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Joint Commission revises Medication Management EPs

The Joint Commission has revised Medication Management elements of performance (EP) for several of its programs. The changes will go into effect on January 1, 2018 and will impact hospitals, ambulatory care, behavioral care, home care, nursing care centers, critical access hospitals, and office-based practices accredited by The Joint Commission. The revisions will require organizations to:

•    Record the date and time of any medication administered in the patient’s clinical record.
•    Implement a policy to provide emergency backup for essential medication dispensing equipment and for essential refrigeration for medications.
•    Have a written policy addressing the control of medications between when they are received by a provider and given to a patient. Those policies should now include what to do for the “wasting of medications.”
•    Implement a policy describing the types of medication overrides for automatic dispensing cabinets that will be reviewed for appropriateness and the frequency.

The revisions vary depending on the program.

CMS withdraws proposal to have AOs post survey reports online

A proposal by CMS to have accrediting organizations (AOs) post the details of survey reports online was withdrawn by the agency, not because of negative comments — although there were plenty — but because, well, it might be prohibited under federal law.

CMS first made the proposal in April, tucking it into the latter pages of the always-long proposed on changes to the Inpatient Prospective Payment System (IPPS) for the upcoming fiscal year.

The proposal was to have AOs post final survey reports online within 90 days that the same information is available to the hospital or other health care organization, including details of all initial and recertification surveys at that provider in the prior three years, as well as the accepted plans of correction (PoCs).

AOs now post only whether an organization is accredited or not, and do not make details of findings public.

CMS argued its proposal was to promote transparency in health care, and noted that it posts its own  survey reports online. But critics responded that the CMS reports are made available in a hard-to-read spreadsheet and that the federal agency was responsible for far fewer surveys at health care organizations that were often surveyed only after a complaint (IJC 5/1/17).

In public comments to CMS concerning the proposal, The Joint Commission said that requiring survey details be made public would have “chilling effect” on efforts to raise standards of quality. Dr. Mark R. Chassin, president and CEO of The Joint Commission, wrote: “There will be a race to the bottom on quality as health care organizations seek out oversight bodies that will report on the least number of standards comparable to the Medicare requirements. This may also lead to a growth in non-accredited facilities that will then be surveyed at taxpayer expense and with fewer oversight visits.”

Other groups similarly weighed in against the proposal, and offered alternatives. In the end though, it was shot down because it might potentially be prohibited.

In the IPPS final rule published Aug. 2, CMS noted that its proposal included revising the federal regulations overseeing Medicare to incorporate the requirement for AOs to post report details publically.

“Section 1865(b) of the Act prohibits CMS from disclosing survey reports or compelling the AOs to disclose their reports themselves. The suggestion by CMS to have the AOs post their survey reports may appear as if CMS was attempting to circumvent the provision of section 1865(b) of the Act. Therefore, this provision is effectively being withdrawn.” — A.J. Plunkett (


The clarification process: Is it worth it?

It can’t be emphasized enough that you should consider which issues have the potential for successful clarification as soon as you are aware of the findings. Start your research as soon as you suspect there is an issue. Don’t waste valuable time waiting for the final report to be posted to your extranet site.  Because clarification audits are very time-consuming and must be completed within 10 days of the survey, any extra time you can buy for the data review process is helpful. Focus on the key issues and problem areas, especially direct impact findings.

Important Note: If you feel you can successfully clarify a specific issue and you will need to go beyond the ten days allowed, consider asking your accounting representative for an extension. Organizations have stated that The Joint  Commission is open to an extension, so asking for one can work to your advantage.

Think about how you would respond to the actual requirements. This means noting surveyor scoring errors (yes, they do still occur). Avoid responding to a surveyor’s misunderstanding of a standard or his or her preference in how it “should” work in your organization. The Joint Commission has been very careful in standards development and interpretation to allow organizations the flexibility in implementing them. However, your process should parallel acceptable practices, such as those recommended by the U.S. Centers for Disease Control and Prevention (CDC) or specialty societies, for example. Many organizations and some consultants even preach “best practices” for all, but in reality, patient issues and resources may vary across the United States, and you need to find the process that works for you while being compliant.

Consider all sources of information from The Joint Commission, such as the actual EPs in the standards manual and  the officially published Perspectives and standards FAQs on the Internet.

Editor’s note: This blog post is an excerpt from The Joint Commission Survey Coordinator’s Handbook, Thirteenth Edition, by Jean S. Clark, RHIA, CSHA, and Jodi Eisenberg, MHA, CPHQ, CPMSM, CSHA