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What will your survey include? Some old things, some new

Surveys are resuming in areas deemed safe for on-site visits even as the coronavirus pandemic continues its waves of surge and decline. With COVID-19 still on everyone’s mind, expect to be asked for documentation of inspection, testing, and maintenance (ITM) of critical systems and to show lessons learned from the public health emergency (PHE).

CMS has permitted 1135 waivers during the PHE, which allow hospitals to delay such things as regular fire drills, ITM on some non-critical systems, the location of alcohol-based hand rub dispensers needed to ensure infection control, and certain requirements in temporary care locations. Other requirements are very much still in force, notes  Ernest E. Allen, ARM, CSP, CPHRM, CHFM, a former life safety surveyor and now a patient safety executive with The Doctor’s Company in Ohio.

Expect surveyors to require the same documentation of ITM on critical systems such as:

  • Monthly elevator recall testing
  • Monthly and annual emergency generator testing
  • ATS testing
  • Monthly and annual fire extinguisher testing
  • Fire pump testing
  • Daily inspection of means of egress during construction or implementation of Interim Life Safety Measures

As accreditation organizations (AO) have resumed surveys along with CMS, here are some of the things they have been looking at, according to Allen and other consultants, including Gayle Nash, RN, MPH, CEO of Nash Healthcare Consulting:

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