COVID-19 Pandemic: Accreditation Agencies Halt Surveys

In light of President Trump’s declaration of a national emergency with respect to the COVID-19 pandemic and so as not to distract vital health care providers from preparing for and caring for patients, three accreditation organizations with deeming authority from the Centers for Medicare & Medicaid Services (“CMS”) have decided to postpone surveys or modify their survey practices. Below is the most up-to-date information we have on accreditation agency survey changes.

The Joint Commission

Effective Monday, March 16, 2020, the Joint Commission (the “JC”) is suspending all regular surveying. The JC may carry out a limited number of surveys for high‑risk situations. For those organizations that go past their accreditation due date, accreditation will be extended without interruption. CMS has assured the JC that Medicare payment status will not be affected by a delay in an accreditation survey. The JC will provide further details on what surveys are proceeding soon.

We expect that the halt in the JC’s regular survey activities will last at least six weeks. The JC has stated that it does not at this time have an anticipated restart date.

Healthcare Facilities Accreditation Program

In response to CMS’s call for a suspension of most state agency and accreditation organization survey activities for an indefinite period, the Healthcare Facilities Accreditation Program (the “HFAP”) has curtailed its survey activities with certain exceptions enumerated below. HFAP surveys will continue for the following:

1. Incoming immediate jeopardy complaints alleging infection control breaches or abuse and neglect;
2. Complaint Surveys (lower level than immediate jeopardy (“IJ”)) alleging infection control breaches;
3. Currently scheduled Focused Resurveys;
4. Initial Surveys (for organizations without a CMS Certification Number);
5. CLIA laboratory surveys; and
6. Surveys of facilities with an IJ-level infection control deficiency in the last three years.

HFAP surveys may continue for the following:

1. Surveys of facilities with a history of infection control deficiencies (lower level than IJ);
2. HFAP accreditation surveys for which the facility and the surveyor have agreed to proceed.

The HFAP has provided certain reassurances and clarifications to its accredited facilities:

• For organizations whose reaccreditations are delayed due to the suspension of surveys, CMS will not assess any penalties. Since the survey suspension period is indefinite, CMS has not indicated any length of the “catch-up” period once survey activity resumes.
• For organizations that maintain certifications for specialized programs (e.g., stroke certification), the HFAP will permit organizations to move forward or postpone a scheduled certification survey. The HFAP surveyors also will have the option to decline to perform a survey which may lead to longer periods between application to on-site survey.
• The HFAP recommends that organizations NOT delay submitting applications during the public health emergency. Once the emergency lifts, having pending applications in hand will help the HFAP to efficiently plan and process its backlog of surveys.

Det Norske Veritas National Integrated Accreditation for Health Care Organizations

Det Norske Veritas (“DNV”) is preparing an advisory notice to be published shortly that will explain how it intends to manage accreditation surveys during the COVID-19 public health emergency. Here is what we know so far on DNV’s survey plans:

1. DNV does not intend to cancel all accreditation surveys but will be flexible with hospitals that wish to push back their survey dates. Many hospitals have requested a postponement and DNV has agreed to such postponements.
2. DNV is not conducting routine surveys in Washington, New York or California at this time.
3. DNV is assessing those hospitals that are due for survey between now and May and DNV will reach out to these hospitals to establish a survey date. DNV has proposed an option to the CMS for conducting some remote surveys.
4. DNV has requested that hospitals contact DNV through its Dropbox to advise DNV of the hospital’s circumstances.

Practical Takeaways

The COVID-19 public health emergency and the responsive governmental and NGO directives, orders and recommendations are evolving at dizzying speeds putting great pressure on hospitals and other health care facilities to adjust their responses nimbly. CMS’s and accreditation organizations’ decisions to postpone regular surveys and limit survey activity to that essential for safety will enable hospitals and health care facilities to direct their time and energy to caring for patients during the emergency.

For those hospitals that have already been surveyed and await a final report/recommendations/request for plan of correction, we recommend that the hospital reach out to its accreditation organization contact for information on whether the survey process will be completed timely or postponed. We also anticipate that the postponed survey activities will be reviewed on a weekly basis and the schedules could be further refined or updated.

Please stand by for updates on this topic.

Please refer to Hall Render’s COVID-19 resource center webpage and hotline at 317-429-3900 for any questions, as well as up-to-date information regarding the virus.

If you have any questions or would like more information on this topic, please contact:

• Brian Jent at (317) 977-1402 or bjent@wp.hallrender.com;
• Adele Merenstein at (317) 752-427 or amerenstein@wp.hallrender.com; or
• Your regular Hall Render attorney.