COVID-19 has affected hospitals and health systems in many ways, extending to the accreditation requirements and processes of The Joint Commission (TJC). Responding to many questions and concerns from accredited facilities, TJC recently offered answers in a webinar.1

The topics were wide-ranging, from the waiver of certain requirements to telehealth and documentation. One topic of concern was the use of “1135 waivers,” referring to section 1135 of the Social Security Act (SSA), which can temporarily modify or waive certain Medicare, Medicaid, CHIP, or HIPAA requirements. A question regarding when the 1135 waivers would be updated or terminated, and whether hospitals would have sufficient notice, was addressed by Maura Naddy, MSN, RNC-OB, CJCP, associate director of the Standards Interpretation Group with TJC.

“Once the effects of the pandemic begin to decrease or diminish at your organization, you should slowly move into normal operations or what the new normal looks like,” Naddy said. “Please note that the waivers have also been extended to match the amount of time to return back to full compliance with the CMS Conditions of Participation.” Despite the hope vaccines are providing, the COVID-19 pandemic is not over quite yet. On Jan. 7, the Department of Health and Human Services extended the public health emergency declaration.2 On Feb. 18, CMS extended hospital survey limitations for an additional 30 days to March 22.(Editor’s Note: At press time, neither agency had issued additional extensions on top of these.)

To determine what aspects of TJC accreditation have been affected by the pandemic, Naddy suggested reviewing an organization’s extranet site and clicking on resources and tools, then “learn more.” That page will provide details on 1135 waivers deferments for each accreditation program.

“The Joint Commission will allow organizations 60 days after the end of the state of emergency to return back to normal compliance,” Naddy said.

Document COVID-19 Response

Regarding the documentation of COVID-19 response measures, Naddy said TJC does not require that all those measures be documented within a policy. However, organizations do need to ensure staff are adequately informed and educated about new processes and procedures implemented. “How this is accomplished is ultimately up to the individual organization,” she added.

Naddy also addressed a question regarding whether 1135 waivers related to medical record documentation would apply only to surge areas of a hospital or the entire facility. Waivers related to documentation can apply to the entire hospital. The waivers should be used in areas where hospitals leaders believe they are appropriate.

The blanket 1135 waivers issued by CMS are available for use by all organizations certified by that agency.

“There is an expectation that your organization has some effect from the pandemic and your organization also activated its emergency operations plan. If you are utilizing those waivers, there are no additional requests that need to be made,” Naddy said. “If you are looking from another Condition of Participation that has not been waived, a request would need to be submitted to your regional CMS office.”

Some hospital leaders have questioned whether TJC will make allowances for a lack of training exercises in hospitals due to COVID-19 restrictions, but Naddy noted TJC does not require annual training. Instead, TJC directs staff to engage in continuing training and education to maintain or expand their competency and, as needed, when employ duties change. Therefore, hospitals do have flexibility in redefining competencies and training during the pandemic.

CMS 1135 waivers are applicable only to deemed organizations, while TJC deferments are applicable to any organization that is accredited, regardless of deemed status. TJC has closely reviewed the 1135 waivers released by CMS and has adjusted scoring guidance based on the applicable standards related to the Conditions of Participation.

TJC Not Assessing Pandemic Period

One webinar participant asked how the 1135 waivers will affect TJC’s survey process and what documentation surveyors will look for regarding the waivers. Naddy said surveyors will not retroactively review compliance during the pandemic period. Instead, the surveyors will examine how the hospital has adapted to provide safe care for patients and a safe working environment.

“Our primary focus during a survey will be the time frame of your last survey up until the start of the public health emergency, which was March 1, 2020. We will then resume survey activity, with our focus being on the time after your organization has provided your survey-ready date or the end of the public health emergency, whichever comes first,” Naddy explained. “The focus of this onsite survey will not be the time of the public health emergency.”

As for documentation, organizations should be maintaining records of any activation of the emergency operations plan. There will be an expectation the hospital has captured how the effects of the public health emergency on care, treatment, or services are reported to incident command and the governing board of the organization.

There is no standardized format for recording and reporting that information. “However, you should be keeping up with how these things have impacted your daily work within your organization. You should do this because you will have to go back and evaluate your organization’s response,” Naddy said. “Without these dates and knowing when to look at data, it would be nearly impossible to determine how you have managed during those specific time frames.”

Surveying Low-Risk Areas

Theresa Hendricksen, RN, MS, FACHE, field director with TJC, notes TJC has been surveying hospitals in low-risk counties since July 2020, with the highest volume in October and November 2020. An increase in COVID-19 cases in December 2020 and January 2021 caused TJC to curtail surveys. But surveys are picking up again in low-risk areas.

“We take into account various statistics to determine that low-risk area and that is how we decide a county is a go county for us,” she said. “We are aware that surveys are past their due date, and CMS is also aware of it. We will conduct those surveys when we are able to do so safely.”

TJC is prioritizing initial surveys and past due organizations. TJC employs several surveyors who have received the second dose of vaccine and can travel to areas with a higher rate of COVID-19. Still, surveyors are required to wear a mask and follow any additional requirements in place at the hospital.

The survey process and components will remain the same as before COVID-19, but TJC encourages hospitals to limit the number of people in group sessions. Virtual attendance can be used to limit meeting size, and TJC surveyors can interview patients and staff by phone.

If surveyors need to visit a different location, such as an ambulatory surgery center off the hospital campus, TJC instructs the surveyors to drive themselves.

“We will not enter an at-risk or confirmed COVID-19 zone or home. We will avoid visiting a unit with confirmed COVID-19 patients when possible, though we have learned in a short period of time that is not always possible,” Hendrickson said. “We may have to visit the unit, but we will not enter the patient’s room.”

Waivers for QAPI Program

Naddy indicated there are waivers specifically related to the CMS Quality Assurance and Performance Improvement (QAPI) program.

Noting that normal hospital operations have been disrupted during the pandemic, Naddy explained TJC does not require a specific number or frequency of quality meetings that need to occur within a calendar year. Hospitals can adjust their quality meetings during the pandemic, and virtual meetings are acceptable.

During a survey, TJC would ask for documentation of who was present for the quality meetings and who participated in the QAPI process.

Regarding telehealth services, Naddy addressed the expectations for telehealth documentation when only the provider and patient are participating, without the screening and documentation a nurse typically provides.

Quoting TJC guidance released in 2020, Naddy said: “Each organization defines the scope and content of screenings, assessments, and reassessments, and how such activities are documented in the medical record. During an emergency, documentation requirements, including timeliness of entries, may be modified to meet their capabilities and needs. When temporary modifications are made, entries should remain sufficient to ensure that safety, quality, and continuity of care within and across disciplines is maintained.”4

Assessments and the frequency they are performed is determined by the needs of the individual patient, along with organizational policies. Similarly, screenings are determined by the complaint and diagnosis of the patient.

Disaster Telehealth Credentialing Possible

A common question regarding telehealth involves the credentialing of telehealth providers. Disaster privileging requirements are found in the emergency management chapter of the hospital accreditation manual. Those requirements apply only when the hospital has activated its emergency operations plan. Licensed and independent practitioners the organization has privileged and credentialed who would provide the same services to patients via a telehealth link would not need any extra privileging or credentialing, according to Naddy. “Medical staff determine the services that are appropriate for telehealth. Currently, it is not necessary for telehealth to be considered a separate privilege.”

For licensed and independent practitioners who are volunteers and are not already credentialed by the organization, this group could receive disaster privileges following requirements detailed in the emergency management chapter of the accreditation manual.

Infection Control Issues Addressed

Tiffany Wiksten, MSN, RN, CIC, associate director of the Standards Interpretation Group with TJC, addressed questions related to infection control, COVID-19, and TJC standards. A common question was whether TJC requires organizations to specifically address COVID-19 in its infection control plans.

The answer is no, according to Wiksten. Many organizations include COVID-19 by addressing broader topics, such as infectious disease or high-consequence infection disease.

Wiksten offered advice on quality improvement opportunities related to infection control. “Each organization will have improvement opportunities that are unique to their individual settings,” she said. “Common ways that organizations identify improvement projects include, but are not limited to, conducting an event review and identifying opportunities that occurred during the public health emergency, performing a gap analysis to compare actual performance to what was expected or desired to identify process gaps, and reviewing internal goals and data. This is critical, as the CDC has identified that organizations managing surges of COVID-19 patients may be vulnerable to outbreaks of multidrug-resistant organisms.”

A review of external benchmarks also is important, including reportable hospital-acquired infections such as central line-associated bloodstream infection and catheter-associated urinary tract infection.

“It is the responsibility of the organization to follow their processes for prioritizing and selecting outcome measures that will align with the organization’s goals and objectives,” Wiksten said.

Wiksten addressed a question regarding whether policies and procedures are expected to reflect every CDC or health department change related to COVID-19.

“While there is no requirement for policies to reflect every update and source citation, the organization needs to ensure that there is a method for employees to have access to the most up-to-date organizational processes, procedures, and policies,” she explained. “The organization must ensure that changes are communicated, education is provided, if necessary, and processes are implemented.”


  1. The Joint Commission. COVID-19 Q&A webinar for hospital accreditation. Feb. 25, 2021.
  2. U.S. Department of Health and Human Services. Renewal of determination that a public health emergency exists. Jan. 7, 2021.
  3. Centers for Medicare & Medicaid Services. Hospital survey priorities (revised). Feb. 18, 2021.
  4. The Joint Commission. Documentation challenges under an emergency operations plan. April 24, 2020.


  • Theresa Hendricksen, RN, MS, FACHE, Field Director, The Joint Commission, Oakbrook Terrace, IL. Phone: (630) 792-5800.
  • Maura Naddy, MSN, RNC-OB, CJCP, Associate Director, Standards Interpretation Group, The Joint Commission, Oakbrook Terrace, IL. Phone: (630) 792-5800.
  • Tiffany Wiksten, MSN, RN, CIC, Associate Director, Standards Interpretation Group, The Joint Commission, Oakbrook Terrace, IL. Phone: (630) 792-5800.