State Recognition Details | Joint Commission
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Thursday 3:44 CST, January 18, 2018

State Recognition Details

State Recognition Contact Directory


The Joint Commission actively monitors state legislative and regulatory activities for the purpose of identifying additional opportunities for state reliance on Joint Commission accreditation/certification.

The Joint Commission’s various accreditation/certification programs are recognized and relied on by many states in the states’ quality oversight activities. Recognition and reliance refers to the acceptance of, requirement for, or other reference to the use of Joint Commission accreditation, in whole or in part, by one or more governmental agencies in exercising regulatory authority. Recognition and reliance may include use of accreditation for licensing, certification or contracting purposes by various state agencies. 
 

STATE: PROGRAM:


State: Massachusetts
Program: Laboratory
Agency: Department of Health
State Reference: 105 MA ADC 180.030 
Setting/Service: Laboratory
Type of Recognition: Licensure

(A) Application. Clinical Laboratories functioning under the control of a hospital or clinic licensed pursuant to M.G.L. c. 111 § 51 shall apply for a certificate of approval. Any person or entity who operates a health promotion screening program shall apply for a letter of approval in accordance with 105 CMR 180.030(D). All other clinical laboratories shall apply for a license issued pursuant to M.G.L. c. 111D. Any laboratory which is accredited, certified or licensed by a program which is deemed equivalent to these regulatory standards by the Department will be considered to meet the requirements of 105 CMR 108.000. Any laboratory services not inspected and accredited, certified, or licensed by a deemed equivalent program shall comply with all requirements for licensure or approval.

State: Massachusetts
Program: Behavioral Health Care
Agency: Department of Mental Health
State Reference: 104 MA ADC 27.03
Setting/Service: Mental Health Facilities - Inpatient Mental Health Services and Residential Treatment Programs)
Type of Recognition: Licensure

(2) Types of Licenses. Licensed mental health facilities shall be issued a single license which may incorporate one or more of the following classes:

(11) Accreditation.

(a) A facility seeking a license as Class II, III, IV, V, VI, Limited VI, VIII, or any combination thereof, or a renewal of such license, shall be accredited by the Joint Commission or other nationally recognized accreditation agency approved by the Commissioner utilizing the applicable standards as promulgated by said Joint Commission or agency. Facilities that have not yet attained accreditation shall be in substantial compliance with those standards, and must submit a plan for obtaining accreditation within a reasonable period of time.

(b) A facility seeking a license as Class VII, or a renewal of such license shall be accredited as a residential treatment program by the Joint Commission or other nationally recognized accreditation agency approved by the Commissioner. Facilities that have not yet attained accreditation must be in substantial compliance with the standards for residential treatment programs set forth by said Joint Commission or agency, and must submit a plan for obtaining accreditation within a reasonable period of time.

(12) Deemed Status. In addition to the Departmental action on license applications as set forth below, and any additional requirements for Class VII facilities set forth in 104 CMR 27.04, the Department may approve licensure of accredited facilities in accordance with the following requirements for deemed status.

(g) A facility whose deemed status has been revoked may be subject to a licensing review or full survey pursuant to 104 CMR 27.00.

(13) If a facility is not yet accredited by the Joint Commission or if an accredited facility chooses not to apply for deemed status, it shall be subject to a full survey for licensure by the Department.


State: Massachusetts
Program: Behavioral Health Care
Agency: Department of Public Health
State Reference: 105 MA ADC 164.311
Setting/Service: Substance Abuse Programs and Opioid Treatment Programs
Type of Recognition: Licensure

(C) Accreditation:

The licensee shall be accredited by an accrediting organization approved by the Substance Abuse and Mental Health Service Administration. If the licensee has operated an opioid treatment program for less than one year, the licensee shall obtain accreditation by the end of the first year of operation.


State: Massachusetts
Program: Ambulatory Health Care
Agency: Department of Public Health
State Reference: 105 CMR 140.102
Setting/Service: Ambulatory Surgical Center
Type of Recognition: Licensure

(C) Deemed-by-accreditation Licensure for Ambulatory Surgery Centers. Consistent with M.G.L. c. 111, § 53G, the Department may deem the conditions of original or renewal licensure in 105 CMR 140.000 to be satisfied for an ambulatory surgery center (ASC) that meets the requirements of 105 CMR 140.102(C).

(1) Deemed-by-accreditation Original License.
An ASC that meets the following criteria shall be eligible to apply for a deemed-by-accreditation original license from the Department.


(a) on the date of application, the entity is accredited to provide ambulatory surgery services by the Accreditation Association for Ambulatory Health Care, Inc. (AAAHC), the Joint Commission, the American Association for Accreditation of Ambulatory Surgery Facilities (AAAASF) or any other national accrediting body as determined by the Department; and
(b) on the date of application, the entity is certified or has applied for certification as an ASC by the Centers for Medicare and Medicaid Services for participation in the Medicare program;

(2) Deemed-by-accreditation Renewal License.
An ASC that meets the following criteria shall be eligible to apply for a deemed-by-accreditation renewal license from the Department:

(a) on the date of application, the entity is accredited to provide ambulatory surgery services by the Accreditation Association for Ambulatory Health Care, Inc. (AAAHC), the Joint Commission, the American Association for Accreditation of Ambulatory Surgery Facilities (AAAASF) or any other national accrediting body as determined by the Department; and
(b) on the date of application, the entity is certified as an ASC by the Centers for Medicare and Medicaid Services for participation in the Medicare program


State: Massachusetts
Program: Hospitals
Agency: Department of Public Health
State Reference: 105 MA ADC 130.202
Setting/Service: Hospital
Type of Recognition: Licensure

105 CMR 130.202: Accreditation as Equivalent: Deemed Status

(A) If a hospital is currently accredited by the Joint Commission , AOA, or another accrediting body approved by CMS and the Commissioner, the Commissioner or his or her designee may deem the hospital to meet all the requirements of the Conditions of Participation except any requirement promulgated by regulation by the Secretary of Health and Human Services pursuant to 42 U.S.C. § 1395x(e)(9) which the Secretary, after consulting with the Joint Commission, AOA or another accrediting body approved by CMS and the Commissioner, identifies as being more stringent or more precise than the requirements for accreditation; and except the requirements for utilization review specified in 105 CMR 130.200; and with respect to psychiatric hospitals subject to licensure, except the special requirements specified in 105 CMR 130.201.

(B) Each accredited hospital which desires to obtain deemed status shall release to the Commissioner or his or her designee a copy of the hospital's current accreditation letter and the accrediting agency's explanation of its survey findings. The hospital shall also sign a Department consent form indicating it:

(1) Agrees to permit Department observers at the summation conferences scheduled at the completion of an accreditation; and

(2) Agrees upon request to release to the Commissioner or his or her designee any other accreditation information requested


State: Massachusetts
Program: Behavioral Health Care
Agency: Division of Medical Assistance
State Reference: 130 MA ADC 425.405 
Setting/Service: Psychiatric Inpatient Hospital Services
Type of Recognition: Insurance

Payment for the services described in 130 CMR 425.000 will be made only to psychiatric inpatient hospitals participating in MassHealth on the date of service.

(A) In-state. To participate in MassHealth, an in-state psychiatric inpatient hospital must

(1) be a MassHealth provider;

(2) be licensed as a hospital by or be operated by the Massachusetts Department of Mental Health (DMH);

(3) be accredited by the Joint Commission on Accreditation of Health Organizations (JCAHO) or be certified by the Massachusetts Department of Public Health; and (4) participate in the Medicare program.

(B) Out-of-state. To participate in MassHealth, an out-of-state psychiatric inpatient hospital must

(1) be a MassHealth provider;

(2) be approved as a psychiatric inpatient hospital by the governing or licensing agency in its state;

(3) be accredited by the JCAHO or be certified by the public health agency in the state in which the psychiatric inpatient hospital is located;

(4) participate in its state's medical assistance program;

and

(5) participate in the Medicare program. .


State: Massachusetts
Program: Home Care
Agency: Division of Medical Assistance
State Reference: 130 MA ADC 427.404
Setting/Service: Oxygen and Medical Equipment Providers
Type of Recognition: Insurance

(A) Participating Providers. Payment for the services described in 130 CMR 427.000 are made only to providers of oxygen and respiratory therapy equipment and repair services who are participating in the Medical Assistance Program as of the date of service and who are accredited by the Joint Commission on Accreditation of Health Care Organizations (JCAHCO) as oxygen and medical equipment providers.

State: Massachusetts
Program: Behavioral Health Care
Agency: Division of Medical Assistance
State Reference: 130 MA ADC 422.404
Setting/Service: Providers of Transitional Living Services
Type of Recognition: Insurance

(3) Providers of Transitional Living Services. To provide transitional living services described in 130 CMR 422.431 through 422.441, the organization must:

(a) submit a proposal for review by the MassHealth agency in accordance with MassHealth's proposal requirements;

(b) obtain written authorization from the MassHealth agency to become a MassHealth provider of transitional living services;

(c) demonstrate the appropriate licensure or program accreditation by a recognized body for the provider's type of program; and

(d) obtain a MassHealth provider number.


State: Massachusetts
Program: Office-Based Surgery
Agency: Massachusetts Medical Society
State Reference: Guidelines for Office-Based Surgery
Setting/Service: Office-Based Surgery
Type of Recognition: Requirement for Anesthesia Use

Level II office surgery includes the following:
Any procedure that requires the administration of minimal or moderate intravenous or intramuscular sedation/analgesia, thus making intra-operative and postoperative monitoring necessary. Level II office surgery shall be limited to procedures where there is only a moderate risk of surgical and/or anesthetic complications and the likelihood of hospitalization as a result of these complications is unlikely.

Facility Accreditation: The surgeon must obtain Level II accreditation of the office setting by one of the approved agencies. The facility or surgeon shall obtain accreditation of the office setting by AAAASF, AAAHC, JCAHO, HFAP/AOA, AAOMS/MSOMS, or other agency approved by the Massachusetts BRM.

All expenses related to accreditation or inspection shall be paid by the surgeon or facility.

Level III office surgery is any procedure that requires, or reasonably should require, the use of deep sedation/analgesia, general anesthesia, or major conduction blockade, and/or in which the known complications of the proposed surgical procedure may be serious or life threatening.

The facility or surgeon shall obtain accreditation of the office setting by AAAASF, AAAHC, JCAHO, HFAP/AOA, AAOMS/MSOMS, or other agency approved by the Massachusetts BRM. All expenses related to accreditation or inspection shall be paid by the surgeon or facility.

The Joint Commission maintains a listing of state agencies that recognize accreditation/certification. These lists have been compiled from a variety of sources and are intended to identify state regulatory agencies that recognize and/or rely on accreditation in lieu of specific state licensure or certification requirements. The Joint Commission makes no claims about the accuracy of this list and it should be considered a reference document. Joint Commission accredited organizations are strongly encouraged to inquire with their state regulatory agency for a full description of the recognition and any additional requirements the state agency may have.