steve misenko project manager external reporting accreditation and certification operations

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The Joint Commission: Deeming Authority and the Integrated Survey Process for Psychiatric Hospitals and the Special Conditions

February 6, 2012

Steve MisenkoProject ManagerExternal ReportingAccreditation and Certification Operations

Mark E. Schario MS, RN, FACHEField DirectorSurveyor Management and DevelopmentAccreditation and Certification Operations

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Presentation Objectives

Brief review of the federal deeming process for hospitals and the special conditions

Overview of framework for Joint Commission approach to deeming for the special conditions

New standards, crosswalk and documents for special conditions

Survey process specific to the special conditions of participation

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The Basics

Application submitted in July 2010Application process is 210 days

– Review of standards, survey process, procedures, survey team composition, etc

Approval was published in the Federal Register on Friday, February 25, 2011

Term of approval is four years

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Deeming Authority

Accreditation is voluntary; free State Survey Agency (or Contractor) option

Federal requirements are in law and regulation

Defined application/renewal processesEstablished oversight processes

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CMS’ Deeming Authority Oversight

Validation surveys– Generally performed by State Survey Agencies (SSA) on

behalf of CMS

– Task is to validate accreditation organization’s performance in assessing compliance with the CoPs/CfCs

Types of validation surveys include:–Mid-cycle –Complaint (allegation) –Look-behind (traditional)

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Validation Surveys

Prior to MIPPA only hospitals and labs included in the Annual Report to Congress

Since 2009: hospitals, CAHs, hospice, ASCs, home Care, labs,

Starting in 2012 psychiatric hospitalsHospitals: largest number of validation

surveys FY 1999 (235), lowest number FY 2004 (44), last year 150

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Complaint Surveys

Complaint/Allegation Survey– Response to an allegation of a significant

deficiency

–Narrow focus on the area(s) of complaint

–For deemed organizations must be approved by CMS RO

–About 5,000 complaint surveys conducted in TJC hospitals every year

–Small percent (4 to 6) are substantiated with a condition-level finding

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Look-Behind Validation Surveys

CMS’ CO selects “representative” sample Conducted 60 days after an AO survey

– Performed to determine a match between the AO’s findings and the SA’s Condition-level findings

Results provided to Congress

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Data Reporting Requirements

Facility specific demographic and deficiency information

Survey schedulesNotification letters (sent to both CMS

CO and appropriate RO) after a surveyAdverse decisions reported within 48

hours of the Committee’s decisionSurvey reports upon request

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Deemed Data to Date

420 Medicare certified psychiatric hospitals accredited

133 facilities have requested the psychiatric hospital deemed status option

2012 due = 137 2013 due = 164 2014 due = 119

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Psychiatric Hospitals

What makes you different:

-primary purpose is for diagnosis and treatment of the mentally ill under the supervision of a physician

-must meet all the conditions of participation for Medicare hospitals

- Must meet two special conditions for psychiatric hospitals

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Joint Commission Process

Psychiatric Hospital approach:

Will use our existing hospital survey process

Will add standards and crosswalk specific to the special conditions

Will add survey process specific to the special conditions

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Standards and Elements of Performance

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Background:

Existing hospital standards requirements were crosswalked to the psychiatric hospital CoPs (482.60, 482.61, and 482.62)

As a result of this crosswalk, it was determined that 57 existing hospital EPs could be applied to these psychiatric hospital CoPs

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Background for specific issues:

Additional EPs were needed in order to better address the details in some of the CoPs

7 new EPs and a “note” have been added to the existing hospital standards.

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PC.01.02.13 EP7 –Psychiatric evaluation completed within 60 hours

PC.04.01.03 EP3 –New “note” regarding social services staff responsibilities

RC.02.01.01 EP10 –who records progress notes and how often

New Elements of Performance

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MS.06.01.03 EP7 – Qualifications of director of inpatient psychiatric services

HR.01.02.05 EP16 – Qualifications of director of psychiatric nursing

LD.04.03.01 EP14 – Requirement to provide psychological, psychiatric nursing, social work, and therapeutic activity services

New Elements of Performance

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HR.01.02.05 EP18 – Qualifications of director of social work services

LD.04.01.01 EP16 – Administrative requirement for special provisions for psychiatric hospitals at 482.60

New Elements of Performance

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E-dition

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Condition of Participation

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Crosswalk

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Survey Process

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Survey process

Increase in survey time to address specificity

Survey activities impacted

New activities developed

Changes related to the special hospital Conditions of Participation:

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Survey Forms…a familiar place

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Impact on Survey Activities

Individual Tracer Activity– Evaluate degree and

intensity of treatment provided

– Patient tracer selection guideline/sampling

– Psychiatric evaluation complete within 60 hours

– Progress notes are recorded

– Review compliance with B-tags (B-105 through B126 and B132)

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Survey activities

Credentialing and Privileging Session

– Qualifications, roles, and responsibilities of the clinical director

– Qualifications of physicians who provide psychiatric services

– Discuss physician coverage on evenings, nights, and weekends

– Review data on CMS Form 729 from hospital

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New survey activities

Staffing Review Session

– New 60 minute activity– Staffing based on

qualifications and mix of staff

– Confirm a registered nurse is available 24 hours a day

– Review data on CMS Form 727 and 728 from hospital

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New survey activities

Discharge Planning/Death Record Review– New 60-90 minute activity– Review discharge records to

evaluate compliance with discharge planning requirements

– Death record review, when necessary, include review of conclusions and recommendations of the Mortality Review Board, determining if proper treatment was provided, and reviewing the autopsy report

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CMS Forms (Hospital access)

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Follow up information can be obtained from:

Mark Schario, mschario@jointcommission.org

Steve Misenko, smisenko@jointcommission.org

Trisha Kurtz, pkurtz@jointcommission.org