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How to Prepare for Your Accreditation Survey Among COVID-19

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How to Prepare for Your Accreditation Survey Among COVID-19

Normal operations in hospitals have come to a screeching halt since the pandemic made its way to the United States. Luckily for healthcare facility managers, CMS has also changed how it’s handling accreditation surveys. Certain CMS testing and maintenance has been adjusted. On April 21st, CMS released testing guidance. (This link expands into clinical areas of CMS testing. Updates continue to be made to the original document since April 21st.) We’ve compiled some helpful ideas to prepare your physical environment for your next survey.

Below are five areas CMS specifically identified with NO adjustment in testing. These areas are still considered too critical for the internal functions of the hospital.

  • Sprinkler system monthly electric motor-driven and weekly diesel engine driven fire pump testing.
  • Portable fire extinguisher monthly inspection.
  • Elevators with firefighters’ emergency operations monthly testing.
  • Emergency generator 30 continuous-minute monthly testing and associated transfer switch monthly testing.
  • Means of egress daily inspection in areas that have undergone construction, repair, alterations, or additions to ensure its ability to be used instantly in case of emergency. (CMS 4/29 Release.)

Other Ideas to Help Prepare for Upcoming Testing:

  1. Ensure to immediately make every effort to complete testing as soon as the SOE is lifted. Do not procrastinate until the end of the window and then schedule it.  
  2. Track and document your process. This will enable you to accurately speak to issues and provisions made to complete testing.  
  3. If you do in-house testing on certain standards, make every effort to complete the testing in the required time. If not, make sure you can accurately speak to why testing was not completed.
  4. Try to keep staff focused on their daily tasks as much as possible. This will help you return to normal operations rapidly and narrow your focus on the accreditation survey.
  5. If possible, try to utilize digital automation to keep on track during these hectic times. This allows the ability to do more with fewer resources.
  6. Continually remind your staff that they are an essential part of the survey process and praise them for their efforts during the COVID-19 response. Make sure the work they have been asked to do during the pandemic has not gone unnoticed.  

As a testament to our systems, hospitals were able to implement processes that have been in place for years, but many were never actually utilized until now. It’s refreshing to know the process works!  It’s also worth noting that both accrediting organizations and CMS released advocacy statements in our facility’s time of need. If you have the opportunity, pass on your appreciation to these organizations for minimizing maintenance/testing and allowing facilities to focus on their outbreak response.  

We all hope we are never subjected to this type of outbreak again. Having been a facility director and Joint Commission surveyor during SARS, Zika, Ebola, H1N1, and now COVID-19, the reality is viruses will affect humanity again and will require a concerted effort response from healthcare. Our hope is that each facility will build upon this experience and communicate with staff and facility managers to return to normal operations as soon as possible. Let’s continue to collectively learn and draw on these challenges to better prepare for the next outbreak.


For more information regarding the CMS directive to healthcare in relation to response, please refer to the link below.  


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