Accrediting Organizations Suspend Most Survey Activities to Focus on COVID-19

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By A.J. Plunkett

If you are expecting a survey from your accreditation organization (AO) in the upcoming weeks and months, check in with your liaison. Some AOs are suspending most or all survey activities as COVID-19 takes hold of the nation.

Three of the four major AOs have made changes to their survey activities:

  • The Joint Commission (TJC) announced that as of March 16 it was suspending regular surveys until further notice.
  • HFAP said on March 6 it would limit surveys on a case-by-case basis following CMS’ announcement that its own surveyors would primarily focus only on infection control.
  • The Center for Improvement in Healthcare Quality (CIHQ) has suspended routine reaccreditation surveys through the end of April.
  • DNV GL Healthcare has said on its website that it would continue surveys but will be assessing on a regular basis.

The Joint Commission

Mark Pelletier, RN, MS, TJC’s chief operating officer/chief nursing executive for Accreditation and Certification Operations, announced suspension of surveys in a letter posted on the AO’s website March 16.

“In light of President Trump’s declaration of a national emergency regarding the COVID-19 virus and to assure we are not interfering with the work you are doing to prepare and care for your patients during this pandemic, The Joint Commission is suspending all regular surveying beginning Monday, March 16, 2020,” wrote Pelletier.

“In some cases, there may be a small number of surveys that will need to continue, such as high-risk situations. We will provide more details soon on what surveys are proceeding. At this time, we do not have an anticipated restart date. All postponed survey events will occur once we resume operations. If any organizations go past their accreditation due date, accreditation will be extended without disruption to their accreditation status. The Centers for Medicare and Medicaid Services has assured us that Medicare payment status also will not be affected,” he added.

CIHQ

In a statement from CIHQ, Richard Curtis, RN, MS, HACP, and CEO of the Texas-based AO, said that CIHQ is working with CMS “on an ongoing basis to evaluate the need for accreditation surveys. At this time, CIHQ has suspended routine reaccreditation surveys for at least the month of April 2020. We will be evaluating the suspension on a month-to-month basis or until we receive direction from CMS.  We will continue to perform initial surveys for new hospitals, and surveys if needed to address infection prevention and control issues in our accredited facilities.”

CIHQ says it will go forward with a special webinar on March 20 for member organizations to ask questions about  surveys and the regulatory expectations related to COVID-19.

HFAP

HFAP says its decision to limit surveys followed a joint conference call March 6 with CMS officials, including David Wright, director of CMS’ Quality, Safety & Oversight Group, and Karen Tritz, director of CMS’ Division of Acute Care Services, and representatives with all four AOs.

The call was to help the AOs understand a CMS decision announced March 5 saying it was suspending survey activities except for certain cases, including immediate jeopardy complaints, allegations of abuse and neglect, and infection control concerns, including facilities with potential COVID-19 or other respiratory illnesses.

In a statement on its website, HFAP quoted Wright as telling AOs “the recent CMS survey guidance was unprecedented.” Wright further said that “the rapidly developed policy was driven, in part, by the need to build capacity on the part of State Agencies to respond to the evolving and heightened public health concern. He explained that on the state agency side, surveys would continue to be limited to the priority events listed in the March 5 announcement.”

HFAP stated that “going forward, AOs will not be limited in their survey activity but instead are encouraged to increase focus on infection control giving priority to states with emergent threats. This goal is to be balanced with the need to protect AO surveyors and to avoid stressing those providers who may already be managing depleted resources.”

HFAP also said it would develop criteria to guide its survey decisions and “specific surveys may be postponed without penalty to the provider.”

Among several other concerns swaying whether a survey will be conducted includes how organizations will be reporting suspected or confirmed cases of COVID-19, whether there are other quarantine or isolation activities in the area and if CDC is onsite. According to the statement:

“When onsite, HFAP surveyors will place special focus on infection prevention and control issues and emergency management. This will not increase the length of your survey and CMS has confirmed that:

  • Surveys performed by HFAP can result in a full term of accreditation even if all conditions/standards are not surveyed due to the added emphasis of survey activity in the areas of infection control and emergency management.
  • Strict adherence to the 36-month cycle window is waived.  If a hospital is affected by COVID-19, its accreditation will not automatically expire; HFAP will communicate to CMS the reason for delaying the survey.”

DNV GL

Meanwhile, in an advisory notice to providers posted on DNV’s website March 17, the AO said it was continuing its surveys for accredited hospitals and critical access hospitals.

The statement by DNV GL’s President Patrick Horine noted that the AO’s work to safeguard “life, property and the environment” of its accredited organizations “extends to protecting hospital staff, contractors, visitors and communities, along with our own surveyors and their families from the risks of infectious disease. We continue to balance the CMS requirement to ensure compliance in accredited hospitals with the guidance of national authorities and individual hospital circumstances when planning surveys.”

“At this time, incorporating CMS guidelines, our prioritization of surveys remains in effect. With exceptions in New York, Washington, and California, we continue to conduct unannounced annual and reaccreditation surveys, prioritized complaint investigations, follow-up surveys, initial accreditations, and special surveys such as changes-of-ownership, facility replacements or service extensions.”

“CMS has offered new flexibility to AOs to communicate with their customers in advance of survey, while protecting the unannounced nature of every accreditation visit. DNV GL has already requested proactive status reports from our customers and will begin reaching out directly to assess each hospital’s situation and readiness for survey.”

DNV says it is also exploring the ability to survey sites remotely “using secure technology similar to telehealth, and CMS has indicated their willingness to evaluate such an approach for purposes of deemed accreditation. This option would allow us to continue to assess compliance while protecting surveyors, limiting travel, and reducing disruption to hospital operations.”

While other AOs are suspending surveys in part or entirely, DNV “must meet federal requirements however, and CMS must approve any programmatic changes we make,” wrote Horine. “CMS continues to prioritize infection risk as a focus for all surveys in all provider types and DNV GL will apply this focus for the duration of the current crisis.”

A.J. Plunkett is editor of Inside Accreditation & Quality, a Simplify Compliance publication.