Accreditation Basics for Home Care Organizations ... · The Road to Quality. The Joint Commission 2...

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Accreditation Basics for Home

Care Organizations:

Strategies for SuccessPresented by:

Julia Finken, BSN, MBA, CPHQ, CSSBB

The Road to

Quality

The Joint Commission

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Independent, not-for-profit organization

Accrediting Home Care organizations since 1988

Accredits over 5,000 Home Care programs

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Today’s Discussion includes:

• First steps for a provider considering accreditation Eligibility requirements

How to apply

• Basics of the accreditation experience Standards to support your quality efforts

Strategies to enhance compliance

• Demonstrating your performance excellence Unique onsite survey experience

• Sustaining quality and sharing your success Quality distinction within the industry

Access to helpful tools and resources

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Why Joint Commission Accreditation?

Our Customers say it best…

“It’s the industry’s most highly regarded quality

framework for delivering consistent best-in-class care.”

“It provides opportunity to learn from the industry’s most

trusted name in quality and safety – on survey, from

their Standards team and through their many, free

online tools.”

Home Care Providers Eligible for Accreditation

• Home Health

• Hospice

• Personal Care and Support

• Pharmacy

• DMEPOS

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Pre-application Considerations

• Available accreditation options:

Accreditation

Accreditation with federal recognition

Deemed status for home health

Deemed status for hospice

Recognition for DMEPOS providers

Eligibility Requirements

Company is operational and providing care

Traditional accreditation and DMEPOS recognition

• Must have served 10 clients/patients, minimum of 2 active at time of survey

State notified that agency will use The Joint Commission for deemed

Home health deemed status

• Must have served 10 skilled patients, minimum of 7 active at time of survey

Hospice deemed status

• Must have served 5 patients, minimum of 3 active at the time of survey

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Additional Requirements for Deemed Status Applicants ONLY

Approved CMS Form 855a

State notified that agency will use The Joint Commission for deemed status

Successful test transmission of OASIS data (Home Health only)

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Applying for Accreditation is Easy

• You determine when you are ready to apply Create a “reverse road map”

Be realistic with your goals and expectations

• Reviewing the standards Register online for the Free 60-day access to help determine a

realistic target date

• Access to the application Register online for access to your extranet

• Access to supportive team members Business Development

Standards “Help Desk”

Account Executive

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• Visit http://www.jointcommission.org/accreditation/home_care.aspx

• Call the Home Care line at 630-792-5070

Request an Application

Access to Joint Commission Connect

Completing the Application

• Who has access to the extranet?

• Submit accurate organizational information Names, addresses, titles

Services provided

Hours of operation

• Submitting payment

• Scheduling the survey What is the “Ready Date”

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Getting Ready for Survey

• Make the E-dition your online handbook

• Compare performance to standards

• Make compliance everyday work

• National Patient Safety Goals

• Take advantage of the resources available to help you

Standards E-dition

As You Begin Survey Preparation

• Understand and identify laws/regulations for your state

• Use the Standards Manual as a Reference Guide Review Written Documents Required

Review National Patient Safety Goals

• Risk Areas/Clinical Service Emergency Preparedness

Infection Control

Human Resources

Leadership

Performance Improvement

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Accreditation Survey Prep

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Considerations for Deemed Status Survey Prep

• Home Health – Conditions of Participation Professional Advisory Group

Home Health CoPs: http://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/downloads/som107ap_b_hha.pdf

• Hospice – Conditions of Participation Planning for scope of service

Hospice CoPs: http://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/downloads/som107ap_m_hospice.pdf

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The Onsite Survey

• Patient/Client-centric & educational Observation of patient/client care with permission

Individual and system tracers guide the time

• Determining Compliance Observations shared as they are made

Leaders/managers encouraged to participate

Preliminary, printed findings provided on site

• Minimal interruption of care activities; flexible Survey agenda accommodates operational systems

and schedules

Joint Commission Surveyors

• Home Care Professionals Professional Experience in Home Care

Clinicians and administrators

Collaborative

Open communication

• Rigorous hands-on initial education

• Ongoing professional education

• Announced vs. Unannounced Posted on extranet at 7:30 a.m.

Surveyor bio and picture

Survey agenda

• Opening Conference - orientation to the organization

• Surveyor Planning

• Staff interviews

• Individual tracer activities, patient/client record review

• Systems tracers

• Daily Briefings

• Leadership session

• Exit Conference

Typical Onsite Survey Agenda

Other Survey Prep Tips

• Check your Extranet site daily

• Keep manuals, contracts, personnel files and documentation ready and accessible

• Once the surveyor arrives, have plan ready to notify the field

• Have a daily list of scheduled visits ready to go every morning

• Have your supervisor available or access to them

• The more you engage with your surveyor, the more meaningful your survey experience

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• On-site survey report will be posted on your extranet site within 10 days

• If your organization has a standard out of compliance – providers must submit evidence of standards compliance within a 45 – 60 day window

• Initial surveys, your accreditation decision is effective from the day The Joint Commission approves your FINAL evidence of standards compliance.

• For Joint Commission to recommend Medicare Certification to CMS: Standard-level deficiencies must be corrected

Condition-level deficiencies for first time surveys require a repeat survey

CMS is notified of our recommendations; they make the final certification notification

After the Survey

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• Based on services provided and individuals served

• Annual and on-site survey fees based on average daily patient/client volumes

• On-site survey fee Inclusive of all surveyor travel and expenses

Non-deemed surveys typically 1-2 days

Deemed status surveys typically at least 3 days

• Accreditation awarded for three-year cycle

Home Care Fees

Sustaining Quality…Sharing Success

• Industry perspective

• National voice

• Quality check

• Practical tools for performance excellence

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Joint Commission Perspectives newsletter - published monthly

Access to the customer-only Leading Practices Library

Home Care Bulletin, a complimentary newsletter

Online Media Kit with ideas to help publicize your achievement

Marketing support through a listing on Quality Check

Center for Transforming Healthcare

For Accredited Organizations

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Next Steps!

Go to:• http://www.jointcommission.org/accreditation/home_

care.aspx Register for the Free 60-day access to the electronic

standards (E-dition)

Review accreditation information

Assess your readiness Request the application

Questions? Contact the Home Care Team Phone: 630.792.5070

Email: homecare@jointcommission.org

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Supportive Resources

If you have a question about…... Please contact…...

GETTING STARTED:

How to get started

The overall accreditation process

The cost of accreditation

How to get a free trial of the standards

How to request an application

THE BUSINESS DEVELOPMENT TEAM:

Call: 630-792-5070

Email: homecare@jointcommission.org

Website: www.jointcommission.org

MANAGING THE ACCREDITATION PROCESS:

Completing the application

Scheduling a survey date

Specific issues related to ongoing

accreditation

AN ACCOUNT EXECUTIVE:

Call: 630-792-3007

OUR STANDARDS:

Complying with specific standards

THE STANDARDS HELP DESK:

Call: 630-792-5900, Option 6

Website: www.jointcommission.org/Standards

MANUALS, EDUCATION AND TRAINING:

Obtaining standards manual

Registering for a Joint Commission

education program

Staff training resources

JOINT COMMISSION RESOURCES (JCR):

Call: 877-223-6866

Email: jcrcustomerservice@pbd.com

Website: www.jcrinc.com

Time for Your Questions!

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Standards Interpretation Help Desk: 630-792-5900

Joint Commission Resources: 877-223-6866 or www.jcrinc.com

Brenda Lamberti, BS

Business Development Specialist

630-792-5252 or

blamberti@jointcommission.org

Home Care Team ContactsJoint Commission Home Care Program

Help Desk: 630-792-5070 or homecare@jointcommission.org

www.jointcommission.org/accreditation/home_care.aspx

Margherita Labson

BSN, MSHSA, CPHQ, CCM, CGB

Executive Director

630-792-5284 or

mlabson@jointcommission.org

Julia Finken

BSN, MBA, CPHQ, CSSBB

Associate Director

630-792-5283 or

jfinken@jointcommission.org