The governing body (Board of Trustees) has the option to issue a written resolution to modify the frequency of committee meetings. The organization would be expected to hold meetings at a frequency that allows the organization and its medical staff to continue to conduct the business of the organization. The resolution would establish a frequency for meetings and the required attendance that is achievable for the members. This resolution should be memorialized in the meeting minutes of the governing body, as well as the minutes for any committees that has had changes to regular meetings.  Because this is a change due to emergency conditions, the governing body should pre-determine intervals to evaluate this decision and modify accordingly.

Relevant HFAP standards include, but are not limited to:

for Acute Care Hospitals
03.01.23 Medical staff bylaws: Meeting frequency and attendance
06.00.07 Utilization Review Committee meeting frequency and attendance
07.01.13 (2018v2 manual)/ 07.00.04 (2020 manual) [Infection Control] Committee (function) structure
11.01.03 Safety Committee
12.01.02 Quality Committee/function
25.00.00 Condition of Participation: Pharmaceutical Services

for Critical Access Hospitals
Safety Committee
05.01.04 Medical staff bylaws
05.01.20 Medical Executive Committee
09.01.03 Quality Committee/Function

for ASCs
01.02.03 Governing Body Bylaws Define Responsibilities
04.00.04 Quality Program Data
04.01.01 QAPI Committee/function
04.01.04 QAPI Committee Reviews Data.


HFAP has paused all survey activity through April. On April 15, we will make a decision about surveys in May. (THiS INFORMATION WILL BE UPDATED MONTHLY WHILE UNDER THE NATIONAL EMERGENCY DECLARATION.)

If it is not possible for us to complete a survey before your accreditation or certification is due to expire, provisions have been made to extend your expiration date so that neither your accreditation/certification nor your organization’s Medicare deemed status will lapse. Please reach out to your account manager directly, or to [email protected], with additional questions about your status.

Refer also to this news item.

You should submit your application on time whenever possible. If you need extra time due to the impact of COVID-19 on your organization or your community, please contact your account manager. When survey activity resumes, there will be a backlog of organizations to visit and having your application on-hand will facilitate our ability to plan and prioritize.


The clinical privileges of providers scheduled to expire during a period of national emergency (as declared by the President of the United States) may be extended for a period of 60 days. Upon activation of the organization’s Emergency Operations Plan, the governing body has the option to issue a written memorandum/resolution to extend clinical privileges of a practitioner for a specified time period unless prohibited by State regulations.
If the emergency continues beyond the time frame established for the extension, the governing body, in collaboration with the CEO, CMO, and President of the Medical Staff should reevaluate the need to continue.

Disaster privileges are one type of temporary privileges that may be granted upon activation of an organization’s Emergency Operation Plan. The hospital defines the clinical volunteers requiring disaster privileges. The hospital may use such volunteers within the scope of their license or certification.
The hospital must have a plan to verify each clinical volunteer’s identity, license, credentials, certifications, malpractice insurance, and privileges granted by other organizations, within 72 hours of activating the Incident Command Center, when possible.
This plan should provide for primary source identification from the volunteer’s hospital. A documented phone call is acceptable.
The volunteer’s identity and evidence of state professional license must be verified prior to providing patient care. Federal, local or state-based systems are used to verify the identity and credentials of health professionals, when possible.
Upon verification, temporary disaster privileges may be approved, as per the medical staff bylaws.
The medical staff must have a process to evaluate the performance of each clinical volunteer granted disaster privileges. Based on this evaluation, the hospital determines, within 72 hours of the practitioner’s arrival, if granted disaster privileges should continue.
Note: “Volunteer” refers to licensed medical professionals such as physicians, nurse practitioners, physician assistants, CRNAs, registered nurses, respiratory therapists, radiology technicians, surgical technicians, and others that come to an organization in response to a community emergency. For more information, see Acute Care Hospital standard 09.01.09 Volunteers.

Physicians and non-physician practitioners (NPP) currently credentialed and privileged by the organization do not require additional credentialing or privileging to provide the same service using telehealth technology.
Physicians and non-physician practitioners (NPP) that are not currently privileged by the organization will require credentialing and privileging prior to providing patient care using telehealth technology. The medical staff determines which services, if any, may be offered using telehealth technology. Disaster privileges may be granted for telehealth, in accordance the medical staff bylaws and state law.


In reference to the use of homemade facemasks, HFAP accepts CDC guidelines. Per the CDC, these are only to be used in “last resort” situations. Homemade masks are not considered PPE since their capability to protect is unknown  In a “last resort” situation a face shield covering the entire front and side of face is recommended for use in conjunction with the homemade facemask.

In reference to employees supplying their own PPE from home, a consideration of all conventional capacities should be made first and this option should again only be used in a “last resort” situation.

For information from the CDC, click here.

Here are CDC recommendations to optimize PPE supplies:

  1. Identify your organization’s inventory and supply chain.
  2. Determine your organization’s utilization rate.
  3. Communicate with healthcare coalitions (local, state, and federal) to identify availability of additional supplies.
  4. Reduce use, when possible, through the following strategies:
  • Increased use of telemedicine.
  • Limited interactions with isolation patients when providing care (e.g. patient blood draw is due around the same time a lunch tray would be delivered so the nurse draws blood and delivers the lunch tray. Healthcare workers should collaborate to eliminate multiple interactions and use of PPE)
  • Cohorting of patients.
  • Use of reusable supplies such as reusable goggles, respirators, and laundered gowns.
  • Use of supplies beyond manufacturers recommended shelf life for staff training and FIT testing.

For additional references, click here.


Relevant standards:

  • (Acute Care Hospital) 04.00.05 Competency
  • (Critical Access Hospital) 05.05.02 Competency
  • (ASC) 05.02.02 Emergency Personnel

Effective March 13, 2020, HFAP allows a 60-day extension for these certifications, as per the recommendations of the American Heart Association (below). The time frame may be extended if the AHA guidelines are revised.

from the AHA:

For Instructor Cards

  • In cases where an AHA Instructor cannot conduct training due to COVID-19 (e.g., the Training Center is in an area with widespread COVID-19 cases), the AHA will allow an extension of the validity of the instructor card for 60 days.
  • Management of this extension, and any record-keeping, will be the responsibility of the Training Center.
  • This allowance may be extended based on the evolving COVID-19 public health threat.

For AHA Provider Cards:

  • The AHA recommends that employers and regulatory bodies consider extending recognition of an AHA Provider Card beyond its renewal date, for up to 60 days. However, please know that it is ultimately up to the discretion of employers and regulatory bodies who require current AHA Provider Cards to consider allowing extensions during this time.
  • The AHA recommends considering extensions of up to 60 days, but this recommendation could be extended based on the evolving COVID-19 public health threat.

Excerpt from ACLS Instructor Manual:

“Students who present an expired provider card…may be allowed to take an update course but will not be given the option of remediation. These students will need to complete the entire provider course if they cannot successfully meet the full course completion requirements when tested. If the student fails any skills test, he or she should be referred back to the full ACLS Course.”

Over the next 60 days, for providers whose cards have expired due to inability to complete training during the COVID-19 outbreak, the AHA will allow the Instructor to provide remediation during update courses.