ARS Regulatory Alerts
CIHQ-ARS notifies member organizations of any new or modified accreditation standard, or CMS COP for acute care hospitals. Each alert summarizes the standard / regulation, likely impact to members, and recommends compliance strategies. Whenever possible, alerts are limited to one-page in length so that they can be quickly read and disseminated.
New Regulatory Alert
Alert Date
July 17, 2020
Alert Subject
Joint Commission's Hospital Accreditation Program Re-Approved by CMS for only Two Years
Alert Applicability
| Acute Care | Ambulatory Care | Behavioral Health |
| Critical Access | Home Health / Hospice | Laboratory |
| Long Term Care | Other: __________ | |
Alert Background
In the on-line edition of Modern Healthcare published July 16, 2020, it was reported that The Joint Commission's hospital
accreditation program was only granted a two year approval by CMS. Programs can be approved for up to six years. According
to the news article, Joint Commission’s hospital program is only approved until mid-July 2022. The article noted that CMS was
explicit that the shortened approval period was based on "concerns" related to Joint Commission surveyor performance and
comparability of the Joint Commission's survey process to that of CMS.
The article went on to state that the Joint Commission is now “requiring additional training for its surveyors related to off-site location standards, reviews of medical records and the level of detail provided to facilities during briefings to ensure it does not change the integrity of the survey process." The article also stated that; “Changes were also made to the Joint Commission's survey process related to "leading and probing questions during interviews," as well as more restrictions on interviewing frontline personal.
Discussion & Recommendations
HACP Professionals can download this alert in its entirety when logged-in to their HACP account. Alerts are also archived for future access and reference.
New Regulatory Alert
Alert Date
July 2, 2020
Alert Subject
The Joint Commission Provides Further Clarification on Resumption of Survey and Review Activities
Alert Applicability
| Acute Care | Ambulatory Care | Behavioral Health |
| Critical Access | Home Health / Hospice | Laboratory |
| Long Term Care | Office-Based Surgery | |
Alert Background
In an online posting dated 7/1/2020, The Joint Commission issued further clarification of resumption of survey and review
activities. As The Joint Commission has resumed select on-site surveys and reviews, some further clarifications have been made
regarding what is and what is not being evaluated.
Compliance with Joint Commission standards will be evaluated from the time of the last full accreditation survey up until the public health emergency (March 1, 2020). Our survey will not focus on the time period of March 1 through either the date the organization has indicated they are ready to accept a survey or the end of the public health emergency — whichever comes first.
However, The Joint Commission will assess how an organization adapted their infection control and emergency management processes in response to the pandemic and will focus its review on current practices to ensure the organization continues to provide safe care and work in a safe environment.
Also, the Centers for Medicare and Medicaid Services-issued waivers are not applicable to Clinical Laboratory Improvement Amendments-certified laboratories. Therefore, laboratories can expect surveyors to include an evaluation of the organization’s ability to appropriately manage Emergency Use Authorizations (EUAs), as well as continued management of their quality control and proficiency testing throughout the full accreditation cycle.
Discussion & Recommendations
HACP Professionals can download this alert in its entirety when logged-in to their HACP account. Alerts are also archived for future access and reference.