Healthcare Compliance Updates: February 2021

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Healthcare Compliance Updates: February 2021

What You Need to Know

ACCREDITATION INFORMATION – issues which could impact the survey process

In this healthcare compliance update, COHAN provides important new information related to CMS, TJC, and DNV, including survey processes during the pandemic.  For friends and clients within the survey window, we also provide some current survey focuses from client surveys from this September and October.

Centers for Medicare & Medicaid Services

In July 2020, the Center for Medicare and Medicaid Services (CMS) renewed The Joint Commission (TJC) as an Accreditation Organization (AO), but only for two years. This is a diversion from the usual 4-6 year extension.  Additionally, CMS stated it was “unhappy with TJC’s survey results” which many feel could lead to increased Conditional Level Deficiencies (CLD) for organizations during upcoming surveys.  CMS also stated TJC should focus on the Physical Environment, especially within off-site locations which could include Life Safety inspections.

The Joint Commission

Recently, a TJC presentation discussed the survey process during the COVID-19 pandemic State of Emergency, stating it will not survey an organization which is still operating under an Emergency Operation Plan that was initiated in response to COVID-19.  A “virtual” survey will be conducted for clients initially requesting TJC accreditations, but others will have the normal triennial survey when the community COVID-19 data indicates it is safe.  The CMS 1135 Waiver for a delay in complying with specific Inspection, Testing, and Maintenance processes can be used if the acceptance of the Waiver is documented.


DNV-GL will conduct its survey virtually for organizations in the first or second year of their Accreditation “Journey,” with the usual in-person survey being conducted in the third year.  An organization preparing for a third-year survey will notify DNV-GL when it is not in a State of Emergency for COVID-19, and community infections are at a safe level, as identified by local health officials.  The survey focuses on the organization’s response to the pandemic, as well as their response plan’s effectiveness and ability to be modified to correct any short-comings.


  Environment of Care

  • Document monthly, conductivity tests for maintenance-free generator batteries (EC.02.05.07 EP5)
  • Demonstrate annual inspection of elevator doors as “fire doors” per NFPA 80 (EC.02.03.05 EP 25)
  • Demonstrate the proper signage for locations containing positive pressured or central systems for medical gas (EC.02.05.09 EP4).

  Emergency Management

  • Document acceptance of 1135 Waiver issued by CMS for delay in ITM activities (EM.02.01.01 EP14)
  • Evaluation of response to the COVID-19 pandemic based on “six critical functions” (EM.03.01.03 EP7-12)
  • Demonstrate modification of Response Plans based on the evaluation or interim measures implemented, until corrective actions occur (EM.03.01.03 EP16).

  Life Safety

  • Demonstrate that exiting doors are not locked, which could limit a path of egress during any emergency (LS.02.01.20 EP1).
  • Provide accurate life safety drawings with the required “Fire Safety Features” information in the legend (LS.01.01.01 EP3).
  • Document the relocation directions in the Fire Response Plan for “permitted” wheeled carts in hallways (LS.02.01.20 EP14).

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