By A.J. Plunkett
DNV GL Healthcare just announced that CMS is now allowing it to conduct full, deemed, reaccreditation surveys remotely, under certain conditions.
In general, those conditions include that the hospital must be located in an area where the safety threat level from the COVID-19 public health emergency (PHE) is still high or medium, has had few or no infection control deficiencies during its last two surveys, has no condition-level deficiencies nor immediate jeopardy situations, and no outstanding ligature risk problems.
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 (TJC) 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.
“We are currently able to meet our survey schedules and obligations by going on-site and see no reason to put our hospitals through a double survey,” said Richard Curtis, RN, MS, HACP.
Since the beginning of summer DNV, like CMS and the other accreditation organizations (AO), has been conducting initial accreditation surveys remotely to broaden hospital capacity and meet the demand for inpatient beds during the COVID-19 pandemic.
CMS later allowed AOs to begin resolving outstanding hospital deficiencies found before the PHE, primarily involving a “desk review” that could also be done remotely.
However, full triennial surveys for reaccreditation still had to be done on site, if they could be done safely.
While TJC and others reported making several hundred on-site surveys by the end of summer, COVID cases began to increase again in many regions.
Discussions were underway earlier this fall between CMS and the AOs on when or how to resume full reaccreditation surveys.
While CMS requires all AOs to do full reaccreditation surveys every three years, DNV’s accreditation model is closely linked to ISO 9000 quality standards and therefore they are on site annually.
DNV’s announcement noted that it has been conducting these annual surveys when possible, if the hospital was not swamped with COVID patients.
“DNV GL currently conducts annual/periodic surveys in accredited facilities remotely using videoconferencing and other secure remote surveying tools and techniques. These surveys have been well-received by our hospitals and have been effective at assessing continued compliance with accreditation and certification requirements,” said the announcement.
“Where non-conformance is found, corrective actions are required following established procedures and timelines. DNV GL will continue to conduct these surveys remotely in 2021 as we continually assess the impact of COVID-19 and the PHE and adhere to CMS guidance.”
The announcement also noted that CMS had allowed initial accreditation surveys to be conducted remotely, and that CMS expected DNV — like the other AOs— to “repeat the full survey on site, with the full complement of surveyors and survey time, when it is safe to travel and survey. Recent procedural guidance from CMS requires this repeat on site accreditation survey to be completed within 9 months of the end of the PHE,” according to DNV.
“These recent changes to CMS procedure for AOs now also permit full, deemed reaccreditation surveys to be conducted remotely, under the following conditions:
- The hospital main facility must be located in a county with a medium or high rate of COVID-19 positivity, as published weekly by CMS at https://data.cms.gov/stories/s/q5r5-gjyu. (Although this data is expressed as “Nursing Home Data” CMS considers it uniform and reliable for hospital survey scheduling and planning.) NOTE: In counties categorized with low COVID-19 positivity, (shown in Green in the CMS data table) AO reaccreditation surveys must be performed on site and on schedule, following established AO procedure.
- The hospital must have had no non-conformances (NCs) in the Infection Prevention and Control requirements for the 2 most recent accreditation surveys. DNV GL considers the 2 most recent surveys to include any of the following; initial accreditation survey, annual/periodic survey, reaccreditation survey, complaint survey, or follow-up survey.
- The hospital must have had no substantiated complaints for 12 months prior to DNV GL scheduling the survey date. CMS requires AOs to consider complaints investigated by any agency with authority for complaint investigations in deemed accredited facilities.
- The hospital must have had no Condition-Level NCs or Immediate Jeopardy Situations of any kind in the most recent accreditation survey.
- The hospital may not have an open Ligature Risk Extension Request and must have no ligature related NCs in the 2 years prior to DNV GL scheduling the survey date.
- The PHE must remain in effect for reaccreditation surveys to be scheduled or conducted remotely
- DNV GL is required to repeat the full reaccreditation survey on site, with the full complement of surveyors and survey time, within 9 months of the end of the PHE. DNV GL remains the only AO with an established annual survey process, and we have proposed to CMS that our routine annual/periodic surveys be used to fulfill this requirement, with modifications as necessary to ensure the surveys are considered timely and complete.”
“The CMS requirement that all accreditation surveys must be unannounced remains in effect. For surveys conducted remotely, CMS has offered AOs the flexibility to communicate with their customers in advance of survey to plan the technology platform and logistics of the remote survey. DNV GL will contact the hospital 3 business days in advance of a remote survey to determine and test the best platform and procedure for inviting survey participants.”
“CMS has not made a provision to extend the timeline or conduct follow-up surveys remotely for condition-level non-conformance found during reaccreditation surveys. Required Follow-Up surveys will be conducted according to the existing timeline and procedure,” according to the announcement.
And just like the other AOs, DNV says that for “any survey activity conducted on site, surveyors will follow the organization’s protocols for screening, masking, sanitizing, and distancing, including use of videoconference technology to address restrictions on staff or access to higher risk areas within the facility. This can also include minimizing our cumulative time on site to complete a follow-up survey activity while completing the essential function of verifying compliance.”
DNV asks clients to direct question about the new survey processes to its drop box: DNVclientdropbox@dnvgl.com