COVID-19 and the Impact on Provider Accreditation Status

The current Coronavirus (COVID-19) Pandemic is having enormous impacts on healthcare providers as they and their employees staff the front lines during this crisis.  From dealing with unbelievable shortages in staffing, to making protective equipment from recycled fabric, the last thing on many of these entities’ minds is compliance with their accreditation standards.  Fortunately for healthcare entities, many accrediting bodies and government agencies have recognized this crisis, and have made adjustments to their day-to-day regulation and enforcement efforts.  The following government and accreditation bodies have made certain changes:

U.S. Department of Health and Human Services (DHHS)

Section 1135 of the Social Security Act permits the Secretary of Health and Human Services to waive provider requirements pertaining to various aspects of their Medicare and/or Medicaid participation. The Secretary of Health and Human Services, Alex Azar, used this authority to waive the following provisions, among others, retroactive to March 1, 2020:

  • Sanctions for violations of certain conditions of participation or certification requirements for various types of health care providers.
  • Requirements that physicians or other health care professionals hold licenses in the State in which they provide services, if they have an equivalent license from another State (and are not affirmatively barred from practice in that State or any State a part of which is included in the emergency area).

It should be noted that waiving this requirement means only that CMS is authorized to allow Medicare or Medicaid payment, but does NOT waive state laws that in most instances require a physician practicing in the state to be licensed by that state.

  • Sanctions under section 1867 of the Act (the Emergency Medical Treatment and Labor Act, or EMTALA) for the direction or relocation of an individual to another location to receive medical screening pursuant to an appropriate state emergency preparedness plan or for the transfer of an individual who has not been stabilized if the transfer is necessitated by the circumstances of the declared Federal public health emergency for the COVID-19 pandemic.

Centers for Medicare and Medicaid Services (CMS)

As CMS is responsible for the maintenance and enforcement of the various health care providers Conditions of Participation (COP) in the Medicare and Medicaid programs, the first provision of the HHS Section 1135 waiver cited above allows CMS to waive certain COP requirements. While CMS has not announced any waivers of COP requirements, on March 20, 2020, CMS released updated guidance to providers indicating that its survey priorities through April 10, 2020 will be focused on immediate jeopardy and complaint-based surveys as well as targeted infection control surveys in facilities that are potential hotspots. It also recommended that facilities perform infection control self-assessments during this period.

The CMS release, including the Focused Infection Control Survey checklist for facilities that is also recommended by CMS as a self-assessment tool, can be accessed at:

Additionally, as of March 24, 2020, CMS has approved requested waivers by thirteen states related to their Medicaid State Plans to allow these states to remove administrative burdens and expand access to needed services for these states’ Medicaid patients. Key areas of these waivers allow many of these states to approve Medicaid payment for licensed physicians who do not hold an in-state license, and for telehealth coverage that was previously prohibited. 

The Joint Commission (previously known as JCAHO)

As of March 24, 2020, the Joint Commission has announced that it has suspended all survey activity, but that it retains the ability to perform limited surveys in high-risk situations. The Joint Commission COVID-19 webpage, contains various links to FDA and CDC resources regarding PPE and ventilator management, as well as additional information regarding its survey standards relating to granting of privileges in an emergency situation.

 This information can be accessed at:

 Utilization Review Accreditation Commission (URAC)

As of March 18, 2020, URAC has indicated that it will suspend all on-site Validation Reviews through April 10, 2020 and convert such reviews to virtual Validation Reviews when appropriate. It will also be evaluating the need to extend accreditation and certification dates without penalty during the delay.

URAC also acknowledged that due to organizations responding to the emergency, there may be instances of non-compliance with program standards. URAC has created a form that accredited organizations should use to document their instances of non-compliance with any standards due to the emergency, and its ultimate resolution.

This information can be accessed at:

It should be emphasized that the actions summarized above provide only limited relief to healthcare providers, and that various regulatory bodies have spent a good deal of effort over the last few years learning from previous disasters and further emphasizing the need for healthcare providers to have emergency preparedness and infection control plans in place for an event similar to that which we are currently facing. Providers should continue to adhere to those plans and not expect relief from regulatory bodies in the absence of specific guidance indicating otherwise.

It is also important to note that state regulatory bodies are also responding to the current situation in ways that may be more closely tailored to how this crisis is impacting them at a local level.

How Frier Levitt Can Help

The attorneys at Frier Levitt are here to assist our clients in any way possible during these challenging times and are actively monitoring activity among all of these regulatory bodies so that we can continue to provide you with timely updates as circumstances change.

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