CMS Approves TJC as an AO for Another Three Years

By A.J. Plunkett

CMS approved The Joint Commission’s (TJC) hospital accreditation program for just another three years. It might have approved it for longer if not for the pandemic.

In an announcement scheduled to be published in the Federal Register on May 2, CMS said that TJC made all the changes required of the agency but that “due to travel restrictions and the reprioritization of survey activities brought on by the 2019 Novel Coronavirus Disease (COVID-19) Public Health Emergency (PHE), CMS was unable to observe a hospital survey completed by TJC surveyors as part of the application review process, which is one component of the comparability evaluation. Therefore, we are providing TJC with a shorter period of approval.”

The approval is through July 15, 2025.

Many of the changes listed by CMS in the announcement will be familiar to those using TJC for deemed purposes to participate in the Medicare funding program. Almost all of those revisions to TJC standards have happened in the last several months, including:

  • Clarifying that a doctor of medicine or osteopathy is responsible for the care of the patient
  • Specifying that the patient has the right to receive his or her medical records based on oral or written request
  • Removing the terminology of “independent” practitioners from several elements of performance, “to be consistent with the regulation.”
  • Adding language that requires the hospital’s fire control plan to contain provisions for cooperating with firefighting authorities

The announcement also hinted that TJC surveyors will be expected to get tougher on hospitals.

In addition to calling on TJC to improve its training for surveyors on “the appropriate level of citations for Governing Body and Nursing Services when deficiencies are found in a hospital,” CMS also said it would be watching TJC and all the other AOs in the future.

“In keeping with CMS’s initiative to increase AO oversight broadly, and [to] ensure that our requested revisions by TJC are completed, CMS expects more frequent review of TJC’s activities in the future.”