Calling all Rehab Professionals: How to Prepare for a Joint Commission Survey


As with everything else, Medicare controls how each healthcare provider gets aid for a procedure or treatment. In the case of rehab departments, as well as any healthcare providers, you must be accredited in order to receive Medicare reimbursements. Because all healthcare organizations are subject to a three-year accreditation cycle, they often find themselves at the face of an impromptu survey by The Joint Commission. We will discuss what the Joint Commission is and the two aspects you, as a rehab professional, should be reared for in the event of an unplanned survey.

The Joint Commission (TJC), formerly the Joint Commission on Accreditation of Healthcare Organizations (JCAHO), advocates the use of patient safety measures, the spread of information, the measurement of performance, and the introduction of public policy recommendations. All health care organizations (excluding laboratories) are subject to a three-year accreditation cycle. With resect to hospital surveys, the organization does not make its findings public, however, it does provide the organization’s accreditation decision, the date that accreditation was awarded, and any standards that were cited for improvement. Organizations deemed to be in compliance with all or most of the applicable standards are awarded the decision of Accreditation.Becoming accredited by the Joint Commission is vital to any healthcare organization and passing the Joint Commission survey will guarantee the necessary accreditation. Facilities that meet such requirements also satisfy the Medicare Conditions of participation, guidelines, which is a requirement for any healthcare provider. Failing the survey however, could rove to be detrimental to the health of your organization, in that Medicare may not reimburse your company, resulting in a revenue loss and even worse, the complete closure of your organization due to non-compliance.

Preparing for a Joint Commission survey can be a challenging process for any healthcare provider. All members of the organization, from a staff therapist to the Director of Rehabilitation, should be familiar with the current standards, processes, policies and procedures as well as understanding what are your facility’s process improvement indicators.

There are two asects to the survey that you need to be concerned about:

The Environment of Care:

  • Review of control logs (temerature logs, ool tem, araffin bath tems, bio-medical checks, AED checks, making sure that walkers and oxygen tanks are off the floor and nothing is above 18 inches from the ceiling).
  • Have an understanding of the rocesses for cleaning gait belts, walkers, and hot ack covers as well as knowing where the including hot and cold ack machines are located.
  • Familiarity with the fire exit lan and the exact location of fire extinguishers and ull station are a must.
  • Know your vendors (orthotics /contract services) and where their files are. You should also be aware if they are licensed and if they have malpractice insurance.
  • Your license should be displayed on the board, in clear view-with your address hidden (make sure the original is posted if a copy is not acceptable).

Patient tracers:

  • In the event that you are asked, you should be prepared to recite any and all relevant information about the patients’ medical records and how it relates to treatment.
  • If your department/ organization is EHR (Electronic Health Record) compliant, make sure you can negotiate the patient care lan backwards and forwards. Also, have a sound gras of where the therapy section is on the chart.
  • You should be knowledgeable on what functional screens are and how they are triggered. You should know your assessment /reassessment lan, whereby you would additionally know how often you have to assess a patient’s functional status.
  • Wash your hands, wear gloves, and know what the two main patient identifiers are (name and DOB). Knock before you enter a room, reserving patient privacy, HIA, and don’t forget that a smile goes a long way.

These surveys are inevitable and should be welcomed, provided you are always doing your art with regard to the environment of care and patient tracers. In an industry where oversight and revenue are directly related, you must comply or your department may become the unneeded center of attention within your organization. Here at Centra Healthcare Solutions, we have many rehab therapy positions just waiting for a skilled professional to fill them. Whether you’re looking for the excitement of a travel therapy job, the flexibility of temporary positions or if you desire a regular, full-time position contact us today.

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