversight |
private, not-for profit company |
governmental entity |
|
Compliance |
voluntary |
mandatory |
|
Emphasis |
evaluation |
inspection |
|
Frequency |
triennial |
annual |
|
Notice |
announced |
unannounced |
|
Funding |
provider fees |
tax dollars/licensing fees |
|
Focus |
What is the organization doing right? How can it improve? |
What is the organization doing wrong? |
|
Expectations |
achievable standards |
minimum expectations |
|
Scoring |
systems and processes |
individual deficiencies |
|
Value |
improvement |
enforcement |
|
Process |
survey to standards |
survey to regulations |
|
Approach |
education/consultation |
sanctions/penalties/fines |
|
Findings |
recommendations for improvement |
citations |
|
Award |
accreditation |
licensure and/or certification |
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You can complete our online Quality Incident Report Form. For more information, please call 800-994-6610.
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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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Standards FAQs
Who can answer a question about standards interpretation?
Please check our the Standards FAQs section of our website. If you don't find your answer there, you can complete our Online Standards Form or call 630-792-5900.
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Survey Process FAQs
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. We will evaluate the past four months of service for compliance with the standards. If your organization is 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 six months from the date it is submitted. You may request a specific month for your initial survey and we will try to accommodate you.
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This varies considerably from organization to organization and depends on the amount of time and resources available to prepare for survey. Most organizations take nine to 12 months from the point of the initial decision to the actual survey date.
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You must be in compliance for four months on an initial survey, one year on a resurvey.
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This varies with the number of surveys conducted in the previous month but averages about 45 days. 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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We do not automatically transfer accreditation to new owners who acquire an accredited health care organization.
Accreditation will not continue if significant changes occur to the circumstances 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.
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Yes, your subacute beds would be surveyed at under the long term care standards and elements of performance. For 2006 there are 10 subacute specific EPs.
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Yes. The dementia specific elements of performance will apply to all residents with dementia regardless of where they live in the long term care facility. A separate dementia special care unit certificate is no longer issued.
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If the long term care facility owns and operates your pharmacy, you'll be surveyed by the long term care survey team as part of the facility's survey, using the standards in the CAMLTC. If, however, your pharmacy is an independent organization that rents space in the long term care facility, you will be surveyed as a long term care pharmacy using the standards in the CAMHC. You must voluntarily request and apply for accreditation separately from the facility. You are not required to be accredited just because the long term care facility is.
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Yes, all contracted services for which we have standards are included in the scope of the survey process. This includes laboratory, consultant pharmacist services, nursing services, equipment maintenance services, and so on. It is unlikely that the organizations providing these services will be visited on site, but they will be surveyed through observation and interviews at the long term care facility seeking accreditation. You must list all such contracts on the questionnaire sent to you prior to survey.
Waived laboratory test (non-CLIA eligible) are included in the scope of the survey process. Non-waived (CLIA-eligible) laboratory services must undergo a separate survey by a laboratory surveyor using the Comprehensive Accreditation Manual for Clinical Pathology and Laboratory Services. For more information, please contact Laboratory Accreditation Services at (630) 792-5738.
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The Joint Commission establishes survey fees annually. You can call the Pricing Unit at (630) 792-5115 to receive an accreditation fee quote for your organization.
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Contact the Customer Service Center toll free at (877) 223-6866. You can view an online catalog of all our publications at the Joint Commission Resources' website.
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