Equipment and Utilities ITM: Special considerations for surveys during, after COVID-19
As announced in late May, The Joint Commission has resumed limited survey activities this month. As organizations consider whether they are survey-ready, it is important to note that 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.
However, the PHE continues and there are several requirements in the Environment of Care (EC) chapter that relate to the inspection, testing and maintenance (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. The Joint Commission wants to be transparent in its survey process due to the criticality of these ITM-related elements of performance (EPs) provided in the tables (for the Hospital, Behavioral Health Care, Nursing Care Center and Home Health Care Accreditation Programs.
For the impacted EPs that have been deferred or waived during the PHE, current noncompliance would be scored, and the Evidence of Standards Compliance process would 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 the COVID-19 pandemic. 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 the impacted EPs listed in the table are found to be out of compliance after the organization’s established survey ready date, a requirement for improvement (RFI) will be scored.
If the organization is non-deemed, the normal post-survey process will take place. If the organization is deemed and an EP from one of the tables is scored, the cross-walked Centers for Medicare & Medicaid Services (CMS) Conditions of Participation (CoP) also would be evaluated. Whether the CoP would be scored at either standard or condition level would 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).
View the tables.