AOs ramping up for accreditation surveys

Hospital Safety Insider, May 21, 2020

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By A.J. Plunkett (

Get ready—The Joint Commission (TJC), DNV-GL Healthcare and HFAP have announced they are going start doing limited surveys in June. Meanwhile, the Center for Improvement in Healthcare Quality (CIHQ) said it has already begun reaccreditation surveys on a case-by-case basis. 

All four hospital accrediting organizations (AOs) followed CMS in March in announcing a suspension of regular survey activity as the coronavirus pandemic swept the nation. Complaint surveys have continued as needed. And at the urging of CMS, were to continue to conduct initial accreditation surveys for new healthcare facilities as a way to increase patient capacity during the COVID-19 national emergency.

DNV said in an online advisory dated May 13 that it would conduct remote surveys for annual review of its NIAHO® Standards compliance as well as condition-level follow up surveys as of June 1.

“If your annual survey is expected on or after June 1, 2020 you can expect to be a candidate for a remote survey,” said DNV, adding that if a facility remains in a COVID-19 surge area, has staff furloughed, or other challenges, the facility should reach out to DNV’s client offices “for further consideration.”

 “The remote survey has an advance notice provision process and will include a phone call to the primary contact approximately a week prior to the survey to discuss the process and any barriers or questions. There will be no surveys conducted remotely for Deemed status organizations whose next expected survey is for reaccreditation. These surveys remain suspended indefinitely until otherwise advised by CMS,” said the DNV notice. “CMS continues to assure us that lapses in accreditation due to the public health emergency will not affect Medicare participation, however, hospitals must still stay compliant with accreditation requirements and conditions of participation at all times.”

Meanwhile, HFAP posted an online notice on May 15 stating that it also expected to resume surveying in June. The AO said that it has been collecting weekly data from facilities since mid-March, “as each entered the six-month period (the “survey window”) prior to the stated expiration of accreditation/certification,” according to the notice.

The relaunch of surveys “will be a measured re-entry based on data collected from a variety of resources. In addition to the COVID-19 information provided by organizations, we will prioritize surveys based on past deficiency reports, regional and local outbreak ‘hot spots,’ geographic location of available surveyors to compose an appropriate team, and state and/or local travel restrictions, among other criteria,” said HFAP.

“We will continue to evaluate and re-assess the process on a case-by-case basis in order to minimize risk to our organizations and the communities they serve, as well as to our surveyors who will be assigned with a minimum of 14 days between surveys in most cases.”

HFAP also said that any organization with a pending application for reaccreditation or recertification that reached its expiration date before an onsite survey could take place would have its accreditation or certification automatically extended. “This includes Medicare-certification,” said HFAP.

While a spokesman said that HFAP has not conducted any initial accreditation surveys so far, the AO did seek and receive approval for an individual remote resurvey of an organization that had a Condition of Participation (CoP) out of compliance. However, HFAP has not sought approval from CMS  to conduct portions of any regular accreditation or reaccreditation surveys remotely. CMS would have to approve the process, according to the spokesman.

CIHQ has begun performing routine reaccreditation surveys, says its chief executive officer, Richard Curtis RN, MS, HACP, based on the following criteria:

The hospital must not be adversely impacted by the COVID-19 pandemic “so as to effectively prevent it from undergoing the survey safely (for both the hospital and our survey team).”

The hospital must have the ability, including necessary staff, infrastructure and logistical support, to facilitate the survey.

And CIHQ surveyors “must be able travel to/from the state in which the hospital is located without restriction or quarantine.”

If the facility did not meet those conditions for the reaccreditation survey, it was postponed until those conditions could be met, and “the hospital’s accreditation remains in good standing during this time – even if it exceeds its scheduled expiration date,” said Curtis, responding to questions by email.

CIHQ was managing follow-up and complaint surveys remotely, through correspondence, “unless there is a significant infection control concern; in which case an onsite survey may be performed,” Curtis said.

Meanwhile, new hospitals seeking to participate in Medicare were being scheduled for initial accreditation “as quickly as possible to get the hospitals into the Medicare pipeline and increase capacity in the system,” said Curtis.

In its advisory, DNV also indicated that initial accreditation surveys were going forward.

“CMS has also been quite clear that initial accreditation surveys are important to expand capacity of the health system, and will permit remote accreditation surveys for hospitals that are applying for initial participation in Medicare (855 Initial surveys) during the public health emergency, with a stipulation that these surveys be followed up with full onsite surveys when it is safe to do so. DNV GL Healthcare will work with new applicant hospitals to arrange initial accreditation surveys using the remote survey process,” said the DNV advisory.

In a brief statement released May 22 in response to questions, TJC officials indicated that surveys would begin again in June and that remote surveys were already being conducted in some cases.


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