CMS announced on March 5, 2020 that the majority of deemed status surveys would be suspended due to the threat of COVID-19. This policy has been revised to allow hospital, CAH, and ASC surveys performed by HFAP and other accrediting organizations to resume.
The four accreditation organizations (AO) with deeming authority for hospitals (HFAP, DNV, CIHQ, TJC) met with CMS (David Wright, Director, Quality Safety & Oversight Group, Karen Tritz, Director, Division of Acute Care Services, and additional Baltimore office staff) via conference call on March 6 at 2:00 pm CT. The impetus for the call was a request for additional clarification of intent and action regarding the suspension of survey activities.
“The recent CMS survey guidance was unprecedented,” said Mr. Wright, who explained 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.
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 will develop criteria to guide its survey decisions and specific surveys may be postponed without penalty to the provider.
In the coming days, HFAP will be developing a full set of criteria but our initial concern is to launch a communication process that includes:
- Developing guidance for all organizations to proactively report presumptive or confirmed cases of COVID-19.
- Contacting organizations within their survey window to make an environmental check to establish the feasibility of going forward with a tentatively scheduled survey. We may ask:
- Are you experiencing community actions: school closings, quarantines, etc.?
- Are you experiencing staffing shortages/furloughs?
- Are you experiencing an influx of COVID-19 testing requests?
- Do you have/ have you had presumptive or confirmed cases?
- Is CDC onsite?
Based on this conversation, we will make a determination about postponing a survey.
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.