COVID-19 Alert for Joint Commission Accredited Hospitals

By Jill T. Ojserkis, Esq., LL.M. and Brittany A. Bonetti, Esq.

Due to President Trump’s declaration of a national emergency regarding COVID-19, on March 16, 2020, The Joint Commission announced its suspension of all regular surveying. The Joint Commission advised that there may be a small number of surveys that will need to continue, such as high-risk situations. The length of the survey moratorium period is unknown. During this time The Joint Commission advised that accreditation will be extended without disruption of status. The Centers for Medicare and Medicaid Services has confirmed that Medicare payment status also will not be affected.

Hospitals should be aware of Joint Commission guidance, which indicates that if an established provider’s privileges are scheduled to expire amid a national emergency declaration, The Joint Commission will allow an automatic extension of medical staff reappointment beyond the 2-year period under the following conditions:

  • A national emergency has officially been declared
  • The organization has activated its emergency management plan
  • Extending the duration of providers’ privileges during an emergency is NOT prohibited by State Law.

According to Joint Commission guidance, the duration of the extension cannot last more than 60 days following termination of the state of emergency declaration. Organizations utilizing this privileging extension option are responsible for determining how the extension will be documented. This privileging extension guidance is not unique to the COVID-19 national emergency declaration and instead is applicable to national emergencies in general.

Now is the time for hospitals to review their current emergency operations plan. Although not new, when a hospital activates its emergency operations plan, The Joint Commission permits hospitals to grant disaster privileges to volunteer licensed independent practitioners (LIP) and volunteer practitioners who are not licensed independent practitioners, but who are required by law and regulation to hold a license, certification, or registration (non-LIP).  A disaster is deemed to exist when there is an emergency that, due to its complexity, scope or duration, threatens the organization’s capabilities and requires outside assistance to sustain patient care, safety, or security functions. In order to exercise this option medical staff bylaws must identify those individuals responsible for granting disaster privileges to volunteer LIPs. The hospital must also identify, in writing, those who are responsible for assigning disaster responsibilities to non-LIPs. Even in the midst of a disaster, the hospital must verify licensure and have a written description of its methodology for overseeing the performance of volunteer LIPs and non-LIPs. It is important to keep in mind that this flexible privileging option is only available to volunteer LIPs and non-LIPs and that hospitals must determine how to distinguish volunteers from hospital staff.