Joint Commission’s Psychiatric Hospital Accreditation Program Approved for Another 6 Years

By A.J. Plunkett

After providing additional training to its surveyors to increase oversight of a hospital’s plan of correction, The Joint Commission (TJC) has been approved by CMS to accredit psychiatric hospitals for participation in Medicare for another six years.

CMS required the accrediting organization to increase training of its surveyors, as well as make other procedural changes, to ensure TJC was aligned with the federal agency’s oversight of psychiatric hospitals, according to an announcement in the Federal Register, scheduled to be published on February 27.

The approval is effective February 25, 2023, through February 25, 2029.

CMS said it compared TJC’s psychiatric hospital accreditation program requirements and survey process with those set out by Medicare, and had TJC revise certain processes and requirements before approval. TJC was asked to:

  • Provide additional training to ensure that TJC psychiatric hospital surveyors document findings of noncompliance consistent with the regulatory requirements.
  • Provide additional training to surveyors on the CMS Statement of Deficiencies and Plan of Correction “to ensure any actions taken by the facility to address deficiencies include specific information in the corrective measures” as required by CMS in the main State Operations Manual (SOM), Chapter 2.
  • Revise its intake and triage “process for all complaint requirements to ensure comparability with CMS requirements.”
  • Revise its “complaint policy regarding offsite investigations and maximum timeframes to investigate complaints as described in SOM, Chapter 5.”

A.J. Plunkett is editor of Inside Accreditation & Quality, an HCPro publication.