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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A proposal by CMS to have accrediting organizations (AOs) post the details of survey reports online was withdrawn by the agency, not because of negative comments — although there were plenty — but because, well, it might be prohibited under federal law.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 (aplunkett@h3.group)

Resource:

Maintaining security during a Joint Commission survey

Facilities often have questions when surveyors come to visit. Some of the most frequently asked questions involve security and confidentiality, how to make sure surveyors see what they need to without violating hospital safety. In the July issue of Perspectives, The Joint Commission answered some of the most frequent questions.

Access to Computer Systems: Surveyors will sign security agreements with the facility in order to receive a user ID and password to access a computer system (for example, in order to review policies and medical records) if the facility requires it.

Confidentiality Agreements: If a facility wants surveyors to sign a confidentiality agreement, then that agreement has to be sent to the Joint Commission Central Office for review before the survey.

That said, asking surveyors or reviewers to sign an agreement is unnecessary, according to The Joint Commission. Accreditation and certification contracts, plus the Business Associate Agreement between The Joint Commission and the facility, already bind individual surveyors and reviewers to confidentiality.

Security Sign-In: If a facility requires visitors to sign into the building as part of the organization’s regular security process then surveyors will sign in too. In lieu of asking to copy a surveyor’s driver’s license, Joint Commission badge, or any other form of ID, facilities should refer to surveyors’ pictures and biographies on the Joint Commission Connect™ secure extranet site.

Videotaping Survey Activities: Videotaping or recording any part of a survey or review, including the exit conference is forbidden.

The Focused Standards Assessment tool goes temporarily offline in July

The Focused Standards Assessment (FSA) tool on The Joint Commission’s Intracycle Monitoring (ICM) Profile will be taken offline from June 30, (5:00 PM Central Time) through  July 10 (9:00 PM CT)

The FSA is an interactive standards self-assessment tool for facilities that lists the standards applicable to each organization’s accredited programs and services. An extension due date will be set to Monday, July 24, 2017 for facilities with an ICM submission date between July 1 and July 10.

https://www.jointcommission.org/facts_about_the_intracycle_monitoring_process/

Joint Commission Updates on HAI-related National Patient Safety Goal on HAIs

The Joint Commission has revised several of its requirements for National Patient Safety Goal (NPSG) 7, which focuses on the issue of healthcare-associated infections (HAI). The revisions go into effect on January 1, 2018, and apply to hospitals, critical access hospitals (CAH), and nursing care centers (NCC).

NPSG 07.03.01: Multidrug-resistant organisms (MDRO)

•    NCCs are now expected to follow the MDRO NPSG.07.03.01. Nursing homes experience a high rate of MDROs such as methicillin-resistant staphylococcus aureus (MRSA) and vancomycin-resistant enterococci (VRE). This was particularly concerning because nursing home patients were bringing MDROs to hospitals and vice versa.
•    The Joint Commission is adding a new infection, carbapenem-resistant enterobacteriaceae (CRE) to NPSG.07.03.01. This change applies to hospitals, CAH, and NCCs.

NPSG 07.04.01: Central line-associated bloodstream infections (CLABSI)

•    The EPs for the NPSG 07.04.01 have been reordered.
•    EP 11 was revised to specify the use of chlorhexidine for antiseptic skin preparation.
•    For both NPSG 07.03.01 and NPSG 07.04.01, facilities are now allowed to determine how frequently they need to re-educate staff and licensed independent practitioners on MDROs and CLABSIs.

Joint Commission deletes standards during third phase of EP review

On April 25, The Joint Commission announced it had completed the third phase of its Element of Performance (EP) review project. Phase three looked at standards from seven Joint Commission programs, deleting those deemed duplicative or have become standard operating procedure.

It should be noted that what was deleted varies based on each program. For example, an EP deleted for the hospital program might still exist for home care. Chapters affected include Environment of Care and Infection Prevention and Control.

Below are links to the various prepublication standards, which are effective July 1, 2017.

Joint Commission FAQs on H&P and titration orders

The Joint Commission has released new FAQs regarding the new updates to history and physical (H&P) updates and titration orders. The FAQs apply to hospitals, hospital clinics, and critical access hospitals.

The FAQs cover questions such as:

 When is an H&P update required?

What specific elements are required for titration orders? And what other safety and quality factors should be considered?

What are the requirements for updating an H&P after a procedure requiring anesthesia is performed after admission?

Joint Commission seeks comments on proposed suicide prevention requirements

The Joint Commission is seeking comments on its proposed requirements on National Patient Safety Goal (NPSG) 15.01.01 for suicide prevention in healthcare facilities. Specifically, it’s seeking feedback the revisions for hospitalcritical access hospital, and behavioral health accreditation programs. The comment period ends on May 1.

Joint Commission: More details on self-harm assessments

The Joint Commission announced that as of March 1, its surveyors will place special focus on suicide, self-harm, and ligature observations in psychiatric hospitals and units. Now, surveyors will document any and all observations of ligature or self-harm risks in the environment during the survey. The six major areas of assessment will be:

  • Plans and policies on harm mitigation
  • Effective coordination of staffing to deal with mitigation plans
  • Patient suicide risk-assessment processes
  • Policies and practices on what to do for at-risk patients
  • Staff awareness of a patient’s level of risk
  • Facilities’ improvement processes for things like:
    • Tracking patients’ histories
    • Root-cause analyses of safety events
    • Compliance monitoring
    • Response to non-compliance

Each observation will be documented, classified as a requirement for improvement, scored at EC.02.06.01, element of performance 1, and placed on the facility’s SAFER Matrix.

See our previous Accreditation Insider and Briefings on Accreditation and Quality coverage on suicide risks.

Measures of Success still apply for sentinel events

Due to the adoption of the SAFER Matrix, The Joint Commission announced that it was discontinuing its post-survey measures of success (MOS) process. However, the accreditor clarified that the sentinel event MOS process is still in effect and unchanged.

Changes to post-survey categories

The Joint Commission has eliminated its post-survey category of “Contingent Accreditation.” Now organizations can only receive one of four decisions: Accredited, Accredited with Follow-up Survey, Preliminary Denial of Accreditation, or Denial of Accreditation.

Accreditation— Given to a facility that’s compliant with all applicable standards or has successfully addressed all Requirements for Improvement (RFI). Once the Evidence of Standards Compliance (ESC) is submitted, the organization will get a notice of full accreditation. Follow-up surveys must be done within six months to show that an organization is compliant with their ESC.

Accreditation with follow-up survey— Given to a facility that isn’t in compliance with specific standards that require a follow-up survey within 30 days to six months. Also requires that problem areas listed in an ESC submission are corrected. Once the ESC is submitted, the organization will get a notice of full accreditation. Follow-up surveys must be done within six months to show that an organization is compliant with their ESC.

Preliminary denial of accreditation— Given to a facility when there’s evidence of one or more of the following:
•    An immediate threat to health or safety to patients or the public
•    Falsified documents or misrepresented information was given to surveyors
•    The facility is missing a required license or certification
•    The facility is significantly out of compliance with Joint Commission standards

Additional rules for receiving a “Preliminary Denial of Accreditation” ranking have been listed in the “important updates” section of Joint Commission Connect and are as follows:
•    Failing to fix all Requirements for Improvement (RFI) after two opportunities to submit ESCs have passed
•    Failing a second Medicare Deficiency Survey for not meeting a Condition of Participation or a Condition Level Deficiency
•    Evidence reveals patients have been put in jeopardy due to potential fraud or abuse committed by the organization

A Preliminary Denial of Accreditation (PDA 02) decision is made; organizations are now expected to submit a Plan of Correction (POC) within 10 business days of the final report’s posting. After which, there’ll be a survey within two months to validate the implementation of the POC.  This will be done in lieu of submitting ESC within 60 days.

For PDAs, facilities can appeal The Joint Commission to review this decision.

Denial of accreditation - A facility is completely denied accreditation. This happens when a facility:
•    Doesn’t to pay its survey or annual fees
•    Refuses to let The Joint Commission conduct a survey
•    Fails to address the conditions of their Accreditation with Follow-up Survey status
•    Fails to submit an ESC

At this point, there are no more appeals or reviews that a facility can use to stay accredited.

Finally, The Joint Commission’s governance structure has changed. Now, decisions on accreditation matters will be made by an executive team rather than an Accreditation Committee. The executive team is now in charge of making accreditation decisions, considering survey reports, follow-up activities, staff recommendations, and any unusual problems raised by the organization seeking accreditation.
Check out Briefings on Accreditation and Quality to learn more about the importance of avoiding denial of accreditation.