The Alliance

Spotlight Series

The executive insight series is designed for healthcare senior executives. These brief, bi-annual issues focus on topics relevant to top-tier hospital leadership. For each topic, you can find related references, resources, and tools.

Spotlight Series Past Issues

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Transplantation is one of the most highly regulated fields in the medical industry, however, conducting site surveys in the midst of a pandemic puts us in unprecedented and uncharted territory.

Coronavirus (COVID-19): Impact on Site Surveys

Coronavirus (COVID-19): Impact on Site Surveys Transplantation is one of the most highly regulated fields in the medical industry, however, conducting site surveys in the midst of a pandemic puts us in unprecedented and uncharted territory. Highlights of changes to CMS and OPTN|UNOS site surveys during the COVID-19 pandemic are outlined below.

Impact on CMS Site Surveys

  • To date CMS has issued two QSO Memorandums with regards to CMS surveys during the COVID-19 pandemic:
    • QSO-20-12 was issued March 4
    • QSO-20-20 was issued March 23 • Based upon these QSO Memorandums, CMS site surveys will be limited to the following types of surveys:
  • Based upon these QSO Memorandums, CMS site surveys will be limited to the following types of surveys:
    • Complaint/facility-reported incident surveys
    • Targeted infection control surveys
      • A streamlined review checklist will be utilized to minimize the impact on provider activities, while ensuring providers are implementing actions to protect the health and safety of individuals to respond to the COVID-19 pandemic.
      • Hospitals and transplant programs can use this infection control survey checklist to perform a self-assessment of their infection control plan and protections.
    • Initial certification surveys in accordance to current guidance and prioritization.
  • Key Focus Areas for COVID-19 Related CMS Surveys:
    • Improper transmission precautions procedures
    • Lack of staff knowledge of transmission precautions
    • Improper staff use of PPE and/or inadequate hand hygiene
    • High-risk, significant environmental cleaning issues
    • Ineffective and/or improper laundering of linens
    • Possible Infection Control (IC) surveillance program issues – also consider how influenza & pneumococcal programs are managed
  • Standard Surveys NOT BEING CONDUCTED during the COVID-19 Prioritization Period:
    • Hospitals
    • Long term care facilities (nursing homes)
    • Home health agencies (HHAs)
    • Intermediate care facilities for individuals with intellectual disabilities (ICF/IIDs)

Impact on OPTN Transplant Site Surveys

  • Site surveys will be conducted virtually at least through the end of June.
  • Members will receive a phone call from Member Quality six to eight weeks before their scheduled site survey to see if it is a good time for the survey to take place.
  • If it is not a good time, members can request a delay when they receive the phone call or they can preemptively submit a delay request by emailing
    • Include the following information: Name, Position, Contact Information, Organization/Code, Circumstances that make survey delay necessary
    • Member Quality will reach out to postponed programs every four to six weeks to see if it is a good time yet for the survey to be conducted. If not, the survey will be delayed for another four to six weeks. This process will be repeated until the survey can be scheduled.
  • Virtual surveys can be conducted using secure Go To Meeting platform.
  • Medical records reviews can be done virtually via SFTP drop box (secure file share), screen sharing, or secure email.
  • Member Quality is closely monitoring the COVID-19 impact on members and adjusting survey schedules and processes accordingly.

Helpful Resources

The information presented in this issue is current as of April 2020. We recommend checking the UNOS and CDC sites regularly for updates and new developments.

Questions & Comments

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A Special Thanks to This Series’ Contributors

Deanna Fenton
About the Editor |
Deanna Fenton

Deanna is a knowledgeable and versatile professional with diverse experiences in healthcare, client relations, marketing, project management and demonstrated skills in leadership and advocacy. Prior to joining The Alliance, she worked in Hospital Development at her local OPO in the state of New Jersey where she served as the clinical liaison to a number of Level 1 Trauma & Neuroscience centers as well as community hospitals. Her personal connection as a donor family and friend fuels her passion to support her colleagues across the donation-transplantation continuum through the development of valuable educational resources that ultimately boost performance and improve outcome measures. Deanna holds a Bachelor of Arts in Psychology and a minor degree in Public Health from Montclair State University. In her spare time, Deanna enjoys visiting vineyards, spending time with her family, and traveling in hopes of visiting all seven wonders of the world.

Valinda Jones
About the Editor |
Valinda Jones

Valinda holds more than 40 years of health care experience, including such roles as assistant hospital administrator, chief nursing officer, director of a school of nursing, administrator of a dialyisis facility and group administrator for home dialysis programs. She has served in large teaching hospitals, as well as community and critical access health care facilities, and taught in LPN, diploma, BSN and MSN schools of nursing. Prior to joining The Alliance, Valinda worked as a quality coordinator for a kidney-only transplant program, and as a 10-year kidney recipienet herself, has been an active volunteer with Gift of Life Michigan for many years. She is currently a member of both the UNOS Board of Directors and the Kidney-Pancreas Transplant Committee. Valinda enjoys spending time with family and friends, international traveling and learning about the culture, food and customs of different countries.

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