So what does it mean when a Joint Commission surveyor informs you a finding is at the “Condition” level?
As The Joint Commission (TJC) further aligns its scoring practices with CMS survey methodology, more and more organizations are reporting being cited with Condition-level deficiencies during survey. Although these changes became effective in July 2009, many organizations are still unprepared to respond to Condition-level findings and confused about what they mean for the survey process and their implications for accreditation status. To better understand what constitutes a Condition-level deficiency and where an organization may be vulnerable, let’s take a look at how CMS classifies non-compliance.
According to the CMS State Operations Manual, compliance with a particular Condition of Participation depends upon the manner and degree to which the provider satisfies the various standards within each Condition.When one or more standards are not satisfied, CMS cites deficiencies.In determining the severity of these deficiencies, CMS classifies noncompliance at either the Standard or the Condition level, depending on the nature (how severe, how dangerous, how critical) and extent (how prevalent, how many, how pervasive, how often) of the lack of compliance. The cited level of the noncompliance is determined by the interrelationship between the nature and extent of the noncompliance.
A deficiency is at the Standard level when there is noncompliance with any single requirement (or several requirements) within a particular standard that is not of such character as to substantially limit a facility’s capacity to furnish adequate care, or which would not jeopardize or adversely affect the health or safety of patients if the deficient practice recurred. A deficiency at the Condition level may be due to noncompliance with requirements in a single standard that, collectively, represent a severe or critical health or safety breach, or it may be the result of noncompliance with several standards within the condition. Even a seemingly small breach in critical actions, or at critical times, can kill or severely injure a patient, and such breaches would represent a critical or severe health or safety threat.
CMS gives several examples of deficiencies throughout the Conditions of Participation that must be cited at the Condition level. These include:
- Restraint/Seclusion – A violation of any of these patient rights constitutes an inappropriate use of restraint or seclusion and would be cited as a Condition-level deficiency.
- Utilization Review – A hospital that does not satisfy the UR Conditions of Participation through either its own program or a QIO agreement may be cited for violating not only the UR Condition of Participation at the Condition level, but also the provider agreement requirement at 42 CFR 476.86(e).
- Alcohol gel – Failure by a hospital to develop and implement appropriate measures to reduce the risk of fires associated with the use of alcohol-based skin preparations in anesthetizing locations should be cited as Condition-level noncompliance.
- Emergency Services – A hospital policy or practice that relies on calling 9-1-1 in order for EMS to substitute its emergency response capabilities for those the hospital is required to maintain is not consistent with the CMS Condition of Participation. For example, a hospital may not rely upon 9-1-1 to provide appraisal and initial treatment of medical emergencies that occur at the hospital. Such policy or practice should be considered as Condition-level noncompliance with the applicable Condition of Participation, 42 CFR 482.55 or 42 CFR 482.12(f).
- Immediate Threat to Health or Safety – CMS terms these deficiencies as “Immediate Jeopardy” and when identified, these are always cited at the Condition level.
The implications of a Condition-level deficiency are significant and should not be underestimated.Whenever The Joint Commission cites a Condition-level deficiency, they are also required to include a Condition -level deficiency in the leadership standards, in keeping with the CMS expectation that the Governing Body is ultimately accountable for ensuring compliance with the Conditions of Participation throughout the organization.
In addition, when Condition-level deficiencies are found, a follow-up TJC survey (also unannounced) must occur within 45 calendar days of the last day of the accreditation survey. If the problem remains, a second follow-up survey must occur within 30 calendar days of the first follow-up survey. Failure to clear a Condition-level deficiency after the second survey results in notification of CMS, then it affects the accreditation decision.
Keep in mind that the follow-up survey will focus on those requirements for improvement (RFIs) that were determined to be Condition-level deficiencies, but surveyors can score other issues that are identified during the follow-up survey.The follow-up survey will most likely occur before you submit your organization’s evidence of standards compliance (ESC) from the original survey and usually consists of one surveyor for one day.
But, that’s not the end of it. The organization can not only expect a follow-up survey by TJC, but also a full CMS survey. Remember, CMS is bound by its rules to follow up with any organization found to have a Condition-level deficiency (even if it is subsequently cleared on the follow-up survey) by conducting a FULL CMS survey to review for compliance with all Conditions of Participation.
Some tips for responding to Condition-level deficiencies include:
- Make sure you understand the deficiency finding. If you are unclear about what is out of compliance, ask the surveyor to clarify.
- Implement corrective action immediately. Include a description of how the Governing Body will oversee the corrective action and be accountable for compliance.
- Don’t rely on a clarification to remove the Condition-level deficiency. Proceed with a corrective action plan immediately.
Of course, the best way to deal with Condition-level deficiencies is to avoid them by knowing and complying with the Conditions of Participation. It’s simply not enough to focus only on TJC’s standards. A review of the CMS survey process can be found in the State Operations Manual.