Notifying Joint Commission Organization Changes

Effective in October 2016 for all accreditation programs, The Joint Commission has updated its policy regarding notification of changes within accredited organizations. The “Notifying The Joint Commission About Organization Changes” policy appears in “The Accreditation Process” (ACC) chapter of the Comprehensive Accreditation Manuals.* Historically, the policy required organizations to notify The Joint Commission within 30 days after a significant change occurred. However, because certain changes may result in the need for on-site survey activity, the policy now requires organizations to provide written notification to The Joint Commission when the change is initially contemplated — that is, when leadership within the organization has approved moving forward with the proposed change and identified a time frame for implementing that change. Advance notice of a potential change allows organizations and The Joint Commission to evaluate whether there is any impact from an accreditation standpoint, including the need and timing for any on-site survey activity. Once the change has officially occurred, the organization should update its electronic application for accreditation (E-App) within 30 days. The policy revisions will be included in the fall 2016 E-dition update and the 2017 manuals. Questions may be directed to an organization’s assigned account executive.

*The similar policy “Notifying The Joint Commission About Staffing Firm Changes” in the Health Care Staffing Services Certification Manual will also be updated to reflect the revisions.

Applicable to All Accreditation Programs
Effective October 2016
Notifying The Joint Commission About Organization Changes

Accreditation is neither automatically transferred nor continued if significant changes occur within [an organization]. Organizations must notify The Joint Commission promptly, in writing, when an additional service is contemplated* so any potential impact to accreditation can be determined. Medicare-certified organizations must also notify the Medicare Administrator Contractor promptly, in writing, when an additional service is contemplated. Once the change has actually occurred, the E-App must be updated to reflect the change as well. 

Changes Affecting E-App Information
At any time during the accreditation process, an organization may undergo a change that modifies the information reported in its E-App (see APR.01.03.01 in the APR chapter). Organizations must notify The Joint Commission promptly, in writing, when an additional service or location is contemplated so any potential impact to accreditation can be determined. Medicare-certified organizations must notify the Medicare Administrator Contractor promptly, in writing, when an additional service is contemplated. Once the change has actually occurred, the organization must update its E-App within 30 calendar days. Information that must be reported includes any of the following:

  • A change in ownership
  • A change in location
  • A significant increase or decrease in the volume of services or individuals served
  • The addition of a new type of health service, program, or site of care
  • The deletion of an existing health service, program, or site of care
  • The acquisition of a new component
  • The deletion of an existing component

The Joint Commission may conduct an additional survey at a later date if its surveyor or survey team arrives at the [organization] and discovers that a change was not reported. The Joint Commission may also survey any unreported services and sites addressed by its standards during the survey as appropriate. The Joint Commission makes the final accreditation decision for the [organization] only after surveying all or an appropriate sample of all services, programs, and sites provided by the [organization] for which The Joint Commission has standards. Information reported in the E-App is subject to The Joint Commission's Information Accuracy and Truthfulness Policy.