RSSRecent Articles

Carbon-dating compliance: What happened when…

…and how responsible are you for the sins of the past (turns out, quite a bit).

Kind of a mixed bag of things this week, so please bear with me.

First up, in looking back over the last little while of survey activity, I keep looping back around to one (possibly unanswerable) question: How many of the survey findings being generated are the result of conditions that pre-existed the prior survey? I think we can all agree that there are noncompliant conditions lurking throughout our buildings (including that pesky loaded sprinkler head we talked about a couple of weeks ago), some of which (and perhaps quite a few) are the result of actions or inactions occurring a long time ago (in a galaxy almost too close to home). I’m going to guess there are few of us that have not encountered the angst of having a surveyor pop a ceiling tile or wriggle into some crawl space and find some condition that had previously escaped prying eyes (I suspect that the most common previously undetected finding relates to things attached to sprinkler piping and supports, which supports LS.02.01.35 being the most frequently cited Joint Commission standard). And, as onerous as it may be on the face of it (and every other aspect), we are on the hook for all of it (grandfathering of conditions can help in very limited ways, but there’s really very little in the way of grandfathering noncompliant conditions and practices).

For better or worse (likely more the latter than the former), in these increasingly resource-challenged times, it is almost impossible to ferret out every little imperfection. Particularly in the sense that noncompliance happens in three dimensions—square footage just doesn’t work for this process. So, the questions I ask of you, dear readers, are these:

  • Do you proactively attempt an exhaustive search of your facility from top to bottom (and all the nooks and crannies)?
  • Do you “roll the dice” and correct deficiencies as they appear and if there’s stuff out there, let the surveyors find them?

I’m keen to see how this is going to “split.” I know if we could we would take the higher road of proactivity, but not everyone is in that position.

One other item I’ve been hanging on to for probably longer than I should relates to the management of medical gas and vacuum systems. I would hardly think that this blog is the only resource for information, commentary, etc. (though I do like to think it’s an entertaining and perhaps randomly enlightening one), there is one dedicated to the management of medical gas systems, etc., that I think you’ll find useful (and since it doesn’t publish as often, it’s an easy one to add to your bloggy queue) is sponsored by Compliant Healthcare Technologies (CHT). Recently, Tim Richards at CHT penned a blog post on upcoming changes in NFPA 99 relative to medical gases, etc. As I’ve noted once or twice in the past, I really see NFPA 99 compliance as a likely source of heartburn for facilities and safety folks in the coming survey cycles, so any resource that can increase our operational understanding of what is actually required, etc. gives us a leg up on the survey front. I encourage you to check out the information.

As a final note, it appears that we are gearing up for another wild summer of weather and I wanted to take a moment to send best wishes to those in areas already in the throes of severe weather and those that may find themselves in the same. I do believe that, as an industry, we have done some extraordinary work in the practical preparations to deal with emergencies (I would feel better if appropriate preparedness would “drive” regulatory compliance a little more closely, but perhaps in time) and I trust that we all manage the coming season with minimal impact and disruption.

Let’s begin again, begin the begin: CMS ligature risks codified!

While I have little doubt that we will yet again revisit the management of ligature risks and behavioral health patients, it would seem that chapter and verse are getting towards stone tablet form—but you have a chance to influence the future state. I suspect we will also be looking back to determine how much influence the field has on the final, final or whether the party line from Chicago holds sway (kind of looks like that at the moment, but there is still time):

  • Back on April 19 (and I do apologize for not picking up on this sooner—I need to get a better strategy for monitoring all these goings-on), CMS issued a draft clarification of the interpretive guidelines relating to ligature risk (you can find the skinny here). All things being equal, I suppose the “newest” thing is the formal introduction of the Ligature Risk Extension Request (LRER—just what we needed, another acronym), which outlines a process for correction of ligature risks that will take longer than the official 60-day turnaround time for the correction of deficiencies. One thing is very clear (well, maybe a couple of things): State agencies and/or accreditation organizations are not allowed to grant LRERs. They can, and in most instances, will act as intermediary between the organization seeking the extension and CMS, and will (basically) advocate for approval based on their analysis of the issues. This is not a Life Safety Code® waiver as ligature risks are not a compliance deficiency relative to life safety requirements. From the process outlined, it does appear that this is to be a reasonable process, (potentially) making allowances for obtaining approval of the governing body, engaging in competitive bidding, applying for funding, obtaining permits for physical changes, and lack of or delays in obtaining products and supplies needed for corrective actions. Needless to say, with the invocation of the LRER, there will be
    • Mitigation strategies to implement
    • Progress reporting to be done
    • A re-survey to verify that the deficiencies have indeed been corrected by the state agency or accreditation organization
  • As has been the case pretty much from the get-go, there are two assessment processes that need to dovetail (or perhaps they are concentric circles): An assessment of the environment and the assessment of patients to determine the level of risk for suicidal behaviors. I do believe that eventually we will be left with the latter upon which to focus, but I suppose there will need to be an ongoing due diligence relative to monitoring the environment. Ultimately, it seems to come down to striking the balance between seeing every aspect of the environment as a big hairy monster as opposed to an element in the environment that can be managed by appropriate means. At the very least, I am hoping that the survey focus returns to general patient care and infection control, with perhaps a side of medication management—I think that’s where the meaningful improvements are hiding (in plain sight).

As a final note, we do have until June 6, 2019 to weigh in on the proposed changes, so I would suggest you gather together a little working group, and if the spirit moves you, weigh right in. The data supports this being a whole bunch of ado about very little (approaching a whole bunch of doodoo), so the sooner we can refocus on the “real” challenges, the better.

 

Like the dust that settles all around me: I got those low-down TJC FAQ blues

I don’t know if there’s anything to be inferred by the fact that the latest updates on the ligature resistance front are “buried” on p. 8 of the May 2019 Perspectives (after an onslaught of what I characterize as Joint Commission advertisements), but it would be nice to think that perhaps folks are going to be allowed to move on at their own “pace” as a function of risk assessments, abatement and mitigation strategies and monitoring for gaps in safety, but I guess we shall see what we shall see.

At any rate, the May Perspectives (on p. 8—imagine that!) provides two topics, one of which, video monitoring we discussed a few weeks back (I guess they like to repurpose content as much as anyone…) and a clarification on the (admittedly somewhat awkwardly worded) requirement that self-closing and self-locking (both, not one or the other) doors are required for the separation of areas required to be ligature resistant and those that are not, with the intent being to eliminate reliance on staff to close and lock those doors to prevent patient harm. The FAQ also prohibits the use of hold-open devices of any kind on these doors, so do keep that in mind. This applies to “staff controlled” areas on a behavioral health unit, like med rooms, utility rooms, consult rooms, etc. This is all based on Recommendation #1 published in the November 2017 Perspectives and the guidance that patient rooms, patient bathrooms, corridors, and common patient areas are to be ligature resistant. If this is news to you (I don’t know that we’ve discussed this particular piece of the puzzle), I can’t say that I am surprised as it really didn’t stand out at the time and really required too much in the way of cogitation to figure out what they were getting at, particularly the descriptor (“Nursing stations with an unobstructed view (so that a patient attempt at self-harm at the nursing station would be easily seen and interrupted) and areas behind self-closing/self-locking doors do not need to be ligature-resistant and will not be cited for ligature risks.”) as it was probably a little too all-inclusive. I think I would have separated them into two bullet points:

  • Nursing stations with an unobstructed view
  • Areas behind self-closing/self-locking doors

But hey, as long as we get there in the end, right? Yeah, sure, fine…

In other news, ASHRAE is in the public comment process relative to proposed changes to ASHRAE 170 Standard for Ventilation of Health Care Facilities (you can see the proposed draft here). Given that NFPA 99 defers to ASHRAE on the ventilation front, I can’t help but think that this is going to continue to be a cornerstone compliance document during survey activities. I don’t know that I noted anything particularly egregious, etc., in the proposed update, but I always try to encourage the folks in the field to review and weigh in when these things are open for comment. Before we got to ligature-resistant considerations, the management of procedural environments as it relates to temperature, humidity, air pressure relationships, etc. was the hot-button topic, so any changes might have a similar impact on the industry. Unfortunately, I just got wind of this last week and the comment period ends May 6, so act fast!

Ticking away the moments that make up a dull day: EOC orientation and ongoing education

Going to touch on a couple of things this week. First up? Ed-yoo-ma-cation!

A week or so back, I received an email encouraging me to list what educational competencies are most important relative to preparing for the survey process. Off the top of my head, the list (in no particular order) goes a little something like this (and I will stipulate that competency is the key focal point for these):

  • Fire response, including (and perhaps most importantly) department-level protocols
  • Emergency response, including how to summon assistance in an emergency
  • How to report an Environment of Care (EOC) problem or condition (I like to include “How to recognize an EOC problem or condition” as a subset of this one)
  • How to manage their own care environment (this is a bit of a stretch as it is not specifically mandated by code or regulation, but I will characterize this as something of a distillation of the general duty clause, kind of…)

After that, things get kind of gray, but if you look really closely at that last one, it comes down to everyone being able to demonstrate competency relative to what skills and knowledge are required for them to do their job appropriately (safely, timely, etc.). From knowing how long disinfectant has to keep a surface wet to appropriately disinfect whatever surface you’re disinfecting (say that 10 times fast!) to making sure that folks who are charged with providing on-to-one safety observation of at-risk patients are conversant with what to look for, how to summon assistance, when it is appropriate to intervene, etc. There does appear to be a growing focus on the processes involved in ensuring that folks are competent to administer their job responsibilities. While the list above gives you a sense of the “umbrella” under which organizationwide orientation provides a framework, the devil (as they say ) is in the details—and those details “live” at the department level.

To that end, it may be useful (if you are not already a participant in the department-level safety orientation) to “audit” some of the department programs to see if what folks are receiving matches up with what your expectations are of the entire orientation process. Most of the folks I’ve chatted with over time have found their “time” at orientation to be shrinking almost as quickly as those new pants in a hot water wash—it may be time to leverage some other opportunities to get the safety word out.

The other item for discussion relates to survey findings and the question of how much folks “expand” their surveillance in response to a survey finding. Minimally, you’re on the hook for resolving whatever the specific finding might be and now, with the submission of the corrective action plans to The Joint Commission (or whomever), there’s that whole concept of how you’re going to sustain the processes necessary to maintain compliance. Most of the action plans I’ve seen have a good framework for long-term monitoring, etc., but what about between right now and, say, next week? Or, even, next month? There seems to be a lot of follow-up surveying going on in the healthcare world and how far do you go to prepare for that potential “sooner than later” next visit. As with pretty much all of this stuff, there is very little in the way of guidance, but I was wondering if we could dig up some “best practices” in the name of (perhaps) introducing some non-EOC stuff into next year’s top 10 lists…just sayin’.

Have a most delightful week!

I’d like to know, can you tell me, please don’t tell me: Behavioral health and egress

In response to last week’s modified Top 10 list (there’s been a request for another list regarding point-of-care/point-of-service staff knowledge of EC stuff—coming soon to a blog near you…), I received a question from the Lone Star state that I wanted to chat about with the group at large (I’m never quite sure if folks go back and revisit past questions and I thought this one might generate some comments from folks in general).

The question comes from the folks at a large hospital in east Texas who are in the process of designating a behavioral health “safe room” adjacent to their ER, where they’ll be holding patients for evaluation and eventual transportation to a local behavioral health hospital. The room in question is approximately 900 square feet (30 x 30) and the question raised relates to installing a second door in the space for use in the event of an emergency. The problem (or at least the stated problem, a little more pondering in a moment) is that this second egress door would lead into a major egress corridor. The question resulting from this “problem” is whether, due to the nature of what’s going on in the behavioral health room, having the door swing out into the egress route would be permitted, based on a risk assessment, etc.

First off (and you could certainly look at this as a bit of shameless self-promotion), it would be much more effective to be walking/talking this through in the present physical space, etc., but since I’m not scheduled to visit east Texas any time soon, I’m going to have to work this from afar. To that end, I have one question for the general audience: Do any of you have a behavioral health safe room with more than one “portal”? Since I saw this question, I’ve been racking my brain to recall an instance in which there was a room (as opposed to a designated space within an ER, or indeed, a behavioral health ER) that had a second egress door (and if I’ve visited your “house” and you have a two-door arrangement and I have somehow forgotten, please let me know). Even before I get to the door swinging into the egress corridor (and I think there are ways of being able to do this, but more on that in a moment—though it will require some homework), I start thinking about how you would secure that second door in such a way as to appropriately limit escape by the patient occupant and still provide sufficient access to staff removing themselves from a dangerous situation. Talk about a tightrope. But then I’m thinking, is there a way to configure the space that reduces the potential for a staff person to become “trapped” even with only one way out? I’m intuiting that the request for the second door is based on an actual occurrence in which an entrapment occurred, but I keep coming up against the “reality” that I can’t think of a behavioral health room with multiple ways out and that staff education of appropriate techniques for dealing with patients in a “confined” space would be the way to go.

As to the second egress door itself, while there are instances in which doors do swing out into an egress corridor, I think probably the best way forward, once you have completed the risk assessment, is to seek out the opinion of the authority having jurisdiction (AHJ), which in this instance would be the Texas Department of Health. Having had some experience with CMS surveys conducted by the state in that part of the world (and, truthfully, in most parts of the world) is to embark upon a field modification without providing the AHJ with an opportunity to review the proposed change(s). I think the primary reason that I would encourage this route is that this appears to be a somewhat unusual (if not quite rare, though it may be) arrangement; I understand the safety implications of the second door, but I also understand the implications such an arrangement can have on egress for adjacent occupants and I am not convinced that you’ll get carte blanche from the regulatory folks solely on the basis of a risk assessment in hand.

That said, I suppose you could also investigate a modification to the space that creates enough of an alcove on the egress side of the space to provide room for door swing, though that would certainly reduce the number of folks you could safely manage in the space. It may be that you folks are on the cutting edge of healthcare design, but sometimes the cutting edge “cuts” in the wrong direction. Given the attention being paid to the physical environment at the moment, it is unlikely that such a modification would escape notice (particularly with CMS).

The pendulum may swing back at some point, but I don’t see it happening any time soon—there are so many potential findings that they’d be hard-pressed to turn away. It’s very much like finding buried treasure and then leaving some for somebody else to find—it is not in line with human nature to walk away while there are still riches to be had.

We are hope, despite the times: Steve Mac’s top 10 most troublesome EC challenges

First a quick (moderately revelatory) story: While traveling last week, I had the opportunity to see Creed II on the plane (I found it very entertaining, though somewhat reminiscent of another film—but no spoilers here). Interestingly enough, the image that stayed with me was during a scene on a maternity unit in a hospital where I observed a nicely obstructed fire extinguisher (there was some sort of unattended cart parked in front of the extinguisher). I guess that means I can never turn “this” (and you can call it what you will) off… but enough digression.

About a month or so ago, an organization with whom I had not worked before (they’re on the upcoming schedule) asked for a top 10 list of what I’ve seen as the most challenging physical environment standards, etc. I will admit to having been taken off guard a wee bit (I usually depend on others for top 10 lists), but then I figured it was probably about time that I put a little structure to all the various and sundry things that I’ve seen over the last decade or so.

To that end, here are Steve Mac’s Top 10 Things that will get you in the most trouble in the quickest amount of time (I don’t think there are any surprises, but feel free to disagree…):

Top 10 Critical Process Vulnerabilities – Physical Environment

  1. Inadequately mitigated ligature/safety risks in behavioral health environments
  2. Management of surgical and other procedural environments (temperature, humidity, air pressure relationships)
  3. Construction management process—lack of coordination, inconsistent implementation of risk management strategies
  4. ILSM policy/assessment/implementation—including “regular” LS deficiencies
  5. Management of hazardous materials risks, particularly those relating to occupational exposure (eyewash stations, monitoring, etc.)
  6. Life safety drawings (accuracy, completeness, etc.)
  7. Management of infection control risks in the environment (non-intact surfaces, expired product, high, intermediate and low-level disinfection)
  8. Management of contractors/vendors (documentation, activities, etc.)
  9. Effectiveness of surveillance rounds; integration of work order system, etc., to address compliance concerns
  10. Stewardship of the environment—participation of point-of-care/point-of-service staff in management of the environment.

Now I don’t know that there’s anything here that we haven’t covered in the past, but if you folks would like a more in-depth analysis of anything in the list above (or, indeed, anything else), please let me know. I suspect that I will be returning to this list from time to time (particularly during slow news weeks).

One of your sprinkler heads is loaded: Can you find it before they do?

And now, to the recap of the 10 most frequently cited standards during all of 2018 (in hospitals; other programs are a little more varied), as chosen by somebody other than you (or me): the survey troops at TJC.

The top 10 are as follows:

  • EC 02.01.35—The hospital provides and maintains systems for extinguishing fires (88.9% noncompliance percentage).
  • EC 02.05.01—The hospital manages risks associated with its utility systems (78.7%).
  • EC 02.06.01—The hospital establishes and maintains a safe, functional environment (73.9%).
  • LS 02.01.30—The hospital provides and maintains building features to protect individuals from the hazards of fire and smoke (72.9%).
  • IC 02.02.01—The hospital reduces the risk of infections associated with medical equipment, devices, and supplies (70.9%)
  • LS 02.01.10—Building and fire protection features are designed and maintained to minimize the effects of fire, smoke, and heat (70.7%).
  • LS 02.01.20—The hospital maintains the integrity of the means of egress (67.4%).
  • EC 02.05.05—The hospital inspects, tests, and maintains utility systems (64.7%).
  • EC 02.02.01—The hospital manages risks related to hazardous materials and waste (62.3%).
  • EC 02.05.09—The hospital inspects, tests, and maintains medical gas and vacuum systems (62.1%).

The ongoing hegemony of the top 10’s EOC-centric focus (and I still consider IC.02.02.01 the point upon which infection control and the physical environment intersect—sometimes with spectacular results) leaves little to the imagination (both ours and the surveyors). While you can still get into some significant trouble with certain processes, etc. (more on that next week—I figure if they can have a Top 10 list, then so can I…), the reason that these particular standards continue to jockey for position is because they represent the kinds of conditions (to some degree, I hesitate to call them deficiencies) that you can find literally any (and every) day in your organization. Just think about LS.02.01.35 for a moment: How far would you have to go before you found schmutz on a sprinkler head, something within 18 inches of a sprinkler head, a missing escutcheon (or an escutcheon with a gap), or even something (likely network cabling) lying atop, wire-tied to, somehow “touching” sprinkler piping or supports? I’m going to intuit that you probably won’t have to range too far afield to find something that fits in that category. The only thing I can say is whoever was surveying the “other” 11.1 % of the hospitals in 2018 must not have felt like poking around too much.

At any rate, I don’t know that there is a lot to glean from the 2018 results (same as it ever was…), but if someone out there has a question or concern that they’d like to share, I’m all ears!

Wagering on a sewer thing: How are you managing wastes during an emergency?

Burn, bury, or dump it—apparently there is madness in the method—and your plan needs to reflect the methodologies.

I recognize that, particularly with newly introduced requirements, guidelines, etc., the rarified elements that we collectively (if not quite lovingly) refer to as “surveyor interpretation” are at their most diverse, maddening, arbitrary, capricious, and on and on and on. That said, there is one element relating to the recent CMS update relative to emergency preparedness that I touched upon in the blog a couple of weeks ago , but did not devote a lot of discussion time to it. And that element relates to waste management during an emergency response.

During CMS surveys as recent as March 2019, there has been much discussion about the particulars of how folks are poised to manage the various and sundry waste products generated by/through normal hospital operations, particularly during a prolonged emergency response condition. And while I can’t say I saw this coming (at least not in the first wave of scrutiny), it does appear that the CMSers (or at least some of ’em) are looking for fairly detailed planning in this regard: collection, holding/storage, short-term disposal, long-term disposal, pharmaceutical wastes, chemical wastes, etc. , inclusive of second and third-level backup plans. I suppose, like with just about anything and everything you could name, there is always the potential for external disruption that constricts the ability to remove waste materials from our campuses. And, while I think we tend to focus our preparatory activities on sustaining normal operations, it would seem that there might be some vulnerability relating getting rid of the stuffs that are the result of those normal operations.

At this point, I’m not entirely certain if the focus is more to the consultative than the compliance-related approach—the topic was discussed during survey, but no report has been issued as of this writing (if I hear more, I will certainly let you know), so it’s anybody’s guess. But I do know that these things tend to spread pretty quickly in the field, so it certainly wouldn’t hurt to kick the tires of your waste processes during your next emergency response exercise.

Immediate Jeopardy: How much do you want to wager?

With best wishes to Alex Trebek!

Over the last couple of weeks, the folks at the Centers for Medicare & Medicaid Services (we know them by the cleverly acronymic CMS) have been busy generating lots of guidance for the folks in the field, healthcare organizations and surveyors alike. One of these missives covers the revision of Appendix Q of the State Operations Manual to provide guidance to surveyors and, (by extension) folks charged with compliance at the organizational level, for identifying Immediate Jeopardy (IJ) conditions during surveys. For those of you that have not had the dubious fortune of encountering an IJ in your organization (and I dearly hope that trend continues), it is difficult to describe the impact this can have on an organization. Short of shutting the place down, I cannot think of a more—oh I don’t know, words really seem to fall short in describing the sheer awfulness of an IJ finding.

But as they say, forewarned is forearmed (more on that delightful turn of phrase here). So let’s chat a bit about how one gets to an IJ.

The pieces that comprise an Immediate Jeopardy finding go a little something like this (the entire notification can be found here):

“To cite immediate jeopardy, surveyors determine that (1) noncompliance (2) caused or created a likelihood that serious injury, harm, impairment or death to one or more recipients would occur or recur; and (3) immediate action is necessary to prevent the occurrence or recurrence of serious injury, harm, impairment or death to one or more recipients.”

I think you could probably imagine any number of scenarios that might fit that particular bill; by the way, one of the revisions to this guidance was a change to (2). In the revision, the term “likelihood” replaced “potential.” While I do think “likelihood” is a somewhat higher bar to meet than “potential,” I still see a lot of room for surveyor interpretation. Hopefully, the administration of this judgment call will be more judicious than not. Time will tell…

Fortunately, we do have the opportunity to get a “leg up” on the process by visiting the CMS surveyor training page and working through the education materials provided there (the education is open to providers, so don’t be scared off by the link). I have not yet partaken of the education (it’s on my to-do list) and I will surely provide an update in this space once I have done so.

Keeping an eye on things: Managing behavioral health patients

What, again?!?

Recently, our friends in Chicago added a new FAQ to the canon, this time reflecting on the use of video monitoring/electronic sitters for patients at high risk for suicide (you can find the details here). For those of you paying attention over the years—and I think that’s everybody within the sound of my “voice”—the situational requirements are based on a clear invocation of the “it depends” metric. I think it is pretty clear (and pretty much the standard “problem” relative to the management of behavioral health patients at serious risk for suicide) that providing sufficient flexibility of staffing to be able to provide 1:1 observation of these patients is where folks are looking for that flexibility in technological monitoring and the FAQ pretty much puts a big stop on that front. I think the quote that comes into focus for this aspect is, “The use of video monitoring or ‘electronic-sitters’ would not be acceptable in this situation because staff would not be immediately available to intervene.” So, as a general practice, a 1:1 observation means that somebody (a human somebody) is “immediately available to intervene,” which means all the time, at any time.

At this point in the discussion, I think the important piece of this is (and is likely to remain so) the clinical assessment of the patient, inclusive of the identification of the risk level for suicide. I don’t think that the “reality” of having to deal with way more of these patients than we would prefer is going to change any time soon, and with it, the complete unpredictability of that patient volume as a function of staffing (full moons notwithstanding).

The FAQ goes on to discuss the use of video monitoring in those instances in which it is not safe for staff to be physically located in the patient’s room, but the use of video monitoring has to result in the same level of observation, immediacy of response, etc. It also indicates that video monitoring for patients that are not at high risk for suicide is at the discretion of the organization, indicating that there are no “leading practices” in this regard. I guess that means that you’re really going to have to make your own way if you chose the video monitoring route, which should include (as also noted in the FAQ) provisions for reassessment of the patient(s). Interesting times, my friends, interesting times…

As a final (and almost completely unrelated) note, I wanted to bring to your attention some discussion over at the Motor & Generator Institute (MGI) relating to recent CMS guidance regarding expected temperatures in the care environment during normal power outages and how, if you have a long-term care facility in your mix, a risk assessment might not be enough. You can find the details here and the folks at MGI are encouraging feedback, so I think it might be worth checking out and weighing in.