American College Of Surgeons - Inspiring Quality: Highest Standards, Better Outcomes

Clarification of the Verification Extension and Site Visit Postponement

Clarification on Extension and Postponement Q&A Webinar

The VRC Office has prepared a webinar to further clarify the postponement and to respond to questions from trauma centers regarding COVID-19 extensions.

If a site visit application was previously submitted and an acknowledgement was received, the trauma center does not need to reapply for their site visit. We will reach out to trauma centers when we are ready to reschedule site visits.

2020 Site Visits—Reverification

Previously confirmed (scheduled dates with review team) or pending (not confirmed) reverification site visits March–December 2020 now postponed

Trauma centers currently verified through 2020 will receive a 1-year verification extension (COVID-19 extension) through 2021. For example: current expiration date of March 31, 2020—new expiration date of March 31, 2021

Confirmed site visits (scheduled dates with review teams) March–June 2020

  • Site visits that had confirmed dates for 2020 will be rescheduled 1 year from the original date. For example: if the site visit was scheduled in March 2020, it will now be rescheduled in March 2021—ACS will contact centers when we are ready to reschedule visits
  • PRQs:
    • Programs will keep the same reporting period based on the original scheduled site visit date
    • Programs that are currently working on the PRQ should complete it within 30 days of the original scheduled site visit date
    • Medical records for review will remain the same as the reporting period based on the original scheduled site visit date

Pending site visits (not confirmed) July–December 2020

  • Programs with requested site visit dates during this period will be scheduled 1 year from the original requested dates. For example: if the site visit was requested in August 2020, it will now be scheduled in August 2021—ACS will contact centers when we are ready to reschedule visits
  • PRQ submission options (please select one):
    1. Programs will keep the same reporting period as the requested original site visit dates
    2. Programs will use reporting period consistent with the new site visit dates
    3. Medical records for review will be based on PRQ submission option a or b—must advise the VRC office to open the PRQ to be updated

2020 Site Visits—Consultation/Verification

Previously confirmed (scheduled dates with review team) or pending (not confirmed) consultation or initial verification site visits March–December 2020 now postponed
Confirmed site visits (scheduled dates with review team) March–June 2020

  • Site visits that had confirmed dates for 2020 will be rescheduled 1 year from the original date. For example: if the site visit was scheduled in March 2020, it will now be rescheduled in March 2021—ACS will contact centers when we are ready to reschedule visits
  • PRQs
    • Programs will keep the same reporting period based on the original scheduled site visit date
    • Programs that are currently working on the PRQ should complete it within 30 days of the original scheduled site visit date
  • Medical records for review will remain the same as the reporting period based on the original scheduled site visit date

Pending site visits (not confirmed) July–December 2020

  • Programs with requested site visit dates during this period will be scheduled 1 year from the original requested dates. For example: if the site visit was requested in August 2020, it will now be scheduled in August 2021—ACS will contact centers when we are ready to reschedule visits
  • PRQ submission options (please select one):
    1. Programs will keep the same reporting period as the requested original site visit dates
    2. Programs will use reporting period consistent with the new site visit dates
  • Medical records for review will be based on PRQ submission option a or b—must advise the VRC office to open the PRQ to be updated

2020 Site Visits—Focused Site Visits

Previously confirmed (scheduled dates with review team) or pending (not confirmed) focused onsite visits March—December 2020 now postponed

Focused Onsite Visit (FOV)

Trauma centers that are currently verified and were awaiting a focused onsite visit through 2020 will receive a one-time 1-year verification extension through 2021

For example:

  1. Initial expiration date of March 31, 2019—verified for 1 year with a FOV through March 31, 2020—COVID-19 extension through March 31, 2021—FOV successfully verified for 2 years through March 31, 2023
  2. Initial expiration date March 31, 2019—not verified—schedule FOV by March 31, 2020—schedule extended through March 31, 2021—FOV successfully verified for 3 years through March 31, 2022—COVID-19 extension through March 31, 2023

Confirmed site visits (scheduled dates with review team) March—June 2020

  • FOV that had confirmed dates for 2020 will be rescheduled 1 year from the original site visit date. For example: if the site visit was scheduled in March 2020, it will now be rescheduled in March 2021—ACS will contact centers when we are ready to reschedule visits
  • A corrective action plan must be submitted 30 days prior to the original scheduled site visit date, if not already done so
  • Medical records for review will remain the same as the corrective action period

Pending site visits (not confirmed) July—December 2020

  • FOV with requested dates during this period will be scheduled 1 year from the original requested site visit dates. For example: if the site visit was requested in August 2020, it will now be scheduled in August 2021—ACS will contact centers when we are ready to reschedule visits
  • Corrective action plan options (please select one):
    1. Programs will keep the corrective action plan period on the requested original site visit dates
    2. Use the corrective action plan period consistent with the new site visit dates— the new period must be documented in the corrective action plan
  • Medical records for review will be based on corrective action plan option a or b

Focused by Mail (FBM)

Trauma centers currently verified and received a FBM request must submit the corrective documentation by the deadline noted in the initial verification letter*. These programs will receive a 1-year verification extension (COVID-19 extension) following their focused verification cycle

For example:

  1. Initial expiration date of March 31, 2019—verified for 1 year with as FBM through March 31, 2020— submit FBM by deadline*—successfully verified for 2 years through March 31, 2022—COVID-19 extension through March 31, 2023
  2. Initial expiration date of March 31, 2019—not verified—submit FBM by deadline*—successfully verified for 3 years through March 31, 2022—COVID-19 extension through March 31, 2023

Verification 2021 through 2023

Trauma centers that are currently verified through 2021, 2022, and 2023 will receive a 1-year verification extension (COVID-19 extension). For these programs, the reporting period and medical records for review will reflect the new expiration date
For example:

  • Current expiration date March 31, 2021—new expiration date March 31, 2022
  • Current expiration date March 31, 2022—new expiration date March 31, 2023
  • Current expiration date March 31, 2023—new expiration date March 31, 2024

2021 PRQ Reporting Period Table

Below are two reporting period options for an upcoming site visit in 2021. If your visit is in a different year, these dates must be adjusted accordingly to reflect 14 months of data prior to the site visit date.

Visit Month

Reporting Period Option 1

Reporting Period Option 2

January

10/1/19

9/30/20

11/1/19

10/31/20

February

11/1/19

10/31/20

12/1/19

11/30/20

March

12/1/19

11/30/20

1/1/20

12/31/20

April

1/1/20

12/31/20

2/1/20

1/31/21

May

2/1/20

1/31/21

3/1/20

2/29/21

June

3/1/20

2/29/21

4/1/20

3/31/21

July

4/1/20

3/31/21

5/1/20

4/30/21

August

5/1/20

4/30/21

6/1/20

5/31/21

September

6/1/20

5/31/21

7/1/20

6/30/21

October

7/1/20

6/30/21

8/1/20

7/31/21

November

8/1/20

7/31/21

9/1/20

8/31/21

December

9/1/20

8/31/21

10/1/20

9/30/21

Please forward questions to: COTVRC@facs.org.