CMS updates accrediting organizations on when to pause surveys

by A.J. Plunkett (aplunkett@decisionhealth.com)

DNV GL Healthcare, the second largest of the hospital accrediting organizations (AO), announced on February 5 that it was altering its on-site and remote survey process based on new guidance from CMS. The federal agency has told its own surveyors to suspend most surveys temporarily.

While CMS told AOs they could do the same, the Center for Improvement in Healthcare Quality (CIHQ) CEO Richard Curtis RN, MS, HACP, told Accreditation Insider that they had no plans to change current practices.

The Joint Commission (TJC) said it has reviewed the CMS memo on suspending hospital surveys for 30 days. “The Joint Commission has submitted clarification questions to CMS and will know more about our direction after we hear back. In the meantime, we continue to conduct on-site surveys in low-risk counties for COVID-19, as well as off-site surveys,” said a TJC statement.

CMS’ Quality, Safety & Oversight Group promised new guidance to AOs on when to suspend surveys as part of an announcement on January 20 that the agency was temporarily suspending or limiting on-site surveys because of the COVID-19 patient surge.

CMS told its own state survey agencies in January it was putting a general hold on hospital surveys, except for those dealing with immediate jeopardy situations, for at least 30 days, in recognition of growing COVID-19 patient surges in many areas.

At the time, CMS said AOs were also being asked to do the same, but that more information would be made available to the AOs later. DNV President Patrick Horine, MHA, told IAQ at the time that the memo seemed to catch some people even inside CMS by surprise.

Horine also reiterated what DNV, The Joint Commission and other AOs have said in the past—if a hospital is within their three-year survey window but is in the middle of a COVID patient surge, hospital accreditation officers should inform their AO liaison.

Similarly, CMS has said that hospitals and states where crises of care protocols were being implemented or considered should also reach out to the federal agency for help.

DNV’s latest announcement noted that the newest CMS’ guidance again is based on the county-level positivity data—ranked as red, yellow, and green—the agency has been collecting to use, in part, as a starting point for if and when a facility can be surveyed. Hospitals in areas with high positivity rates, meaning there is a higher COVID-19 patient surge, have a lower priority for survey.

CIHQ said in note to clients that AOs received a letter from CMS on February 1 requesting “a hold on most routine reaccreditation surveys scheduled to be performed through February 19, 2021. The hold can be extended for additional 30-day increments for the duration of the public health emergency (PHE). This follows a notification to State Agency’s earlier in January to do the same.”

The Texas-based AO said, “during this time, CMS has instructed AO’s to base the decision to proceed with scheduled reaccreditation surveys on State/County COVID-19 prevalence data. CMS utilizes a green (mild) to red (severe) color coded display of the data which is updated in 14-day increments.”

CIHQ told clients that “reaccreditation surveys will continue to occur as scheduled for any hospital that is in a ‘green’ zone. For hospitals in any other zone (yellow through red), the AO may delay the survey for up to two weeks if the situation in the hospital would make a survey burdensome or otherwise not advisable.”

In addition, CMS has also given CIHQ and the other AOs “the option of utilizing a ‘Hospital Focused Modified Reaccreditation Survey Model’ (HFMS). If an AO chooses to do so, CMS will provide the AO with a list of hospitals due for reaccreditation that will receive an HFMS survey, regardless of their county prevalence. Hospitals will be placed on this list based on the following:

  • Complaints received by the AO (or immediate jeopardy occurrences) during the PHE related to infection control and patient safety;
  • Media reports regarding health and safety concerns during the PHE; or
  • OSHA violations during the PHE.”

“The HFMS model consists of limiting the number of surveyors/days on-site and conducting aspects of the survey remotely (virtually). Activities such as patient interviews, observations of care, limited building tours, infection control observations, and assessing restraint use would be conducted on-site. Other activities such as document review, medical record review, and staff / leadership interviews would be done remotely. An AO will be required to submit specific policies and procedures to CMS for approval before being granted permission to perform an HFMS,” wrote CIHQ.

“This allowance is different than that which may have been previously granted to an AO to perform virtual surveys requiring follow-up on-site surveys once the PHE ends. Under the HFMS model, it appears the survey will be accepted by CMS. A hospital would not be required to undergo a second reaccreditation survey once the PHE ends.”

According to DNV:

“Based on the new guidance, DNV GL is adjusting our schedule of NIAHO® accreditation surveys for hospitals, critical access hospitals and psychiatric hospitals to align with the new CMS survey priorities, effective immediately:

  • Hospitals in low-prevalence counties (less than 5% positivity over 14 days, indicated in Green on the CMS table), that are due for reaccreditation in the first half of 2021, may now be scheduled for full onsite survey at any time. These surveys will continue to be unannounced.
  • Hospitals in medium- or high-prevalence counties (5% or greater positivity over 14 days, indicated in Yellow or Red on the CMS table), and who are also near or beyond the accreditation effective date shown on their NIAHO® certificate, will be prioritized for county prevalence monitoring and scheduled for unannounced survey as soon as county prevalence drops below 5%.
  • Other DNV GL accredited hospitals in medium- or high-prevalence counties with reaccreditation due in 2021 may be considered for HFMS survey if the suspension period is extended beyond February 19. If the suspension period ends February 19, DNV GL will begin scheduling reaccreditation surveys as soon as possible with priority based on certificate expiration dates and prior year survey timing. CMS may provide subsequent revisions to prioritization at that time and we will communicate any adjustments as they emerge.
  • Annual/Periodic accreditation surveys in all counties will continue to be conducted remotely until further notice. Hospitals that are expecting an annual survey (non-reaccreditation) in the first half of 2021 may be scheduled for survey at any time. These surveys remain unannounced but we will continue to follow the advance notice provision in our established procedure for remote surveys.”

The DNV announcement went on to say that the AO “is considering participation in the HFMS program and is working with CMS on practical implementation matters, the likelihood of additional 30-day suspension periods, and potential benefits to our accredited hospitals. CMS is also developing lists of hospitals for each AO, identifying specific hospitals that meet qualifying criteria for the HFMS program and those that must have a 100% onsite survey. We will provide more information on HFMS participation, program details and qualifying criteria once we have more information and approval from CMS.”

DNV GL said its “survey and audit activities that are not governed by CMS QSO oversight, such as service-line certification programs, ISO-only audit activities, CIP, VAD and annual/periodic accreditation surveys are not subject to these restrictions but may still be limited due to local COVID-19 conditions. DNV GL may continue conducting these surveys remotely, or onsite where it is safe, so if your hospital has been provided a date or advance notice of any of these activities, please be prepared to continue with survey until further notice or clarification from DNV GL.”

The CIHQ letter to clients observed that CMS’ “request to hold /postpone reaccreditation surveys reflects the ongoing challenges [of a] ‘business as usual’ method during the pandemic. The allowance for a HFMS model is likely the result of requests by some AOs for increased latitude in conducting reaccreditation surveys to avoid extensive backlog.”

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