November 08, 2018 | | Comments 0
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CMS Report: AOs missing fire safety and IC deficiencies during survey

Expect CMS to continue pressuring The Joint Commission (TJC) and other accrediting organizations (AO) to find more of the serious life safety, environment of care, and infection control issues the federal agency says they are still missing during surveys.

In the newest report to Congress assessing AO performance, CMS says the overall disparity rate between serious problems identified by the AOs at hospitals and those found by CMS surveyors within 60 days of survey was 46% in fiscal year 2016, up from 38% and 39%, respectively, in the two preceding fiscal years.

Most of those disparities were in infection control and physical environment, says the report. CMS is particularly concerned that AOs are missing key Life Safety Code® (LSC) deficiencies, with fire and smoke barriers, sprinkler systems, electrical systems, hazardous areas, and means of egress taking the top five categories for missed problems in fire safety at hospitals.

Hospitals already face funding challenges to meet fire code requirements after CMS finally adopted the 2012 LSC, and it will get even worse as survey scrutiny increases, predicts Ernest E. Allen, a former TJC surveyor and current consultant and patient safety executive with The Doctor’s Company in Columbus, Ohio.

This is on top of TJC’s response to criticism in the report released last year. TJC began pushing its own surveyors to cite every life safety deficiency, no matter how small, Allen says.

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Filed Under: AccreditationCMSInfection ControlPatient SafetyQuality

About the Author: Brian Ward is an Associate Editor at HCPro working on accreditation, patient safety, and quality news.

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