On February 15, 2021 DNV Healthcare USA Inc. announced changes to our survey scheduling approach for NIAHO® accreditation surveys in hospitals, critical access hospitals and psychiatric hospitals, based on newly revised CMS guidance. In March, CMS lifted suspensions on federal survey activity, restored timelines for follow-up surveys and POC timelines, and advised accreditation organizations to return to normal survey activity.
DNV was already conducting initial accreditation and reaccreditation surveys onsite, along with complaint investigations and associated follow-up activities, according to guidance CMS provided us beginning in August 2020 which ensured that we took proper precautions and minimized risk based on local conditions. Since then, DNV has continued to monitor CMS’ COVID-19 prevalence data while measuring the comparative effectiveness of our remote surveys and assessing customer feedback on the overall process. Now that COVID-19 prevalence rates are down, vaccines are widely available, and travel restrictions are being lifted, all indicators are pointing towards a return to full onsite annual surveys.
Starting September 7, 2021, all DNV NIAHO® accreditation surveys in hospitals, critical access hospitals and psychiatric hospitals will be unannounced onsite activities with no advance notice provision. This includes initial accreditation, annual/periodic surveys, follow-ups, special surveys, complaint investigations, and reaccreditation surveys.
This advisory provides 60 days’ notice for our accredited hospitals to prepare for onsite survey. We acknowledge that normal variations in our year-over-year survey scheduling, combined with a return to unannounced onsite visits, will cause some uncertainty for our customers who expect annual survey in August or September. This notice allows us adequate lead time for surveyor scheduling and cost-effective travel planning but does not leave room for changes or new exclusion requests. If your facility is due for annual/periodic survey in this timeframe, we encourage you to stay prepared for an advance notification of remote survey throughout July and August. If you do not receive advance notice by August 30, expect an unannounced onsite survey after the Labor Day holiday.
DNV Stroke Certification Program surveys will remain announced and will be conducted remotely throughout the rest of calendar 2021. Plans for Stroke Program surveys in 2022 are still in development.
DNV Certification Program surveys for Orthopedics, Cardiac, Infection Prevention, Sterile Processing and Palliative Care will remain announced and will return to full onsite surveys, beginning September 7, 2021.
DNV Training Programs will include a mix of public and private, remote and onsite courses for the rest of calendar 2021, and activities that have already been scheduled will follow the agreed arrangements.
For all onsite survey activity, surveyors will wear face coverings according to CDC guidance for healthcare facilities. Surveyors will also follow your organization’s protocols for screening, sanitizing and distancing, including use of video conference technology to accommodate restrictions on staff or access to higher risk areas within the facility. All NIAHO® surveys will continue to emphasize infection prevention & control and emergency preparedness.
DNV appreciates the accommodations our accredited hospitals have made to support remote annual surveys and we believe those efforts, along with the ongoing commitment of our surveyors, have helped keep our hospitals safe, compliant, and on-cycle for accreditation and ISO 9001 compliance. The experience of implementing and refining our remote survey process has helped build resilience into all of our programs and our overall customer experience. We will use elements of the process in future national emergencies, but also for individual calamity situations that would ordinarily create risk or disrupt the survey process.
The HHS COVID-19 Public Health Emergency remains in effect until at least July 19, 2021 and is expected to continue throughout calendar 2021. DNV will continue to monitor the PHE, along with local and national conditions using weekly data provided by CMS and CDC. We will adhere to any AO process changes that may be required by CMS and communicate any future adjustments as they emerge.
Any questions or comments can be forwarded to the Healthcare Client Drop Box: dnvclientdropbox@dnv.com.
