Select deemed status survey to save time

Joint Commission option eliminates need for survey

No hospice manager looks forward to any type of survey, but agencies that elect to undergo a deemed status survey by The Joint Commission can take care of two surveys in one visit.

The deemed status survey option not only serves as The Joint Commission accreditation survey, but also replaces the state Medicare survey. "The deemed status survey determines compliance with federal conditions of participation [CoP] requirements and conditions of coverage and evaluates compliance with The Joint Commission's standards," says Debra Zak, PhD, RN, executive director of the Home Care Accreditation Program.

Although the survey is not a state licensure survey, The Joint Commission is recognized in 24 states for renewal of licenses, says Zak. "Our survey is not recognized by states for the initial license," she adds.

Because the Centers for Medicare & Medicaid Services (CMS) has fewer requirements for a hospice survey than The Joint Commission, agencies must meet Joint Commission requirements for eligibility, says Zak. The Joint Commission requires that a hospice has served 10 patients with two active patients at the time of the survey. CMS has no patient volume requirement.

A significant change to The Joint Commission's general eligibility requirements is the elimination of the need to have four months' data on compliance, says Zak. "Now, every organization is expected to be compliant at the time of the survey," she explains.

Agencies that already are accredited by The Joint Commission can request a deemed status survey be conducted at the same time as their accreditation survey when it is scheduled or, if an agency is a year or more away from the regular survey, an agency can request a Medicare CoP survey prior to the accreditation survey, says Zak." Agencies cannot request a Medicare-only survey for an initial survey," she adds.

Even if an agency is Joint Commission-accredited and Medicare-certified, it cannot be automatically given deemed status, says Zak. "Deemed status is an option and must be selected by the agency," she adds.

Following the survey, an organization has a 10-day period to explain reasons that a document could not be produced or respond to other items on the report. If an organization has a standard out of compliance, there is a 45-day period to submit evidence that the organization is in compliance, says Zak. "Standard-level deficiencies must be corrected before Joint Commission can recommend accreditation to CMS," she points out.

In addition to cutting one extra survey out of your busy schedule, Zak points out that CMS is overburdened and cannot always perform surveys in a timely manner. Agencies also have the ability to talk one-on-one with trained professionals to discuss best practices that can help with challenges that are faced by the organization, she adds. [Editor's note: To apply for a deemed status survey, contact Jasmina Juric, business development specialist, at (630) 792-5251 to request an application. An online application can be accessed at]