Acute Care Hospitals
Critical Access Hospitals
Ambulatory Surgery Centers
Clinical Laboratories

Please share this with individuals in the following roles:
Accreditation Coordinator
Quality Director
Medical Director – Laboratory services

Key points:

CMS has issued guidance to the state agencies for conducting resuming state surveys and prioritizing the backlog of surveys. For all surveys, CMS will continue focusing on infection prevention and control.
Desk reviews may be performed by State surveyors for all open surveys that cited any level of noncompliance, including noncompliance that was cited at the IJ level when the IJ finding was verified as removed or moved to a lower level of noncompliance. The only exception to the expanded offsite review policy is unremoved IJs, which require an onsite revisit. This expanded desk review policy applies only to outstanding enforcement actions which were held per QSO 20-20-All memorandum, from March 23, 2020, through May 31, 2020.

CMS has defined the prioritization of the surveys for hospitals, CAHs, and ASCs as follows, in descending order of priority:

  1. Revisit surveys, for past non-compliance that do not otherwise qualify for a desk review;
  2. Complaint surveys triaged as non-IJ level or IJ that have not been completed;
  3. Special Purpose Renal Dialysis Facilities;
  4. Initial surveys of new providers;
  5. Past-due recertification surveys with a statutorily required survey interval;
  6. Past-due recertification surveys without a statutorily required survey interval.

CMS has defined the prioritization of the surveys for CLIA Laboratory Survey Activities as follows:

  1. Perform on-site surveys, considering individual laboratory location limitations and restrictions.
  2. Complaints that represent situations in which immediate corrective action is necessary.
  3. Any revisit to resolve current enforcement actions;
  4. Recertification actions for certificates that have been extended to August 31, 2020, and any other soon-to-expire certificates;
  5. Initial certifications;
  6. And lastly, other complaints.

Validation surveys for accredited hospitals, CAHs, and ASCs will resume, based on a State’s reopening and availability of resources, but validation surveys for laboratories and Provider Performed Microscopy Project surveys will not resume at this time.

Are any HFAP Standards affected? No. This is provided for information only.
Effective date: August 17, 2020
Read the entire memo here.

If you have questions please contact