However, the accrediting body for the Centers for Medicare and Medicaid Services (CMS) is gamely moving forward, using virtual technology for some facilities, and conducting on-site inspections at hospitals. In a May 3, 2022, webinar, several TJC officials answered submitted questions about infection control aspects of the survey, COVID-19 vaccine documentation needed for healthcare workers, and the extension of CMS 1135 waivers. Like everything else in pandemic, restoring the full survey process is a work in progress.
“As everybody knows, in the past two and a half years, if nothing else has been certain, it is the fact that everything changes,” said Diane Cullen, MSN, MBA, RN, CIC associate director of standards interpretation at TJC.
Cullen reviewed the traditional hierarchy of expectations, including compliance with applicable local, state, and federal regulations, including CMS conditions of participation (CoPs), as well as following manufacturers’ instructions for the use of medical equipment and devices. TJC’s default position for “evidence-based guidelines” are those from the Centers for Disease Control and Prevention (CDC).
“For hospitals, CMS for hospitals defers to evidence-based guidelines, and right now the big one we have is CDC interim recommendations,” she said.
To the extent a hospital uses other guidelines or methods, they should be ready to explain the rationale to surveyors.
“For the most part, it’s up to your organization to choose which evidence-based guidelines you’re going to be following and implement those into your policies and procedures,” she said. “If your state rules and regulations require you to follow a specific evidence-based guideline, then that’s what we’re going to be expecting.”
Hand Hygiene Non-Negotiable
Another key exception is that TJC infection control standards incorporate CDC guidelines for standard precautions, transmission-based precautions, and hand hygiene.
“Outside of those three things, it’s up to your organization to choose which evidence-based guideline you will follow,” Cullen said.
CDC masking recommendations for communities depend on the level of risk, and healthcare facilities in low or moderate community transmission areas may consider exceptions for staff who have had an initial vaccine series. (i.e., two doses for Pfizer and Moderna, one for Johnson & Johnson.)
“While it is generally safest to implement universal use of source control for everyone in a healthcare setting, … healthcare personnel who are up to date with all recommended COVID-19 vaccine doses could choose not to wear source control or physically distance when they are in well-defined areas that are restricted from patient access (e.g., staff meeting rooms, kitchen),” the CDC notes.1 “They should wear source control when they are in areas of the healthcare facility where they could encounter patients (e.g., hospital cafeteria, common halls/corridors).”
If state or local laws do not mandate masks for all healthcare workers, TJC expects infection preventionists and their colleagues to assess the hospital situation and adopt the appropriate masking policies.
“If regulation does not require masking, it’s the responsibility of your organization to evaluate the updated [CDC] guidelines and determine the best course of action for your staff, patients, and your visitors’ health and safety,” Cullen said. “Organizations that choose to not require masks for source control should be able to explain at the time of survey why they have chosen not to follow a national recommendation.”
Surveyors also will ask what process is in place to prevent and detect hospital transmission.
“What type of surveillance you’re doing to identify transmission, and what is your control plan should a transmission occur?” she said. “In addition, should you detect any transmission, do you have a plan in place for reporting that in your facility and to your state health department? If you’re unsure what is required, reach out to your state local health authorities to make sure that you’re compliant.”
Although COVID-19 booster shots are not required for healthcare workers as part of the CMS vaccine mandate, TJC will review the following required documents during surveys:
- overall COVID vaccination rate of eligible staff, excluding exempted staff;
- a list of all staff, including positions/titles, including COVID vaccination status;
- policies for COVID vaccination exemptions;
- policies for COVID vaccination requirements;
- policies for mitigation of unvaccinated staff;
- a list of staff newly hired in the last 60 days.
Q&A
The answers given to the pre-submitted questions during the webinar included the following.
Question: What will be the focus of TJC survey activities?
Answer: “During the opening conference on the first day, we will have a discussion with you and your team about the impact of the current pandemic and your organization’s response,” said Theresa Hendricksen, RN, MS, FACHE, field director of TJC. “We’ll discuss both infection control and emergency management at that time, besides separate system tracer conversations [following processes of care on selected patients]. The focus of our survey will not be on the timeframe of the public health emergency, but the current situation within your organization.”
Question: TJC uses secure technology to virtually conduct offsite survey and facility review for some organizations. Does that include hospitals?
Answer: “We are conducting offsite surveys for disease-specific care, freestanding behavioral health care programs, and telehealth and sleep centers,” Hendricksen said. “We are not currently doing virtual surveys for hospitals, and that’s due to CMS denied us that request. For the hospital program, you should expect only live visits.”
Question: How does TJC determine where to conduct onsite surveys?
Answer: “We’ve developed a community prevalence dashboard,” Hendricksen said. “We look at three different components to make a determination if a county is safe for survey. We look at the number of COVID-19 cases to ensure they’re lower — there’s less impact to the organizations in that community. We look at cases per thousand population and new cases within that county, and we determine if Joint Commission staff can travel to that area safely and find appropriate accommodations. During the height of the pandemic, many hotels and restaurants were closed, so that also prevented us. That’s no longer the case.”
Question: What instructions do you give your surveyors?
Answer: “First and foremost, follow the most current CDC guidelines,” Hendricksen said. “As my colleagues have said, those guidelines are updated and change frequently, and the surveyors know to continue to monitor that. We tell them do not travel if they are sick or if you’ve been in close contact with individuals with known or suspected COVID-19. We ask that they avoid large crowds and when traveling, we ask that they wear a mask and face covering. We ask that they practice physical distancing and practice good hand hygiene.
“And just a reminder that all Joint Commission surveyors and reviewers conducting onsite [surveys] are fully vaccinated as defined by the CDC. We ask that they review and follow individual state department of health-specific travel regulations,” she added. “Just a reminder that Joint Commission surveyors are designated as essential workers by the Department of Homeland Security. We ask that when onsite, that they wear a medical mask, and eye protection is encouraged. We also tell them that they need to follow your organization’s infection prevention and control policies for entry and use of PPE [personal protective equipment]. They will not enter at-risk or confirmed COVID-19 resident or patient rooms. They will also not enter rooms where high-risk procedures are performed, such as aerosol-generating procedures.”
Question: What has changed about the survey process?
Answer: “The survey process and the components will remain the same; however, here are some guidelines for your survey,” Hendricksen said. “We ask that you limit the number of individuals in group sessions. Any time that you can use technology rather than having people in the same room, we greatly appreciate it. Meaning if you use Skype or Microsoft Teams and people can be in other rooms to participate in those group conversations or your morning daily briefing that would be great. The use of masks will be a routine practice.
“Again, we maximize the use of technology to eliminate the number of people needed to sit directly next to an individual for an extended period of time,” she added. “For example, maybe we can look at screen sharing for [viewing] medical records. We will interview patients and staff by phone whenever possible, and for those of you who have home care and community services, we will be driving in separate cars to those offsite locations.
“Again, we will not enter an at-risk or confirmed COVID-19 room. We’ll do a limited physical review of high-risk and aerosol-generating procedures, and we will talk to your staff about using a simulation of those type of procedures rather than doing the actual procedure,” Hendricksen said. “We will practice social and physical distancing during the survey. We will follow PPE and risk-reduction strategies as established by the CDC. We’ve talked about limiting attendance in group sessions. We would ask that you limit observers or scribes to avoid additional exposure during the survey. We know that you want your team to learn and so we’re not saying none, but just try not to have 10 people following each surveyor.”
Question: CMS 1135 waivers allow facilities to waive some conditions of participation requirements during a national emergency like the pandemic. Examples include physical environment requirements like routine inspections and preventive maintenance. What is the status of these waivers?
Answer: “Once the effects of the pandemic begin to decrease or diminish at your organization, you should slowly move into normal operations or what the new normal looks like,” said Maura Naddy, MSN, RNC-OB, CJCP, senior associate director of SIG operations and quality assurance at TJC.
That said, waivers were extended as part of the Department of Health and Human Services’ April 16, 2022, 90-day extension of the public health emergency declaration, she added.
“The Joint Commission continues to work closely with CMS to ensure organizations are granted some amount of time to return back to full compliance with the CMS conditions of participation,” Naddy said.
Question: If we are using the 1135 waivers for documentation, is it expected that there is a specific policy written to cover this?
Answer: “The Joint Commission does not require all measures implemented during the pandemic to be documented within a policy; however, organizations would need to ensure that they have communicated and educated staff on the new policies and procedures related to those measures implemented,” Natty said. “How this is accomplished is ultimately determined by the individual organization.”
REFERENCE
- Centers for Disease Control and Prevention. Interim infection prevention and control recommendations for healthcare personnel during the coronavirus disease 2019 (COVID-19) pandemic. Updated Feb. 2, 2022. https://www.cdc.gov/coronavirus/2019-ncov/hcp/infection-control-recommendations.html
How far is The Joint Commission behind on healthcare accreditation surveys? By the end of June 2022, they expect to be caught up with scheduled inspections — for 2021. However, the accrediting body for the Centers for Medicare and Medicaid Services is gamely moving forward, using virtual technology for some facilities, and conducting on-site inspections at hospitals.
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