TJC & CMS News Blog
Information for

In light of COVID-19, CMS has suspended routine surveys. CMS wants to allow healthcare organizations to focus on their top priority – responding to the COVID-19 pandemic.

However, that suspension applies only to routine survey activity. It doesn’t mean all CMS surveys will cease. So, here’s an update on CMS survey activity and the types of surveys they will continue to conduct.

COVID-19: CMS Survey Suspension

On March 4th, CMS announced its Suspension of Survey Activities. They suspended “non-emergency inspections” across the country. This includes the validation surveys that CMS conducts on TJC accredited hospitals with deemed status.

CMS indicated the survey suspension is “time limited.” However, they did not set a date for resuming regular surveys.

At the same time, CMS made it abundantly clear they will continue to survey for the seven top priority areas they have established.

COVID-19: CMS Surveys – Top Priority Areas

CMS has identified the following areas as top priorities for which they will continue to survey healthcare organizations:

  1. All Immediate Jeopardy complaints and allegations of abuse or neglect
  2. Complaints alleging infection control concerns. This includes facilities with potential COVID-19 or other respiratory illnesses.
  3. Statutorily required recertification surveys for:
    • Nursing Homes
    • Home Health facilities
    • Hospice facilities
    • Intermediate Care Facilities for Individuals with Intellectual Disabilities (ICF/IID)
  4. Any re-visits necessary to resolve current enforcement actions
  5. Initial certifications
  6. Surveys of facilities/hospitals with a history of infection control deficiencies at the Immediate Jeopardy level in the last three years
  7. Surveys of facilities/hospitals/dialysis centers that have a history of infection control deficiencies at lower levels than Immediate Jeopardy

So, if your psychiatric hospital meets any one of these criteria, be aware that CMS may conduct a survey targeting these top priority areas.

COVID-19: CMS Survey Focus

In its March 4th memo, CMS outlined the scope of its survey process in facilities with active or suspected cases of COVID-19 infection. Surveyors will use a standardized tool to evaluate the facility’s compliance in the following areas:

  • Hand Hygiene
  • Personal Protective Equipment
  • Transmission-Based Precautions
  • Laundry Services
  • Infection Prevention and Control Policies and Procedures
  • Infection Surveillance
  • Antibiotic Stewardship Program
  • Influenza and Pneumococcal Immunizations

COVID-19: CMS and TJC in Sync

In TJC’s March 16th announcement re suspension of surveys, they addressed the issue of deemed status hospitals. COO Mark Pelletier indicated that “CMS has assured us that Medicare payment status will not be affected.” Certainly, that’s good news for all deemed status psychiatric hospitals.

For additional details on TJC survey activity during the pandemic, see our recent post The Joint Commission Suspends Surveys.

CMS and TJC Updates

In conclusion, we’ll continue to keep you posted on CMS and TJC communication about COVID-19 and their respective survey activities. Meanwhile, we send a message of support to all of our healthcare colleagues out there and deeply thank you for your dedication on the front lines.