How do you inspect a nursing home or a hospital in the middle of a pandemic, or discipline a physician or a nurse?
As COVID-19 has spread, the organizations and regulators responsible for ensuring the safety of health-care facilities and providers have run into a conundrum when travel and face-to-face encounters have been nixed.
Florida has become a testing ground of sorts for The Joint Commission, a national health-care accreditation organization that launched a virtual survey process during the pandemic. Mark Pelletier, chief operating officer in charge of accreditation and certification operations for the organization, said a Florida nursing home was the first provider to be surveyed virtually.
The Joint Commission nationwide has conducted 240 virtual surveys, with 41 involving Florida providers.
“The feedback from the surveyors as well as our customers has been extremely positive. And both went into it saying, ‘How can you provide a thorough assessment using a computer?’ And I will tell you all of the feedback we got back from surveyors and customers felt these reviews were very thorough,” he said.
The Joint Commission accredits and certifies more than 22,000 health-care organizations and programs in the United States, from hospitals and ambulatory surgical centers to home health-care agencies and nursing homes. The Joint Commission accreditation is not mandatory, but it has benefits, including in some instances increased Medicare reimbursements.
The Joint Commission announced in mid-March that it would suspend all surveys, and Pelletier said he wasted no time getting to work on what a virtual survey would entail.
“From start to finish, it took us about a couple of weeks to sort out how we were going to conduct those surveys,” he said.
The result is a virtual survey that Pelletier said has proven to be much more efficient, in part because surveyors previously didn't receive needed documents until they arrived at the facilities.
“That was an enhancement,” Pelletier said. “This way we get to review the documents prior to the survey so the surveyors know a lot more about the organization prior to conducting the survey.”
The Joint Commission uses doctors, nurses and other trained professionals as surveyors. Surveyors randomly select patients and review their medical records to ensure compliance with standards. They also speak with the doctors, nurses, and other staff who interact with the patients. Surveyors also speak to patients.
Pelletier said all of that still occurs through the Zoom online platform. Facility staff members are instructed to walk around the facilities by surveyors who are on the calls. The survey process takes three to five days.
The federal government has authorized The Joint Commission to use the Medicare-certified virtual survey only for health care providers that were poised to open before the COVID-19 pandemic, a move that Pelletier said was meant to ensure that there were enough providers available to treat COVID-19 patients.
In the meantime, the commission is conducting on-site surveys in locations where it’s possible to safely do so, which can be challenging with more than 6.3 million COVID-19 infections nationwide and about 650,000 in Florida.
And that means some health-care organizations have overdue surveys. Pelletier said 583 Florida health care facilities were supposed to have on-site surveys between Jan. 1 and Sept. 1, but 345 are still awaiting them.
The Joint Commission sent a request to the federal government June 26 asking that Medicare certify the virtual survey for use in COVID-19 hot zones and assured the government that it would follow up with in-person surveys when possible.
“We are waiting to see what their thinking is,” Pelletier said.
But guidance issued in mid-August by the federal Centers for Medicare and Medicaid Services doesn’t seem supportive of virtual inspections. The agency announced that survey activities at nursing homes were being expanded to include on-site health and safety visits and state inspections. Adequate survey staff and personal protective equipment was a requirement.
In Florida, those Centers for Medicare and Medicaid Services surveys are conducted by the state Agency for Health Care Administration. But in an Aug. 20 phone call with officials from nursing homes and assisted living facilities, a top state regulator said on-site inspections weren’t imminent.
“I will tell you we are not going to be running out next week and start doing full recertification surveys,” said Kimberly Smoak, chief of the Bureau of Field Operations in the Division of Health Quality Assurance at the Agency for Health Care Administration. “I’ll ease your mind with that. We might be coming out to do some visits for (electrical) generator purposes, but we are not going to be coming out and doing full recertification surveys.”
Meanwhile, the state Department of Health has increased its use of technology to regulate health providers. Since COVID-19, state boards that regulate physicians, pharmacists, nurses, chiropractors and other health-care professionals have held 69 telephonic or video meetings, according to a department spokesman.
Board of Osteopathic Medicine Chairman Joel Rose, like Pelletier, sees some advantages to the virtual work approach.
“We can meet more regularly,” he said. “And I think you get more participation because it’s easier to do it (attend meetings) without leaving your home or office.”
But, it’s not without pitfalls.
“There’s always some technology challenges. Outside the Zoom bombing, you may get dropped from calls or get feedback,” Rose, a Tampa-based physician, said. “Those things are always challenging.”
Social challenges also arise when board members don’t meet face to face. To make it less awkward and to ensure members had the chance to discuss issues, Rose called each individual board member by name, based on their seniority on the osteopathic panel.
“That decreased board members from talking over one another and gave everybody an opportunity to ask questions if they had questions to ask. So I thought that worked well,” he said.
