Among the half dozen or so changes to the rules, the most significant is establishment of separate rules for organizations seeking initial accreditation from those who are pursuing reaccreditation. The most relevant change for psychiatric hospitals are clarifications provided in the following new additions:
• CLD01: a condition-level deficiency will trigger a Medicare follow-up survey.
• ESC02/MOS02: a failure to successfully address all RFIs may require an organization to submit a second ESC or MOS
Tip: If you have any indication that your TJC survey included a condition-level deficiency, get prepared for a more rigorous CMS follow-up.  Some of our collaborative members have experienced CMS surveys within 2 weeks of the conclusion of their TJC triennial.