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Post COVID-19: Scoring Compliance Issues When Returning to Survey

06/22/2020

By Robert Campbell, PharmD, director, Clinical Standards Interpretation for Hospital/Ambulatory Programs

The Joint Commission recently announced its plan to return to survey activity. As we begin to resume limited surveys, accredited organizations may be wondering how we will score compliance issues related to the inspection, testing and maintenance (ITM) of equipment and utilities given current waivers and deferments in place.

As organizations consider whether they are survey-ready, it is important to note that the scoring of items that are not compliant will not be the primary focus during the declared time period of the public health emergency (PHE) – defined as March 1, 2020, through the organization’s survey ready date or the end of the PHE, whichever is first.

Our surveyors also will not focus on the implementation of an organization’s emergency operations plan (EOP). Rather, we will work to understand how your organization has adapted to the COVID-19 pandemic and review your current practices to assure you are providing safe care in a safe environment. 

As the PHE continues there are several requirements in the Environment of Care (EC) chapter that relate to the ITM of equipment and utilities. If these equipment and utilities are left unchecked for a full accreditation cycle, they could potentially have a significant impact on the physical environment and raise serious safety concerns.  

Deferred or Waived Elements of Performance (EPs)
For impacted EPs that have been deferred or waived during the PHE, current noncompliance will be scored, and the Evidence of Standards Compliance process will be utilized. The focus will not be on continuous compliance during the PHE as The Joint Commission understands that some requirements may have been impacted based on the effects of COVID-19. 

Therefore, The Joint Commission’s focus will be on an organization’s current compliance at the time of survey. At the time of survey, if any of the impacted EPs listed below are found to be out of compliance after the organization’s established survey ready date, a requirement for improvement (RFI) will be scored.

To be as transparent as possible, here are ITM-related EPs for the Hospital, Behavioral Health Care, Nursing Care Center and Home Health Care Accreditation Programs: 

Hospital Accreditation Program

  • EC.02.03.01 (free and unobstructed egress), EP 4
  • EC.02.03.03 (fire drills), EPs 1, 2
  • EC.02.03.05 (fire protection and suppression), EPs 1, 2, 3, 4, 5, 7, 8, 9, 10, 11, 12, 13, 14, 16, 17, 18, 19, 20, 25
  • EC.02.04.01 (medical equipment risk), EP 4
  • EC.02.04.03 (medical equipment ITM), EPs 2, 3, 10, 20, 21, 22, 23, 24, 34
  • EC.02.05.01 (utility systems risk), EPs 22, 27
  • EC.02.05.05 (utility system ITM), EPs 4, 5, 6, 7 
  • EC.02.05.07 (emergency power systems ITM), EPs 3, 4, 9, 10
  • EC.02.05.09 (medical gas and vacuum ITM), EP 7

Behavioral Health Care Accreditation Program

  • EC.02.03.01 (free and unobstructed egress), EP 4
  •  EC.02.03.03 (fire drills), EPs 1, 2
  • EC.02.03.05 (fire protection and suppression), EPs 1, 2, 3, 4, 5, 7, 8, 9, 10, 11, 12, 13, 14, 16, 17, 18, 19, 20, 25
  • EC.02.04.01 (medical equipment risk), EP 4
  • EC.02.04.03 (medical equipment ITM), EP 3
  • EC.02.05.07 (emergency power systems ITM), EPs 3, 4

Nursing Care Center Accreditation Program

  •  EC.02.03.03 (fire drills), EP 1
  •  EC.02.03.05 (fire protection and suppression), EPs 1, 2, 5, 10, 13, 16
  • EC.02.04.01 (medical equipment risk), EP 4
  • EC.02.04.03 (medical equipment ITM), EPs 2, 3
  • EC.02.05.05 (utility system ITM), EPs 4, 5, 6 
  • EC.02.05.07 (emergency power systems ITM), EPs 3, 4, 9, 10
  • EC.02.05.09 (medical gas and vacuum ITM), EP 7

Home Care Accreditation Program (Inpatient Hospice)

  • EC.02.03.05 (fire protection and suppression), EP 25
  • EC.02.05.01, EP 30

Non-Deemed vs. Deemed Post-Survey Process
If the organization is non-deemed, the normal post-survey process will take place. If the organization is deemed and an EP from the above list is scored, the cross-walked Centers for Medicare & Medicaid Services (CMS) Conditions of Participation (CoP) also will be evaluated. 

Whether the CoP is scored at either standard or condition level will be based on the following guidance:

  • Standard Level: If the issue is out of the organization’s control and evidence that an attempt was made to resolve the issue is provided.
  • Condition Level: If the issue is not out of the organization’s control and no attempt was made to resolve the issue (only applicable if the findings met manner and degree for condition level).

We look forward to working closely with organizations as they begin to recover from COVID-19. Together, we can ensure that ITM equipment and utilities remain safe during and after the recovery phase of the pandemic. 

Robert Campbell, PharmD, is director, Clinical Standards Interpretation Hospital/Ambulatory Programs and director, Medication Management. Prior to these roles, he served as the pharmacist for Clinical Standards Interpretation in the Division of Healthcare Improvement at The Joint Commission. Campbell also surveys as a field representative for The Joint Commission in the Hospital Accreditation and Critical Access Hospital Accreditation Programs and is a reviewer in the Medication Compounding Certification Program. Prior to joining The Joint Commission, Campbell worked in health care organizations and held leadership positions with oversight responsibilities for performance improvement, accreditation readiness, risk management, infection control, medical staff services, as well as inpatient and outpatient pharmacy services.