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The Unannounced Survey Process

  • The Joint Commission conducts unannounced surveys unless it is not feasible or logical to do so.
  • All hospitals and Centers for Medicare & Medicaid Services (CMS) deeming or recognition surveys are unannounced.

The following are exceptions to unannounced surveys:

Announced surveys: First survey conducted by The Joint Commission;* first survey conducted under the Early Survey Policy;* Focused Standards Assessment Options 2 and 3 surveys

The following receive seven-day notice of surveys:

Ambulatory care: Office-based surgery practices; telehealth services; sleep centers; ambulatory surgery centers not using accreditation for deemed status and those that only provide surgery/anesthesia services.

The following ambulatory care organizations with only one of the following services:* medical/dental with less than 5,000 annual visits or less than three licensed independent practitioners; specified diagnostic/therapeutic 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 behavioral health 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: Home care organizations with only one of the following services:* home health/personal care/support services with 30 or fewer patients; hospice with 10 or fewer patients; pharmacy with 50 or fewer patients; home medical equipment services with 50 or fewer patients (unless using accreditation to meet Medicare DMEPOS requirements); home infusion therapy services with 30 or fewer patients.

Laboratory: "Small" organizations with less than 25,000 tests per year; freestanding in-vitro fertilization (IVF) laboratories.

Other facilities: Department of Defense facilities; Bureau of Prison facilities; Immigration facilities.

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

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

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