Contracted Services - Applicability to Joint Commission Standards

Do the standards for contracted services apply if the contracted organization is Joint Commission accredited or certified?

Any examples are for illustrative purposes only

Yes, accredited organization's are expected to demonstrate compliance with all accreditation or certification requirements for their respective program. In general, the contractual agreements that are reviewed during survey are those that relate most directly to resident safety, care, and treatment (see also LD.04.03.09 and HR.01.02.07).  Contracts that relate to other support issues (lawn care, snow removal, and plant technology maintenance) are lower priorities during survey.

Contractual agreements must give the accredited organization's the right to enroll the direct care and support contract employees into the orientation, competency assessment, on-going education, performance evaluation, health screening, and emergency and fire prevention programs that are established by the organization. To these ends, the contracted service/agency/vendor deploys properly trained and credentialed staff and materials. The compliance of all staff, including contracted staff must be documented but this documentation may reside with the employer.   

The accredited organization policies and procedures must be followed by all staff, even if the contract company does not have comparable requirements.  For example, if the organization or the local government or public health entity requires tuberculosis testing and the contract company does not, the contract staff must comply with tuberculosis screening.  The screening can be done by the contractor or by the accredited organization and must be documented.  

Last updated on March 16, 2021
Manual: Assisted Living Community
Chapter: Leadership LD

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