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Post-Pandemic: Be Prepared To Explain How You’re Going To Catch Up

As many facilities have had their hands full with patient surges from COVID-19, the illness caused by the 2019 novel coronavirus, they’ll have work to do to ensure their environment of care is brought up to speed.

Be prepared to explain to surveyors how you will catch up with any inspection, testing, and maintenance (ITM) of non-critical systems that had been delayed because of the coronavirus pandemic.

Update logs and records for any ITM done on critical systems, and make sure you can show that your Emergency Operations Plan (EOP) was activated before you opted for any allowed waivers on maintenance of non-critical systems.

All accreditation organizations (AO) as well as CMS are working on backlogs of surveys delayed by the public health emergency (PHE) declared in March. Waivers will no longer be allowed once that PHE is lifted.

As many facilities have had their hands full with patient surges from COVID-19, the illness caused by the 2019 novel coronavirus, they’ll have work to do to ensure their environment of care is brought up to speed.


Hospitals are able to use their response to the pandemic as one of the two required annual disaster drills as long as the organizations can document activation of the EOP and show a review of their facilities’ performance, says Ernest E. Allen, ARM, CSP, CPHRM, CHFM, a former life safety surveyor and now a patient safety executive with The Doctor’s Company in Ohio.

Under its Emergency Management standards, The Joint Commission (TJC) requires the review to include management of six critical areas: communication, resources and assets, security and safety, staff, utilities, and care for patients.

Documents required by TJC ahead of surveys will likely include information on:

  • Your facility’s EOP plan
  • Fire response plans and drills
  • Fire protection equipment testing, to include quarterly, semiannual, and annual reports
  • Medical equipment ITM
  • Utilities
  • Emergency power
  • Medical gases
  • Safety management plans
  • Annual review

As TJC and other survey agencies have indicated, only surveys for initial accreditation to participate in Medicare will be done virtually. However, re-accreditation surveys may include some virtual elements as documents or patient records are reviewed on a computer and staff are interviewed by video or teleconference.

You may have up to a week to submit some documents to TJC, says Allen.


If you are experiencing a COVID-19 surge, reach out to your accrediting organization. TJC, HFAP, DNV-GL Healthcare, and others have indicated they do not want to interfere with facilities that are managing an ongoing pandemic response.

But expect surveys to intensify in areas where the pandemic response has not been as severe or is easing, say Allen and others.

“Basically, surveys are starting to occur where the COVID numbers are fairly stable,” says Steven MacArthur, a former hospital safety officer and now a senior consul­tant with The Greeley Company in Danvers, Massachu­setts.

That primarily has meant areas in the Northeast, though not exclusively, he says.

While CMS surveys had picked up again in June in Texas and Florida, they were to close out re-surveys for organizations that had received termination notices and had elected to use the Systems Improvement Agreement process to work back into the program, MacArthur says.

Survey activity may also depend on the availability of surveyors, he says.

“I think a lot of where they go is impacted by their ability to field survey teams,” he says.

For example, MacArthur says one of his clients in California had a TJC initial survey at the end of January and was expecting re-survey sometime in March. But then the pandemic was declared and surveys were temporarily suspended.

That facility has since had the follow-up survey, but the survey team was comprised primarily of surveyors from California, including a Life Safety Code® (LSC) surveyor that was part of the January survey.

While AOs are working to identify areas where COVID-19 cases are low, that doesn’t necessarily mean those areas include hospitals that are past due for survey, he notes.

“It does sound like the immediate focus is catching up on the survey activities that are most significantly in arrears/severity,” says MacArthur.


MacArthur and others say that from what they’ve been told, TJC and the other AOs may not get caught up on surveys until well into 2021. And while surveys may resume in your area, you may not see the same kind of survey you’ve had in the past.

While CMS has issued deficiencies for failures at hospitals during the pandemic, including facilities that did not follow their own pandemic-related infection prevention and control policies, the federal agency has said it will continue to focus on complaint surveys and closing out cases opened prior to the PHE.

It is also encouraging AOs to review how hospitals have responded to COVID-19 with lessons learned and improvements made to their processes and procedures, rather than scrutinizing cases from during the pandemic.

While that may offer some relief, note that TJC has also said it is changing the role of LSC surveyors in TJC survey teams. Those surveyors will no longer stay on the main hospital campus, but will also visit any off-site emergency departments and hospital-based ambulatory surgical sites.

In announcing the expanded role, TJC noted that these off-site settings have complex LSC requirements and that “the evaluation of the physical environment and Life Safety Code requirements by the Life Safety Code surveyor will allow the clinical surveyor(s) time to focus on the quality of care and services provided in these settings.”

“All other off-site locations that are visited by clinical surveyors will continue to be evaluated for physical environment and Life Safety Code requirements by the clinical surveyor with an enhanced focus on the business occupancy Life Safety Code requirements,” said the TJC announcement.

While the pandemic may not be over yet, you should be making an effort to return to pre-pandemic accreditation and survey readiness, says Deanna Scatena, RN, BSN, assistant director of certification services/accreditation services-standard interpretation dean for HFAP.

Even with waivers and delays in ITM of non-critical systems, you still are expected to provide a safe environment for your patients and staff.

Surveyors are aware of which hospitals have been making use of CMS waivers and know that you could be behind on some requirements, Scatena says—but expect them to ask how you’re going to catch up. “What is your plan so you don’t stay behind?”


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