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Quality in Nursing Center Care

A blog for and about The Joint Commission’s Nursing Care Center Accreditation Program.

On-Site Surveys Resuming for Nursing Care Centers (NCC) with New Safety Protocols


A female nurse in scrubs and mask  sitting down at a table with another female with a mask.

By Beverly Belton, MSN, RN, field director surveyor management and support, Division of Accreditation & Certification Operations

The Joint Commission has resumed accreditation surveys for nursing care centers, albeit in a different and very careful way. We understand the unique challenges facing nursing homes during this pandemic and are adapting our processes to best serve our accredited organizations and their residents. Here’s how.  
New Protocols for On-site Surveys 

Scheduling: When scheduling where to conduct the on-site visits, we first determine the potential availability of an area for survey. The area must have: 

  1. no state restrictions that would prohibit travel to the site
  2. sufficient testing available to accurately identify new cases (as indicated by a percent positive rate less than 20%)
  3. a new case trend within the past 14 days that is below 0.9
  4. fewer than 0.4 cases per 1000 residents in the last 14 days 

In addition we consider information from the NCC regarding the status of COVID-19 in their facility. Surveys remain unannounced.

Face Coverings: Surveyors are required to wear a face covering when traveling, and they are required to wear a mask throughout the survey process. If the organization requires staff wear additional PPE, surveyors would wear the same.  

Entering the NCC: Upon arrival, the surveyor will call the NCC’s survey coordinator from the parking lot to let them know they have arrived. The surveyor will wait in their car until the survey coordinator or their designee meets them in the lobby. Upon entering the facility, surveyors will follow the NCC’s policies for COVID-19 screening. During the survey process, surveyors will not enter the room of a suspected or known COVID-19 resident, and if possible, avoid visiting an area with a confirmed COVID-19 resident. 

When possible these areas will be surveyed using audio and or video technology. For example, we may conduct a telephone interview with a COVID-19 positive patient or tour a wing designated for COVID-19 positive residents by viewing the area remotely through an iPad or other tablet device controlled by a staff member in the area.

Physical  Distancing: Surveyors have been instructed to practice appropriate physical distancing during the survey. However, this may be challenging at times, for example while reviewing medical records. In those cases, we are asking organizations to consider using electronic methods to share records or allow the surveyor to review records alone. If this is not an option, we ask that surveyors sit as far away as possible from the person reviewing the record. Both parties should wear masks throughout the medical record review time.  

Reduced Staff Presence During Survey Activities: When conducting system tracers (especially the Life Safety building tour) in nursing care centers, the likelihood of maintaining six-foot physical distancing may be limited by the size of the facility. 

We ask that the number of people in the room be equivalent to the space that's available to observe physical distancing. Other participants should call in or use video technology to join the discussion. 

Managing COVID-19 Exposure 
First, surveyors will not be permitted to travel if they display symptoms or report close contact with an individual known or suspected  of  being COVID-19 positive. 

When on-site, surveyors may not enter rooms or wings with patients that are COVID-19 positive or are suspected to have a positive case. If there are procedures in these areas that are key to the survey process, surveyors will observe from outside of the room or watch via iPad. 

Opening Survey Discussion 
Opening discussions during surveys will center on nursing care center’s experience with COVID-19 in each of its patient populations. 

The Centers for Disease Control and Prevention (CDC) Nursing Home COVID-19 Preparedness Checklist, which most nursing care facilities, if not all, have already completed, will be reviewed. 

Infection Control Focus 
Many nursing homes have struggled with infection prevention for several reasons, including:

  • lack of resources and equipment
  • lack of protocols
  • ineffective implementation of plans

To help these organizations, an enhanced focus on infection control will be the central part of the survey. Through our dedicated infection control standards and expert surveyors who are well-versed of the CDC recommendations, we will model the correct implementation of an infection prevention and control strategies to educate and support, not punish, the nursing homes we survey. We also recognize that COVID-19 may have shifted attention from other infection control issues (i.e., MDROs, C.diff, etc) and we want to help nursing care centers restore that attention. 

Virtual Survey Process for Unique Circumstances 
Where our primary method for conducting surveys is on-site, the COVID-19 crisis has restricted travel, thus limiting our ability to conduct in-person events in some areas. When that occurs, we will consider, on a case, by case basis, the possibility of conducting virtual surveys.   

Our virtual process essentially models the on-site process but is performed using a combination of online programs Zoom and SharePoint. The process begins with organizations uploading requested documents to a secure site where the surveyor reviews them prior to interacting with the organization.  

The two-day virtual survey process is conducted via Zoom and includes individual tracers, system tracers, interviews with staff and patients and observations of key care processes. Upon completing the two- day virtual event, if the results of that survey are consistent with our requirements for accreditation, that organization will appear as accredited on Quality Check®.

Lastly, an on-site, one- day visit, will be conducted to allow surveyors the opportunity to conduct in-person observations not possible via Zoom and follow up on any areas with outlying questions. These on-site visits will be scheduled to be completed within 60 days of the end of the public health emergency. Having already conducted 29 virtual surveys, we’re confident this process captures 95% of what would normally be visually observed on-site. But when it comes to patient safety, we must be 100% sure. During the virtual survey process, we use a combination of visual observations, interviews, and document review to ensure a comprehensive assessment. The onsite visit will allow us to engage all of our senses in the survey process.

Role of Accreditors

While we’re all navigating these challenging times, our accredited organizations’ feedback has been consistent that our survey process do provide the framework to validate their compliance with those issues most important during a pandemic. 

Many nursing care centers are still—understandably—in survival mode. But, once the crisis has abated to the extent that an organization’s population has stabilized, our offer to partner in your quality journey still stands. We all have a shared goal:
the safest, highest-quality care and treatment. Period. 

Beverly Belton is presently a field director, NCC and HAP Programs, surveyor management and support in the Division of Accreditation & Certification Operations at the Joint Commission. Over the course of her career, Belton has worked in a variety of settings across the health care continuum-including the United States Army Nurse Corp. She has held clinical, middle-management and executive level positions. Belton has co-authored several articles on topics related to patient safety and infection prevention that have been published in peer-reviewed journals. In addition, Belton has served as a clinical instructor for students in the Graduate Entry Pre-Specialty in Nursing Program at Yale University.