Facts about the unannounced survey process | Joint Commission
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Facts about the unannounced survey process

February 17, 2017

The Joint Commission generally conducts unannounced surveys unless it is not feasible or logical to do so. All hospital and Centers for Medicare & Medicaid Services deeming or recognition surveys are unannounced. The following are exceptions to unannounced surveys:

Announced surveys

 

·    Initial surveys (organizations undergoing their first Joint Commission survey)*

·    The first survey conducted under the Early Survey Policy*

·    Focused Standards Assessment Options 2 and 3 surveys (unless the organization requests an unannounced survey)

Seven-day notice surveys

Ambulatory care

·    Office-based surgery practices

·    Telehealth services

·    Sleep centers

·    Ambulatory surgery centers not using accreditation for deemed status purposes

Organizations with only one of the following services:*

·    Surgery/anesthesia services

·    Medical/dental services with less than 5,000 annual visits or less than three licensed independent practitioners

·    Specified diagnostic/therapeutic services with less than 3,000 annual visits or four or less licensed independent practitioners

·    Mobile diagnostic services

Behavioral health

·    Correction settings

·    Foster care programs

·    Methadone programs

The following organizations with less than 10 staff or average daily census less than 100:

·    “Small” settings

·    Outpatient and day programs

·    24-hour services

·    In-home behavioral health, case management, or assertive community treatment (ACT) program

·    Inpatient freestanding organizations

·    Community-based, freestanding organizations

·    Inpatient crisis stabilization programs

·    Residential/group homes

Home care

Organizations with only one of the following services:*

·    Home health/personal care/support services

·    Hospice

·    Pharmacy

·    Home medical equipment services (unless using accreditation to meet Medicare DMEPOS requirements)

Laboratory

·    “Small” organizations with less than 25,000 tests per year

·    Freestanding IVF (in-vitro fertilization) laboratories

Nursing care center

Organizations accredited under the Medicare/Medicaid certification-based approach converting to Nursing Care Centers Accreditation for the first time

Other facilities

·    Department of Defense facilities

·    Bureau of Prison facilities

·    Immigration facilities

 

 

     

* Unless an unannounced survey is required for deemed status purposes.

For more information
Organizations can refer to their accreditation manual, visit the Connect® extranet, or contact their account executive.

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