February 17, 2021

Joint Commission conducting both virtual and onsite surveys in 2021

By: Judith M. Mathias, MA, RN
Tags: ,

The Joint Commission stopped doing most onsite surveys and reviews from March 16 to May 31, 2020, in response to the COVID-19 pandemic. During that time, they developed processes for conducting offsite or virtual events, and as of mid-December, more than 1,200 offsite surveys and reviews had been conducted across all accreditation and certification programs.

Some surveyors are resuming on-site surveys in areas where the incidence of transmission and positive cases of COVID-19 has diminished.

John R. Rosing,

“CMS [Centers for Medicare & Medicaid Services] very much wants the Joint Commission and other accrediting organizations to start surveying on-site again,” says John R. Rosing, MHA, FACHE, executive vice president and principal, Patton Healthcare Consulting, Naperville, Illinois.

Before surveyors schedule an on-site survey, they do extensive research into what phase a community is in, and they also call hospitals and ask about their conditions. “The surveys are still unannounced, but they may include a virtual, offsite component for which there will be some advanced warning to allow for the uploading of documents to a secure SharePoint or similar document sharing application,” Rosing says.

At the 2020 OR Manager Virtual Annual Conference, he presented updated information on Joint Commission standards and CMS regulations that organizations will need to know for their next survey, whether in person or virtual.


How are the Joint Commission and CMS related?

The Joint Commission is a private not-for-profit accreditation organization (AO) governed by 29 board members representing various healthcare constituencies.

The Joint Commission and three other AOs have earned “deemed status” with the federal government’s CMS to survey on behalf of CMS, hospitals, and other healthcare organizations that receive Medicare or Medicaid funding in order to determine compliance with the CMS Conditions of Participation (CoP). The CoP are the regulations promulgated over time that specify the health and safety requirements that hospitals must meet to participate in the Medicare and Medicaid programs. The Joint Commission standards closely mirror the CoP.

CMS monitors the performance of deemed status AOs via state agencies and regional offices, by conducting validation surveys of about 5% of facilities that have had a survey by any of the AOs. These validation surveys by CMS are unannounced and occur about a month after the AO survey, but in recent years CMS has piloted performing the validation survey concurrent with the AO survey.

CMS does the survey to see if its surveyors can observe additional findings that the AOs missed.

The difference between what CMS and the AOs find is called the “disparity rating,” and it can run in excess of 40%, which is significant, says Rosing. “This disparity rating is one tool CMS uses to encourage more rigorous surveys from accrediting organizations.”


Post-survey Decision Categories

The result of a Joint Commission survey is known as an Accreditation Decision.

One category of Accreditation Decision is termed “denial of accreditation.” This is given to an organization that is in “deep trouble with compliance and is a very rare event,” says Rosing. Other categories are “preliminary denial of accreditation” and “immediate threat to health and safety (ITHS).”

Another category, “accredited with findings,” is what most hospitals receive as a result of their surveys. “It means they are accredited, but they have findings to correct,” he says.

Number of adverse events affecting different categories of accreditation an organization receives, 2018 & 2019. Source for all images: John R. Rosing. Used with permission.

The most recent Joint Commission data on the array of accreditation decisions include (sidebar, “Adverse Events by the Numbers”) the following:

• 2018: One denial of accreditation, 114 preliminary denials of accreditation, and 29 ITHS.

• 2019: Two denials of accreditation, 57 preliminary denials of accreditation (half as many as 2018), and 21 ITHS.

Number and types of adverse events related to the immediate threat to health and safety category of accreditation.

Adverse events related to the ITHS category include (sidebar, “Adverse Events Breakdown of Immediate Threat”) the following:

• 2018: Nine environment of care or life safety events (ECLS), four clinical events, and 16 infection control events.

• 2019: Seven ECLS, six clinical events, and eight infection control events.

Adverse events also can cause a “condition-level deficiency,” which is where the connection between the Joint Commission and the CMS CoP come into play, says Rosing. Joint Commission surveyors use a scoring algorithm that looks at noncompliance with standards that are considered high risk, and gauges how widespread the issue is across an organization.

In 2019, 45% of US hospitals reached the threshold of a condition-level deficiency. “That is almost half of hospitals, and that is significant,” says Rosing. A hospital with a condition-level finding had to do an immediate correction of the issue and have a follow-up survey within 45 days to verify resolution of the problem.


How the coronavirus factors into surveys

“It is time to add coronavirus to your annual infection prevention risk assessment,” says Rosing. “When you are surveyed, they’re going to be looking carefully at how you reacted to the CMS and CDC [Centers for Disease Control and Prevention] bulletins that began to come out in early March and April 2020 and whether you adopted those guidelines for your organization.”

The Quality Safety and Oversight (QSO) Group 20-09 memo from CMS contains numerous CDC links to protocols that hospitals need to follow, as well as guidance on:

• patients scheduling appointments

• EMS (emergency medical services) bringing patients to providers

• separating out patients with respiratory illness

• providing rapid triage and isolation

• providing patient waiting areas with hand sanitizer, tissues, and face masks

• healthcare provider adherence to precautions

• management of visitors to patients with coronavirus

• guidance for home care providers.

The CDC also added more recommendations after the Middle East Respiratory Syndrome was first reported in 2012 and updated them in 2019.

They include:

• minimizing chance for exposures

• ensuring adherence to standard, contact, and airborne precautions

• managing visitor access and movement within the facility

• implementing engineering controls

• monitoring and managing exposed healthcare personnel

• training and educating healthcare personnel

• implementing environmental infection control

• establishing reporting within hospitals and to public health authorities.

“Facilities likely did all of these things, perhaps somewhat chaotically at first, as they were trying to figure out what the best practice was, what the requirements were, and how they were going to protect themselves, their staff, and patients,” says Rosing.

In 2021 surveys, the surveyors will try to do a retrospective review on how facilities executed these processes, he says.

Earlier in 2020 as the pandemic took hold, CMS and, thus, the Joint Commission issued what are known as “1135 waivers.” The waivers allowed hospitals to relax certain regulations without subsequently being cited for doing so, he says. For example, the role of telemedicine was expanded so that personal providers could avoid having direct contact with patients.

The Joint Commission does not plan to look at patient records generated during the period of the Public Health Emergency, notes Rosing. However, they will try to ascertain whether organizations complied with CDC, state, and local guidelines.


Maternal mortality

New for 2021 is a focus on maternal mortality standards. The US has the worst maternal mortality rate of any developed nation, and the rate keeps getting worse, says Rosing.

In 2018, the Joint Commission introduced three new infection-related standards in the Provision of Care (PC) chapter—PC.01.02.01 EP 14, 15, and 16—to improve identification of mothers at risk of transmitting infections to newborns, including:


• hepatitis B

• group B Streptococcus

• syphilis.

As of January 2021, PC.06.01.0—Reduce the likelihood of harm related to maternal hemorrhage—is required.

It includes:

• evidence-based assessment tool to determine hemorrhage risk

• evidence-based procedures for management of hemorrhage during pregnancy and postpartum

• hemorrhage kit

• staff education

• annual drills (real patient events don’t count)

• case debriefing reviews (to learn what went well or what to improve)

• patient education.

PC.06.01.03—Reduce the likelihood of harm related to maternal severe hypertension/preeclampsia—is also required.

It includes:

• evidence-based procedures for measuring blood pressure (identification of severe range blood pressures)

• evidence-based procedures for management during pregnancy and postpartum

• staff education (emergency departments at all hospitals)

• annual drills (real patient events don’t count as drills)

• case debriefing reviews

• patient education.

A new core measure on public reporting of high c-section rates also began in January 2021.


New focuses for 2020 into 2021

The Joint Commission had several new focuses beginning in 2020 that are now a priority in 2021.

NFPA. New in hospitals is a requirement by the National Fire Protection Association (NFPA) for additional testing and a risk assessment for utilities, such as medical gases and electrical equipment. Different utilities must be categorized into high, moderate, or low risk, depending on the seriousness of whether a failure would cause harm or death to a patient or staff member.

“In this way, you are trying to isolate those higher-risk components and make sure you have an inventory of them, and you are inspecting them with greater regularity and rigor, so that you are ahead of the curve in the event you identify some wear and tear or a potential failure,” says Rosing.

Hospitals also must have an elaborate labeling system for their utilities to facilitate partial or complete shutdown.

“You have to know, for example, which valve to turn off to handle medical gases in certain corridors,” says Rosing. “This is more than just the typical set of valves you usually have in your OR. Those isolate one room. These labels are above the ceiling, in mechanical spaces, and other areas that typically have not been well labeled in the past. This is a whole new expectation.”

Fire alarm circuits, also in the high-risk category, must be clearly labeled, and access is restricted to authorized personnel. Also, a legend to identify what area or device each breaker controls is needed (sidebar, “EC.02.05.02, EP 9”).

Fire alarm circuits must be clearly labeled, and a legend to identify what each breaker controls is needed.

“Over the years, this has sometimes become sloppy as wiring gets rerouted and the legend doesn’t get updated,” he adds.

Power strips. Power strips often are used where there is a lot of equipment in an older part of the hospital. “You can’t use any old power strip. To avoid electrical arcing, spark, or short circuit, you need underwriter laboratory (UL)-listed 1363A or 60601-1,” says Rosing.

The power strip also must be attached to the piece of equipment it is powering.

Pre-construction risk assessment (PCRA). The PCRA includes things such as noise and vibration that might occur during a construction project. This is an area where the engineering staff and infection control staff will both be involved.

“If you have any construction going on in the OR, PACU [postanesthesia care unit], or endoscopy, you’re probably already familiar with these concepts because, hopefully, you’ve been involved and are helping to sustain the environmental controls put in place to reduce dust and dirt in the area,” he says.

Room turnover. Surveyors are observing the turnover of a room, be it an OR, standard patient room, or exam room.

The surveyors will look at how staff clean a room and furniture, whether they use the correct cleaning products for surfaces according to instructions for use (IFU), and how they reset the room, such as putting on new sheets.

Relative humidity. In some parts of the country where it’s dry or arid, and particularly in the winter months, it’s hard to keep the relative humidity above 30% (between 30% and 60% humidity). CMS has decided to allow the relative humidity to dip below 30%, to 20%.

This can be beneficial, but managers must ensure that their equipment and supplies are compatible with this reduction. This can be a challenge in the OR because many OR supplies and equipment have labels saying they must be used within a certain temperature and humidity range, Rosing says.

Typically, vendors have tested the stability of their products using the 30% to 60% range, and they haven’t gone down to 20%. For example, IFU for cautery devices and lasers often require 30% to 60% humidity.

Water systems and threat of legionella or other bacterial contamination. Hospitals often have cooling towers on their roofs that are part of their air conditioning system that can pool water. “These are very important systems to have treated and maintained,” says Rosing.

Other water features, such as fountains in lobbies of hospitals, have been added recently. In many instances, these have now been taken out, disabled, or disconnected because of the threat of aerosolizing bacteria inside the hospital.

A water management plan must include a risk assessment and procedures to minimize the risk of legionella collecting in domestic water pipes and fixtures such as drinking fountains, sink and shower plumbing and faucets, and ice machines.

MERV. The American Society of Heating, Refrigerating, and Air-Conditioning Engineers (ASHRAE) introduced a new term, “MERV,” in their ASHRAE 170 standard. MERV, which stands for minimum efficiency reporting value, is an air filtration scale with a reporting value of 1-20.

As an example, says Rosing, “HEPA [high efficiency particulate air] filters have a MERV of 17 or higher, and Class B or C surgical areas must have a MERV of 14 for the second bank.”

Second bank means second filter—as air moves through, it first hits a filter (ie, first bank) that catches bigger particles, and then it hits the second filter or second bank, which is the more fine-tuned filter, he says.

These filters must be gasketed in place, and ORs may not be used when filters are being changed, unless there are redundant filters.

Mold. Expect a lot of attention and emphasis on mold, says Rosing. “Where you have dust, water, nutrients, incubation, and the right temperature, you get mold,” he says. “The human body, wounds, or lungs can provide the nutrients needed, as can the glue on wallboard.”

Areas in particular that are involved are ORs, ICUs, transplant units, IV sterile compounding areas, and any area where there are persistent ceiling leaks or wet carpet.

“Anytime you have a ceiling tile that’s beginning to stain, you want not just to replace the tile, but to have engineering figure out why the leak is occurring and how to fix it permanently,” says Rosing.

The remediation of such occurrences is very complicated, time-consuming, and expensive. The focus is on keeping everyone safe, including staff, and it is a big focus of the Joint Commission going forward, he says.


Infection prevention, environmental rounds

Rosing says one of the things he often finds in mock surveys and the Joint Commission finds in their real surveys is a lack of coordination and oversight of all areas in an organization that performs high-level disinfection or sterilization, such as the wound care clinic, or cardiac diagnostic areas, or endoscopy.

It is important to break down silos and barriers between staff in these departments, Rosing says. This can be accomplished by having an infection preventionist or someone in sterile processing go to these other departments periodically to check on what they are doing and establish that their practices are sound and consistent with evidence-based guidelines and IFUs, he notes.

When making infection prevention, environmental rounds, check for COVID-19 posters showing cough etiquette as well as dispensers for tissues and masks and hand sanitizer in the admissions area.

When making rounds, examples of things to look for include:

• COVID-19 posters showing cough etiquette as well as dispensers for tissues and masks and hand sanitizer in the admissions area (sidebar, “Admission Area”).

• empty soap dispensers, missing ceiling tiles, construction without proper dust containment, food at the nursing station where specimens are handled, and blood-splattered glucometers in the preoperative holding area

• endoscopes not hanging freely or touching the bottom of the cabinet, endoscopes stored incorrectly in a travel case, and uncleanable wooden storage cabinets in the endoscopy procedure area

• clean surgical attire and head coverings (plus proper personal protective equipment), eye wash station, no damaged or stained ceiling tiles, no damaged floors (areas under mats cleaned), separate sink and supplies for hand hygiene, no fans in decontamination area (fans can blow dust, so engineering should make sure enough cool air is pumped into this area for staff comfort)

• containers used to transport sharp instruments are puncture resistant; nonsharps (this is a recent determination by the Joint Commission) can be put in some other type of container, even a plastic bag, so long as it’s not going to poke through the bag and create a risk for a staff member or even a patient or visitor who happens to be in the pathway of where it’s being transported.


Provision of Care requirements

The Provision of Care (PC) chapter has 51 pages of requirements and 12 sections, three of which Rosing says can be especially troublesome for the OR:

Assessment of the patient: The main thing for the OR is the nursing assessment in the preoperative holding area, which dovetails with the anesthesiologist’s assessment and the physician’s/surgeon’s history and physical, notes Rosing. These assessments also occur in other procedure areas, such as endoscopy, interventional radiology, and the cardiac cath lab.

Providing care: Issues for the OR include making sure resuscitation equipment is available for use and that it has a log that tracks frequency of use and testing. “Surveyors are very tuned in to studying the cart, looking at what’s on top of the cart, and checking to see if there are expired items, torn packages, or dust,” he says.

Special procedures: In particular, the requirement for a preanesthesia assessment is often missed when an anesthesiologist is not involved in the case (eg, moderate sedation and emergency department cases). It’s important to make sure an immediate reassessment is conducted before sedation or anesthesia is given, he says. This is true if it’s a GI physician in endoscopy with a nurse administering moderate sedation or in the OR when general anesthesia is given.

The purpose of the reassessment is that the initial assessment might have been done in the preoperative area from a half hour to 2 hours before the patient arrives in the OR. Things can change rapidly, so it’s important to assess the patient one more time to make sure it’s safe to start the case. “This reassessment is often missed or can’t be found in the record even if it is done,” says Rosing. “It has to be documented.” ✥



ANSI/AAMI. ANSI/AAMI ST 58: Chemical sterilization and high level disinfection in healthcare facilities. 2013.


ANSI/AAMI. ANSI/AAMI ST 79: Comprehensive guide to steam sterilization and sterility assurance in health care facilities. 2017.


ANSI/AAMI. ANSI/AAMI ST 91: Flexible and semi-rigid endoscope processing in health care facilities. 2015.


ANSI/ASHRAE/ASHE. ANSI/ASHRAE/ASHE Standard 170-2017: Ventilation of health care facilities. https://www.ashrae.org/technical-resources/standards-and-guidelines/standards-addenda/ansi-ashrae-ashe-standard-170-2017-ventilation-of-health-care-facilities.


CDC. Interim Infection Prevention and Control Recommendations for Hospitalized Patients with Middle East Respiratory Syndrome Coronavirus (MERS-CoV). https://www.cdc.gov/coronavirus/mers/infection-prevention-control.html.


CMS. Information for Healthcare Facilities Concerning 2019 Novel Coronavirus Illness (2019-nCoV). QSO 20-09. https://www.cms.gov/files/document/qso-20-09-all.pdf.


CMS. Notification to Surveyors of the Authorization for Emergency Use of the CDC 2019-Novel Coronavirus (2019-nCoV) Real-Time RT-PCR Diagnostic Panel Assay and Guidance for Use in CDC Qualified Laboratories. https://www.cms.gov/files/document/qso-20-10-clia.pdf.


Joint Commission. NFPA 101 2012—References for Life Safety Code/Environment of Care Compliance. https://www.jointcommission.org/standards/standard-faqs/home-care/life-safety-ls/000001282/


Rosing J R. Mastering Joint Commission standards and CMS regulations. OR Manager Virtual Annual Conference. 2020.

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