Hospitals experienced two significant changes in 2008 related to the Centers for Medicaid and Medicare Services (CMS) deeming authority that should be on the radar of the Medical Services Professional. The first change is in regard to “deeming authority.” On July 15, 2008, Congress enacted a new law requiring The Joint Commission (TJC), and any other accrediting body seeking deeming status, to apply for such through CMS. The second change came when CMS granted new deeming authority to Det Norske Veritas Healthcare, Inc. (DNV). So now, there are 3 major accrediting authorities – The Joint Commission, Healthcare Facilities Accreditation Program (HFAP), and DNV.
The Joint Commission continues to be the largest accrediting authority with over 5,000 hospitals in their foot print. What sets TJC apart is that they are the only one that accredits across the continuum of care. TJC categories of accreditation include:
- Accredited – Hospital is in compliance with all applicable standards at the time of survey or has successfully addressed all requirements for improvement.
- Provisional – Hospital fails to successfully address all requirements for improvement within a specified timeframe.
- Conditional – Nature of the Requirements for Improvement requires an onsite follow-up survey.
- Preliminary Denial – Severity of findings justifies denial of accreditation. Decision is subject to review and appeal.
- Denial – Accreditation has been removed or denied and appeals have been exhausted.
DNV has approximately 350 facilities. What sets DNV apart is the integrated use of ISO 9001 (a set of standards for quality management created by the International Organization for Standardization in 1987) and focus on the CMS Conditions of Participation (CoPs). DNV categories of accreditation include:
- Accredited – Nonconformities resolved pursuant to DNV accepted corrective action plan.
- Jeopardy Status – Organization fails to meet corrective action plan requirements.
- Not Accredited
HFAP has nearly 200 hospitals and has three categories of accreditation:
- Full Accreditation
- Interim Accreditation
- Denial
Now that hospitals have more choices in “deeming authority”, choosing the best Accrediting Agency can be challenging. Documentation requirements and code adoptions can be complex and differ from one AHJ to another. Therefore, LSS Life Safety Consultants can help customers wade through the confusion if converting to a new Accrediting Agency.
Life Safety Consultants are up-to-date with the Life Safety Code and will help customers prepare for their facility’s Life Safety and Environment of Care inspection. Life Safety Consultant will thoroughly review a facility’s documentation personalized to their specific AHJ’s requirements. Not to mention, they can help you understand what the code’s standards say, and which requirements and codes have been adopted in your area.
