Are you a hospital using Joint Commission accreditation for deemed status with the US Centers for Medicare & Medicaid Services (CMS)? If so, are you ready for a CMS survey—every day, at any time? According to federal policy, for 60 days after a Joint Commission survey, any organization that uses accreditation for deemed status is at risk for a validation survey from the CMS. In fact, CMS may elect, at any time, to conduct its own additional evaluation of a hospital with deemed status through a complaint or potential immediate jeopardy investigation. When CMS or the Department of Health arrives at your facility, you need to be prepared.
The 2021 Joint Commission and CMS Crosswalk: Comparing Hospital Standards and CoPs offer easy access to the full—and current as of January 1, 2021—language of the Medicare hospital Conditions of Participation (CoPs) and demonstrates their equivalency with Joint Commission’s hospital standards. A reverse crosswalk, listing Joint Commission requirements with equivalent CoP numbers, shows equivalencies in the opposite direction. This allows staff to easily see how the two sets of requirements relate to each other, whether they are more familiar with the Medicare CoPs or Joint Commission standards. Regulatory staff and accreditation managers can use the crosswalks in this guide to identify how your organization's policies, procedures, and practices support one or more Joint Commission standards and demonstrate compliance with equivalent CMS regulations—or identify gaps.
"This is a detailed resource to help organizations understand how the two sets of requirements align overall to help sustain ongoing compliance and improvement initiatives."
-- Debra DellaRatta, MSN, CPHQ (James A. Haley Veterans' Hospital) Doody's Review - previous edition
The crosswalks in the guide can help hospital staff identify how policies and practices support one or more of TJC standards and demonstrate compliance with equivalent CMS regulations. Sidebars and tables provide additional information on Joint Commission accreditation for deemed status, CMS-related updates, and how both organizations survey for compliance. The crosswalks represent a point in time (Joint Commission standards effective January 1, 2019). The Federal Requirements have CoPs with supporting standards. The Joint Commission has standards with supporting elements of performance.