Healthcare Compliance Updates: May 2021

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Healthcare Compliance Updates: May 2021


DNV GL has a New Name!

As of March 1, 2021, the CMS accrediting organization, DNV GL, has rebranded as just DNV. The current name, DNV GL, has been in place since the merger of Det Norske Veritas and Germanishher Lloyd in 2013. The merger is said to be complete and the name simplified to meet their mission. The healthcare division in the United States will be named, DNV Healthcare USA Inc. Also noted in the announcement:

  • All certificates with DNV GL name and logo remain valid for now
  • New DNV branded certificates will begin being issued on March 1, 2021
  • The transition timeline for certificates will be about 3 years
  • DNV GL and DNV brand will coexist for now
  • Most people already referred to the company as only “DNV”

TJC Resumes Unannounced Survey!

COVID 19 Pandemic saw a cessation in TJC accreditation surveys due to the risks to surveyors and the conditions in the hospitals being surveyed. However, surveys began again on March 15th. The CMS restriction on survey activities during January – February expired, so game is “on” again. Phone calls to determine which areas are “low” risk for COVID prior to the accreditation survey will also be halted. TJC invites hospitals to monitor the TJC site for notification that the survey is about to begin on the first day of the unannounced survey.

Organizations undergoing the accreditation survey should consider the TJC Survey Team as “essential workers” and follow the current CDC Coronavirus Guidelines. While on-site, the Team will do the following:

  • Practice safe physical distancing by limiting groups for tours and reviews
  • Wear personal protective equipment, including masks provided by the healthcare organization, for both the Team and reviewers
  • Utilize enhanced technology, including screen sharing or projection of documents and conference calls to promote physical distancing

If the circumstances in the organization’s area make the survey impossible, TJC will contact the organization to determine if the survey can be performed virtually or otherwise.

Assisted Living Communities to Be Accredited

As announced in the EC News (April 2021), TJC has developed an accreditation program for the Assisted Living Community (ALC), with the Standards published in July 2021. An estimated 30,000 ACLs are in the US, with more than 800,000 residents, which have undergone CMS reviews. The aim of the program is to ensure that highly reliable care, treatment, and services are provided in these locations. TJC states, “The ALC accreditation program standards were developed with consideration of scientific evidence and best practices, as well as with state regulations and the NFPA 101-2012 Life Safety Code.”

The accreditation process will include five performance measures to be reported, which are:

  • ALC-01: Off-Label Antipsychotic Drug Use
  • ALC-02: Resident Falls
  • ALC-03: Resident Preferences and Goals of Care
  • ALC-04: Advanced Care Plan/Surrogate Decision Maker
  • ALC-05: Staff Stability

The incorporation of current Environment of Care, Life Safety, or Emergency Management requirements is not known, but the essential core items are certain to be present in some form.



    Life Safety Code Compliance


Aisle Width in Suites to be Enforced

One of the consequences of the COVID 19 pandemic has been the recent enforcement by TJC and, potentially CMS, of the width of aisles allowed for suites in healthcare and other occupancies. As required in NFPA 101-2012, Section, aisles within suites must have at least 36” of clearance from side to side to facilitate egress (LS.02.01.20 EP45).

The major reason for the enforcement of the aisle, width requirement for a suite was because suites were being used to avoid “corridor” storage limitation during the pandemic. The requirements apply to:

  • Healthcare occupancies, according to the Life Safety Code
  • Hospitals and critical access hospitals using the Life Safety Code provisions for suites

Nursing care centers, behavioral health care and human services, or home care programs may also face this requirement depending on their building occupancies classification according to TJC (EC News, April 2021).


    TJC Findings

Summary of 2020 Survey Findings

The number of TJC accreditation surveys conducted in 2020 was approximately 20% of those surveyed in 2019, due to the COVID-19 pandemic. The list of the top citations followed the same pattern for both years, with five each for the Environment of Care (EC) and Life Safety (LS) standards. The top ten 2020 citations according to TJC’s EC News (December 2020) were:

  • LS.02.01.35, EP 4 Sprinkler systems; wires on sprinkler pipes
  • EC.02.06.01, EP 1 Safe environment; stained ceiling tiles & blocked electrical panels
  • EC.02.05.05, EP 6 Completion rate; non-high risk utility system components testing
  • LS.02.01.35, EP 14 Fire extinguishing; all “other” requirements in NFPA 101
  • EC.02.02.01, EP 5 Hazardous chemicals; eyewash risk assessment & documentation
  • LS.02.01.10, EP 11 Fire door hardware; positive latching and self-closures
  • EC.02.05.01, EP 9 Utility system labeling; emergency shut down – fire alarms breaker
  • LS.02.01.10, EP 14 Wall penetrations; improper material or gaps around pipes
  • LS.02.01.35, EP 5 Sprinkler heads; visible corrosion, dust, & paint
  • EC.02.05.09, EP 12 Gas cylinders; segregation full & empty cylinders & labeling

Even though a proper pressure relationship in critical areas (EC.02.05.01 EP15) was not on the list, it remains a “major” emphasis. This list provides a road map for survey preparation.

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