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The Unannounced Survey Process Fact Sheet

The Joint Commission conducts unannounced surveys unless it is not feasible or logical to do so. All hospitals, critical access hospitals and Centers for Medicare & Medicaid Services (CMS) deemed surveys are unannounced.

The following are exceptions to unannounced surveys for non-deemed organizations:

Announced surveys: First survey conducted by The Joint Commission;* first survey conducted under the Early Survey Policy option.* 

The following receive seven-day notice of surveys:

Ambulatory Health Care: Office-based surgery practices; telehealth services; sleep centers; ambulatory surgery centers not using accreditation for deemed status and those that only provide surgery/anesthesia services.

The following ambulatory care organizations with only one of the following services:* medical/dental with fewer than 5,000 annual visits or fewer than three licensed practitioners; specified diagnostic/therapeutic with fewer than 3,000 annual visits or four or fewer licensed practitioners; episodic care; mobile diagnostic services.

Behavioral Health and Human Services: All settings and services, with the exception of hospital-based Opioid Treatment programs.

Home Care: Home care organizations with only one of the following services: home health/personal care/support services with 30 or fewer patients; hospice with 10 or fewer patients; pharmacy with 50 or fewer patients; home medical equipment services with 30 or fewer sales and/or rentals (unless using accreditation to meet Medicare DMEPOS requirements); home infusion therapy services with 30 or fewer patients (unless using accreditation to meet Medicare Home Infusion Therapy requirements).

Laboratory: “Small” organizations with fewer than 25,000 tests per year; freestanding in-vitro fertilization (IVF) laboratories.

Other facilities: Department of Defense facilities; Immigration facilities.

For more information, organizations can refer to the accreditation manual, visit the Joint Commission Connect® extranet, or contact their account executive.

* Excludes hospitals and critical access hospitals, as well as all events where an unannounced survey is required for deemed status or CMS recognition purposes.

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