More and more hospital surveys may be onsite, depending on conditions

by A.J. Plunkett (

Be aware: As COVID-19 cases go down, your odds for on onsite reaccreditation survey might go up.

Until at least March 22, CMS is continuing to limit its onsite hospital surveys, except those involving complaints of immediate jeopardy to patients or in cases where patients are considered to be in eminent danger.

In a memo initially issued January 20 to CMS’ state survey agencies (SA) and revised on February 18, the federal overseer of Medicare said it was directing accreditation organizations (AO) to also limit hospital surveys based on certain criteria.

However, in many cases hospitals still may be subject to their regular onsite, triennial reaccreditation survey. And they will be unannounced, as usual.

DNV GL Healthcare, in an advisory to clients on February 15, said hospitals due for a triennial reaccreditation survey may be eligible for a two-week postponement, based on criteria provided to the AOs by CMS.

That criteria, according to DNV, states that your hospital cannot have:

  • A history of COVID-19-related complaints
  • Reported OSHA violations
  • Media reports about health or safety concerns

In addition, the main hospital facility must be in an area with a high prevalence of COVID-19 cases, and you must be able to show objective evidence of a heavy patient surge.

That evidence must be in the form of data you have reported to CMS, as required, about COVID-related cases, or documentation that you have informed your state health authorities that you have implemented crisis-of-care standards, as defined by the CDC, HHS’ Assistant Secretary of Preparedness and Response, or your state or local health authority, said DNV officials during a webinar explaining the new criteria on February 18.

CMS keeping a list

Be aware that CMS has told AOs that it is generating a monthly list of hospitals that are up for their triennial reaccreditation, but that also have COVID-related complaints, OSHA violations, or other health or safety concerns reported by the media.

Any hospital on that subset list must be surveyed on time and on site, DNV told clients.

Those facilities that qualify for a postponement maybe able to ask for another delay if they still face a heavy surge, but it is not automatic, said DNV.

Heavy prevalence of cases is determined by the positivity rate CMS has been publishing every week on its data website: While the site says it reflects nursing home data, it is the stated data CMS and the AOs have been using since last year to gauge surge.

The data is separated into county or locality and color coded, with red or yellow as areas with the highest number of current cases.

“Hospitals in low or medium-prevalence counties (10% or lower COVID-19 positivity over 14 days, indicated in green or yellow on the CMS table) that are due for reaccreditation in 2021, may now be scheduled for full onsite survey at any time,” noted DNV in its advisory. “These surveys will continue to be unannounced.”

If you are in a surge and within your reaccreditation window, and can show evidence of the surge as set out in the criteria, DNV sending information to the DNV client dropbox at

Criteria for onsite surveys continues to change

Since the COVID pandemic was declared last spring, DNV and the other AOs — The Joint Commission (TJC), HFAP and the Center for Improvement in Healthcare Quality (CIHQ) —have postponed or conducted virtual or remote surveys as allowed by CMS.

As of the end of January, most AOs were trying to do onsite surveys unless it was dangerous for their surveyors or for the hospital to host as they tried to meet an infectious surge.

The information from CMS continues to change. At one point CMS was allowing partial remote surveys, but said AOs would have to do full reaccreditation surveys onsite at a later date. TJC, HFAP and CIHQ all said they were trying to avoid having hospitals go through what amounted to a double survey.

On February 17, TJC issued a statement that while it had paused surveys through the end of May, it had been contacting organizations about the possibility of remote surveys.

“Currently, not all programs or organizations are eligible for an offsite event. For example, some states have restrictions on allowable offsite processes. As the pandemic has progressed, however, so has the eligibility criteria,” stated TJC. “Offsite events are conducted for eligible organizations located in counties at higher risk of COVID-19 transmission. However, if an organization is in a county determined to be at a lower risk of transmission, an onsite survey or review may still be scheduled if program-specific criteria are met.”

“If an organization meets criteria for an offsite survey or review, it will be contacted by another outreach method (email or phone call) by a member of The Joint Commission’s staff. After this initial outreach, a test of required technology will be scheduled. If an organization has not yet been contacted, it is likely because the organization is not currently eligible for this type of event,” according to TJC’s statement.

Overdue hospitals may go first

In addition, TJC said that “organizations with overdue survey and/or review events due to the pandemic may be prioritized over organizations with upcoming events. Questions may be directed to an organization’s designated account executive.”

DNV’s statement noted that “CMS will continue to monitor national conditions and may modify AO guidance at any time.  DNV GL will review any changes and communicate any future adjustments as they emerge.”

Many of DNV’s other survey activities, including its annual surveys, can be conducted remotely, said DNV officials. “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.”

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