Now more than ever, healthcare provider organizations can benefit from leveraging the broad value of accreditation. Many people associate accreditation solely with compliance and the survey experience, but with the right partner, accreditation is the source of a business relationship that can help drive performance improvement, operating efficiencies, and risk management—all aspects of a successful business growth strategy—while maintaining regulatory compliance.
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.
The proposal could lead to changes in labels and SDSs employers would receive. For example, the agency is proposing a new provision for small container labels for containers with a capacity less than or equal to 100 milliliters (ml). Such labels would be required to include, at a minimum, a product identifier; a pictogram(s); a signal word; the chemical manufacturer’s name and phone number; and a statement that the full label information for the hazardous chemical is provided on the immediate outer package.
This action is expected to “address issues that arose during the implementation of the 2012 update to the HCS, and provide better alignment with other U.S. agencies and international trading partners, without lowering overall protections of the standard,” according to OSHA’s proposed rulemaking.
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.
Providers will have at least 60 days’ notice before the blanket waivers of certain Medicare Conditions of Participation and Conditions of Coverage will no longer be in effect. And you will have at least that much time to come into compliance. But you will still have to be in compliance when those waivers, which have allowed providers certain flexibilities to put resources and energy into meeting the challenges of the COVID-19 patient surges, end along with the PHE.
CMS officials said complaint investigations must and still will be carried out, but that to “ensure quality of care oversight, while providing hospitals the ability to focus on serving their patients and communities,” the federal agency is limiting the scope of hospital surveys for at least the next 30 days, with the potential for 30-day renewals to follow.
Long-discussed and first announced last fall, the new and revised requirements on workplace violence prevention are in the Environment of Care, Human Resources, and Leadership standard chapters.
DNV is also required to do another full reaccreditation survey onsite within nine months of the end of the PHE, said the announcement. Expect The Joint Commission and HFAP to follow suit as they work out details with CMS. However, the CEO for the Center for Improvement in Healthcare Quality said his AO was unlikely to change its current survey process.
As part of the Acute Hospital Care At Home program, CMS has established an online portal to expedite waivers of the Hospital Conditions of Participation statute. The statute includes several requirements for inpatient-level care, including the 24/7 availability of nursing services on the premises of a hospital-level care setting.