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Do you miss the safety professional you once had time to be?

I think we can agree that things in the safety world are moving along at a pretty good clip, particularly when it comes down to ensuring ongoing compliance with the various and sundry nuances that are flowing forth from the regulatory firehose. Now I’m sure are those of you that would like nothing better than to pore over the various and sundry code handbooks to figure out best to apply the latest changes to your practices/organizations. But I can tell you this: That’s getting to be very close to a full-time job all on its own—and too many of the current generation of survey findings have as much to do with managing the behaviors of staff at point of care and point of service as they do in figuring out what interpretation is going to win the day going forward. So, as I hear of some findings that I would tend to characterize as “frequently cited,” I want to make sure that I share them with you. This week, here’s a couple of items relating to emergency power:

Under the standard dealing with the setup of your emergency power system, there is a “new” performance element that requires a remote manual stoop station (with identifying label) “to prevent inadvertent or unintentional operation.” The performance element also points toward having a remote annunciator (powered by a storage battery) outside the EPS location. Anecdotally, I understand this is coming up with a fair frequency out in California, so probably worth a look-see for your gen sets.

Under the standard dealing with the inspection, testing, and maintenance of emergency power systems, the weekly inspection (and associated documentation) finally shows up as a specific performance expectation, as does the annual fuel quality test (to ASTM standards, so please make sure that your documentation of those activities is up to date).

As a final note for this week; some updates to the behavioral healthcare Life Safety chapter considerations, mostly shifting the Life Safety Code® chapter references from Chapter 26 (Lodging or Rooming Houses) in the 2000 edition to Chapter 32/33 (new and Existing Residential Board and Care occupancies). The changes impact “small” facilities that provide sleeping arrangements for four to 16 individuals. I don’t see anything particularly substantive, or indeed troubling, in the new stuff, but if you feel otherwise after checking it out, then please sing out loud and clear.

Hyperbaric oxygen makes some noise. Also: Stop, in the name of…the law? Love? Sanity?

First off, a quick word for those of you with responsibilities relating to hyperbaric oxygen chambers: NFPA 99 (2012) 14.2.4.5.3 states, “A source of breathable gas allowing unrestricted mobility shall be available outside a Class A or Class B chamber for use by personnel in the event that the air in the vicinity of the chamber is fouled by smoke or other combustion products of fire.” Soooooo, if you have not yet ordered a smoke hood with integral filter/air supply (or similar equipment) available for staff to use in case of a fire, then I would advise you to take very quick action on this, particularly if you are anticipating a survey sooner rather than later. Just as the recent medical equipment EP changes relative to oxygen equipment for hyperbaric oxygen environments came down from the mountain on composite-stone tablets, so too must the intricacies of Chapter 14 of NFPA 99-2012 be absorbed. Nothing like more new stuff to figure out…

Next up, a few random thoughts (more or less) about education and ensuring effectiveness (which might very well be a lost cause, yet I remain stubbornly hopeful).

The item that I keep coming up against is the thought/assumption (and yes, I know all about that last one) that the folks I see driving cars in various parts of the country are in fact licensed drivers. With the extended thought that in order to procure said license, there was some level of rudimentary testing of the budding licensee’s knowledge of the rules of the road. Now I will stipulate for all time that there is probably enough focus on simple driving etiquette and likely never will be. But, but, but, I am confident that there are certain elements that are universally covered in driver education and competency evaluation. So, I ask you this simple question: What is octagonal in shape, red in color, and provides what used to be a very specific command? (Hint: It’s a four letter word that, when reversed, describes cookware or perhaps earthenware.)

If you don’t know, it would seem that you are not alone…

It appears to me from my simple (but fairly voluminous at this point) observations that adherence to the octagonal has morphed into a corollary of the traffic signal (green means “go”; yellow means “speed up”; red means “it’s for the person behind me”). It’s gotten to the point where I’ve been honked at for actually coming to a full stop at these points and, to be honest, I’m not really sure how it all came to be widespread. I know it’s not because folks weren’t taught the expectation when encountering a stop sign (though I’m pretty sure that “yield” isn’t covered), but it does lead me to the question of how effectively do we “do” education?

Dragging this out into the hospital realm, I’m sure you’ve all come up against those survey encounters in which you cringe because you can’t be certain that the proper (never mind correct!) response is hard-wired into staff (particularly entry-level). Every day you see people doing things they have been instructed time and time again not to do (parking equipment, etc., in front of fire extinguishers, pull stations—you know the drill). And with alarmingly increasing frequency, you see people acting in a freakishly unsafe manner (e.g., cell phone use while driving); it can’t be that they don’t know and it can’t be that they are not at least somewhat familiar with the consequences. As a boss once told me: “You can’t mandate intelligence” (Ron White made a gazillion dollars converting that to something a little more folksy), but if that’s the case, how big a “stick” do you need to carry? Does a stick even work effectively anymore?

One of the key elements of post-survey corrective action plans is an increasing focus on how we plan to keep whatever it was from happening again. And I look at a majority of the findings and I’m thinking how far does one have to go to resolve each and every little thing for all time? I believe we should always be working towards perfection, but I am not so crazy as to think we’re going to get there anytime soon…

Thank you falletin me: Some survey-related (and otherwise random) thoughts

The first order of business is a word of thanks to anyone and everyone within the sound of my “voice” – I truly appreciate you (sometimes invisible) folks out there in the audience. It continues to be a rare treat having the opportunity to converse with you on a regular basis (the rarer treat is when I get to actually meet folks in the flesh—definitely a delightful happenstance when it occurs) and I hope that I’ve managed to carry on this little slice ‘o safety without being boring, pedantic, etc. Oftentimes, compliance stuff is rather more torturous than not, but what’s the point of doing something if you can’t have a little fun amidst the abject seriousness of it all…

Next up, a couple of items that have appeared during recent surveys that signal (in some instances) a clarification of intent and/or a change in the focus of the physical environment surveys. Some of this you will find endlessly aggravating, particularly if you get cited for it; some of it has the overpowering stench of inevitability as the regulatory folks find new and inventive ways to keep the numbers of findings at record levels. In no particular order:

 

  • In the wake of the clarifying information relative to the management of ligature risks, make sure that (and this is primarily in the ED/regular inpatient settings) for the risk items you have identified as being medically or clinically necessary/essential to the appropriate care of behavioral health patients, make sure that your risk assessment specifically identifies the inherent risks of the remaining risks. For example, if you need to have a medical bed (with side rails, etc.) in the room, make sure that all the specific risk elements of that (or “the”) medical bed are clearly enumerated in the risk assessment. Saw a survey result recently for which the finding was not that the bed was in the room (the finding specifically noted that the bed was medically necessary), but that the risk assessment did not clearly identify the individual components of the bed: side rails, electrical cord, etc. The survey finding indicated that the risk management strategy employed by the organization was appropriate (in this instance, using 1:1 staffing for the at-risk patients), the only “issue” was not identifying the component risks in the risk assessment. I think/hope that this is something of an overreach and if I find out that there is some clarifying information forthcoming, I will surely share it with you.
  • Those of you with older facilities (and perhaps some “younger” facilities as well) are often faced with the proliferation of electrical panels (and sometimes medical gas zone shutoff valves) that are located in spots for which it is almost impossible to ensure that equipment, etc., is not parked directly in front of the panel, etc. Sometimes the panels, etc., are located in the corridors (it really does make one appreciate electrical closets!); some of you may even have the abject misfortune of having electrical panels in your utility rooms (my condolences); and others have panels out in the operational area of busy locations like food services/kitchen areas. I wish that I had good news to impart, but there do seem to be at least a couple of surveyors heck-bent on citing each and every instance of obstructed access to electrical panels. And don’t get me started on corridor med gas shutoffs with electrical receptacles installed directly underneath. Sometimes I wonder if we would run into these types of conditions if the folks doing the design work actually had to live in the space once it is constructed…
  • Staying on the electrical side of things, I’ve also seen an increase in recent findings relating to the use (primarily in patient care areas) of relocatable power taps/power strips/etc. I know the appropriate management of these devices has been “hittable” for a little while now and perhaps there was an unspoken “honeymoon” period for the industry to get things going in the right direction. If that is the case, it appears that the honeymoon is over, so you (particularly if “you” are in the bucket for survey in the next little while) probably should focus a bit on power arrangements in the areas where equipment use and power needs tend to be exponential. I still think the resources provided by ASHE are worth checking out if you have not already done so. It just might save you a painful survey experience.

Closing out, I leave you with this thought/opportunity; I won’t pretend to have an answer for it, but perhaps someone out there in the audience might. Fortunately, it doesn’t happen very often to me personally, but as I get to visit and meet new folks all the time, I am always fascinated by a certain type of individual: they will pledge that they will do anything to help the cause, with the unspoken understanding that that help hinges on their not having to do anything. Sort of a “ask me anything and if it involves no effort on my part, I’ll be all over it.” Again, fortunately, there doesn’t appear to be a proliferation of these folks in healthcare, and if the sounds completely foreign to you, that’s great. But if anyone has any tips for managing the eager-to-pledge non-participant, I’m all ears.

A most joyous and restful Thanksgiving to you and yours!

I am barely breathing: Gas Equipment is on TJC’s Radar!

The past couple of weeks, I’ve been fielding some questions relative to some new performance elements under the Medical Equipment Management standard that covers inspection, testing, and maintenance activities. Apparently, folks have been receiving some sort of notifications from profession groups (in this case, it seems to be the respiratory therapy folks that are being targeted with the notifications.

At any rate, I think we can say (pretty much for all time) that any changes to the standards/EPs is likely to result in (at the very least) consternation and a potential uptick in findings related to said standards/EPs. At least some of the questioning is focused on a certain element of reliance on vendors (and we know how that can go). So, while I do believe that for the most part folks are going to be OK with the changes, I also recognize that a little conversation couldn’t possibly hurt…

In case you’ve not yet encountered the new stuff, what we have is this. For equipment listed for use in oxygen-enriched atmospheres (more on that in a moment), the following must be “clearly and permanently” labeled on the equipment (permanently meaning the labeling withstands cleaning and disinfecting—how many labels are like that?): 1) Oxygen-metering equipment, pressure-reducing regulators, humidifiers, and nebulizers are labeled with name of manufacturer or supplier; 2) Oxygen-metering equipment and pressure reducing regulators are labeled “OXYGEN–USE NO OIL”; 3) Labels on flowmeters, pressure-reducing regulators, and oxygen-dispensing apparatuses designate the gases for which they are intended; and 4) Cylinders and containers are labeled in accordance with Compressed Gas Association (CGA) C-7.

The source material for these “new” requirements is in NFPA 99-2012 11.5.3.1; and please note that color coding is not to be utilized as the primary method of determining cylinder or container contents; I suppose when you come right down to it, cylinders are no different than any other secondary container when it comes to identifying the contents.

The follow-up question becomes one of what constitutes an “oxygen-enriched atmosphere”; in the definitions section of NFPA 99-2012, section 3.3.131 gives us this: “3.3.131 Oxygen-Enriched Atmosphere (OEA). For the purposes of this code, an atmosphere in which the concentration of oxygen exceeds 23.5 percent by volume. (HYP)” Now, you may notice the little tag at the end of this definition, which gives us some indication of where we need to be particularly mindful, with “HYP” referring to hyperbaric therapy. I know there are more hyperbaric therapy locations than there used to be, but some folks aren’t going to have to worry too much about this. But in the interest of a complete picture, I looked over the materials in the NFPA 99 Handbook and I think the information there further narrows down the field of concern:

“The normal percentage of oxygen in air is 20.9 percent, commonly expressed as 21 percent. The value of 23.5 percent reflects an error factor of ± 2.5 percent. Such a margin of error is necessary because of the imprecision of gas measurement devices and the practicality of reconstituting air from gaseous nitrogen and oxygen. Hyperbaric chambers located in areas of potential atmospheric pollution cannot be pressurized with air drawn from the ambient atmosphere. Such chambers are supplied by ‘air’ prepared by mixing one volume of oxygen with four volumes of nitrogen. It is impractical to reconstitute large volumes of air with tolerances closer than 21 percent ± 2.5 percent. The code does not intend to imply that the use of compressed air cylinders in normal atmospheric areas (i.e., outside hyperbaric chambers) would create an oxygen-enriched atmosphere. The compressed air expands as it leaves the cylinder, drops to normal atmospheric pressure, and is not oxygen-enriched. This definition varies slightly from the one appearing in NFPA 53, Recommended Practice on Materials, Equipment, and Systems Used in Oxygen-Enriched Atmospheres [12], which states that the concentration of oxygen in the atmosphere exceeds 21 percent by volume or its partial pressure exceeds 21.3 kPa (160 torr). The scope of the definition is limited to the way the term is used throughout NFPA 99. The definition is independent of the atmospheric pressure of the area and is based solely on the percentage of oxygen. In defining the term, the issue of environments, such as a hyperbaric chamber, where the atmospheric pressure can vary, was taken into consideration. Under normal atmospheric conditions, oxygen concentrations above 23.5 percent will increase the fire hazard level. Different atmospheric conditions (e.g., pressure) or the presence of gaseous diluents, however, can actually increase or decrease the fire hazard level even if, by definition, an oxygen-enriched atmosphere exists. An oxygen-enriched atmosphere, in and of itself, does not always mean an increased fire hazard exists.”

At the moment, given the definition above, I can’t think of anything other than hyperbaric environments that would be covered under the new requirements, but I’ll keep my ear to the ground and pass on any information that seems worth sharing; beyond that, I would do an analysis of equipment for hyperbaric therapy and go from there.

When we consider how we’re going to make this happen (if it isn’t already; I’m thinking/hoping that the gas equipment suppliers are paying attention to the new rules), at the end of the day, compliance with Joint Commission standards and performance elements rests solely in the hands of the organization. Again, presumably/hopefully/expectantly, the vendors from whom you obtain medical gases, equipment, etc., will be familiar with the requirements as they are based on the currently adopted/approved version of NFPA 99, as well as the requirements of the Compressed Gas Association (CGA). I would reach out to them to see what their plans are for compliance, remembering that (at least for the moment) the new requirements apply only to the gases and equipment used in oxygen-enriched atmospheres. I suspect that there will come a time when all related equipment, etc., is similarly labeled, but you may find that in the short term that you will have to keep a close eye on equipment used in surgery, hyperbaric oxygen, etc., to ensure that everything is as it should be. The general concept of not using oil on oxygen equipment is not new, so it may be that this is not going to be as big a struggle as might first appear. I’d be interested in finding out what you learn from the vendors you’re using, just to establish a baseline for advising folks.

 

Breaking good, breaking bad, breaking news: Ligature Risks Get Their Day in Court

As I pen this quick missive (sorry for the tardiness of posting—it was an unusually busy week), the final vestiges of summer appear to be receding into the distance and November makes itself felt with a bone-chilling greeting. Hopefully, that’s all the bone-chilling for the moment.

Late last month brought The Joint Commission’s publication of their recommendations for managing the behavioral health physical environment. The recommendations focus on three general areas: inpatient psychiatric units, general acute care inpatient settings, and emergency departments. The recommendations (there are a total of 13) were developed by an expert panel assembled by TJC and including participants from provider organizations, experts in suicide prevention and design of behavioral healthcare facilities, Joint Commission surveyors and staff, and (and this may very well be the most important piece of all) representatives from CMS. The panel had a couple of meetings over the summer, and then a third meeting a few weeks ago, just prior to publication of the recommendations, with the promise of further meetings and (presumably) further refinement of the recommendations. I was going to “cheat” and do a little cut and pasting of the recommendations, but there’s a fair amount if explanatory content on the TJC website vis-à-vis the recommendations, so I would encourage you to check them out in full.

Some of the critical things (at least at first blush—I suspect that we, as well as they, will be discussing this for some little while to come) include an altering of conceptual compliance from “ligature free” to “ligature resistant,” which, while not really changing how we’re going to be managing risks in the environment, at least acknowledge the practical reality that it is not always possible to provide a completely risk-free physical environment. But we can indeed appropriately manage the remaining risks by appropriate assessment, staff monitoring, etc. Another useful recommendation is one that backs off on the notion of having to install “alarms” at the tops of corridor doors to alert that someone might be trying to use the door as a ligature point. It seems that the usefulness of such devices is not supported by reported experience, so that’s a good thing, indeed.

At any rate, I will be looking at peeling these back over the next few weeks (I’ll probably “chunk” them by setting as opposed to taking the recommendations one at a time), but if anyone out there has a story or experience to share, I would be more than happy to facilitate that sharing.

As a final note for this week, a shout out to the veterans in the audience and a very warm round of thanks for your service: without your commitment and duty, we would all be the lesser for it. Salute!

 

ADA vs. LSC: Projecting into the Future—Are You Ready to Rumble?

One of the nagging things (at least for me) that’s been looming in the background is CMS’ statement (and restatement, with a side of reiteration) emphasizing that the Life Safety Code® (LSC) is not an accessibility code and, thus, does not ensure compliance with the Americans With Disabilities Act (ADA). You can find that statement and some other funky stuff here.

The web page also includes some specific considerations that I suspect that you will find of considerable interest (well, it did for me) in that it appears to represent some sense of how the ADA vs. LSC joust is going to manifest itself in the field. The following are the relevant sections, with a link to the individual paragraphs from the Federal Register:

SECTIONS 18.2.3.4(2) AND 19.2.3.4(2)—CORRIDOR PROJECTIONS

This provision requires noncontinuous projections to be no more than 6 inches from the corridor wall. In addition to following the requirements of the LSC, healthcare facilities must comply with the requirements of the ADA, including the requirements for protruding objects. The 2010 Standards for Accessible Design (2010 Standards) generally limit the protrusion of wall-mounted objects into corridors to no more than 4 inches from the wall when the object’s leading edge is located more than 27 inches, but not more than 80 inches, above the floor. See Sections 204.1 and 307 of the 2010 Standards, available at http://www.ada.gov/​regs2010/​2010ADAStandards/​Guidance2010ADAstandards.htm [2] (“2010 Standards”). This requirement protects persons who are blind or have low vision from being injured by bumping into a protruding object that they cannot detect with a cane. (https://www.federalregister.gov/d/2016-10043/p-78)

Although the LSC allows 6-inch projections, under the ADA, objects mounted above 27 inches and no more than 80 inches high can only protrude a maximum of 4 inches into the corridor beyond a detectable surface mounted less than 27 inches above the floor (except for certain handrails which may protrude up to 41/2″). See section 307 of the 2010 standards for requirements for handrails and post-mounted objects. CMS intends to provide technical assistance regarding strategies for how to avoid noncompliance with the ADA’s protruding objects requirement, as well as how to modify non-compliant protruding objects.) (https://www.federalregister.gov/d/2016-10043/p-80)

SECTIONS 18.2.3.4 AND 19.2.3.4—CORRIDORS

This provision allows for wheeled equipment that is in use, medical emergency equipment not in use, and patient lift and transportation equipment be permitted to be kept in the corridors for more timely patient care. This provision also allows facilities to place fixed furniture in the corridors, although the placement of furniture or equipment must not obstruct accessible routes required by the ADA. See section 403.5 of the 2010 Standards. (https://www.federalregister.gov/d/2016-10043/p-88)

So, it appears that we may be looking at some changes of fixtures, etc. (including fire extinguishers—lots of those wall-mounted lovelies floating around, not to mention hand sanitizer dispensers) and a re-think of how we’re positioning furniture in corridors—should be an interesting ride. A hearty thanks to Kevin Kozlowski, president of Oval Brand Fire Products for planting the seed that germinated into this week’s missive. Among other things, Kevin and his folks manufacture a fire extinguisher that meets ADA requirements for wall projections.

If you’d like me to discuss a particular topic, please feel free to kick something my way. I figure any question one person has, the likelihood of others having the same or similar question it pretty strong, so don’t be afraid.

Workplace Violence: One Can Never Have Too Much Info…

I will freely admit that sometimes it takes me a while to get to everything that I want to share with you folks and this is one of those instances…

Back in May (yes, I know—mea culpa, mea culpa, mea maxima culpa—it was even longer ago that I was an altar boy), ECRI Institute published some information on violence in healthcare facilities that includes a white paper, some guidance on how to share the risk landscape of your facility as it relates to workplace violence and some other information that is accessible upon enrolling in a membership program (they have quite a few different programs, this week’s stuff comes from the Healthcare Risk Control program). I suspect that the provided information may be representative of a loss-leader to drive traffic to their website and service programs (much as this blog is a labor of love and obsession, its function is rather much the same—I don’t know that they would put up with my yammering otherwise), but the information available through the above links are certainly worth checking out (there are also free newsletters; as noted in this week’s headline, information coming directly to you saves having to hunt it down).

Another item on my mental to-do list (and it may very well be that it is on my to-done list, but a little reiteration never hurt anyone) was to encourage you to keep an close eye on The Joint Commission’s standards FAQ page (you have to do a lot of scrolling to get to the Hospitals section—they’ve changed the formatting of this section of their website and it just feels quite clunky to me). At any rate, there are way more FAQs than there used to be (maybe more than there needs to be, but if you make the presumption that the characterization of these questions as being frequently asked, then it is what it is) and you can’t really tell which ones have changed (they do highlight new FAQs; lots of pain management stuff on there right now). They used to include a date so you could more or less keep track of stuff. I’m going to guess that there’s going to be a lot of following up relative to the whole management of ligature risks—and make sure you talk to your organization’s survey coordinator to make sure you access the Suicide Risk Booster (there just seems to be something odd about that as a descriptor). As much as any issue there’s ever been in the physical environment, the management of ligature risks is one for which you cannot be too well prepared (think an infinite number of Boy Scouts and you’ll be moving in the right direction).

 

These are a few of my favorite things: Safety Risk Assessments!

A somewhat mixed bag of news items for you this week: a cornucopia of compelling content, if you will…

The Center for Health Design has published a pretty cool safety risk assessment tool that is available free on its website, although you do have to register (also free). The web page offers an introductory video describing the risk assessment, so you can check it out before you register.

In other news, Maine became the first state to ban flame retardants in upholstered furniture. As I travel the highways and byways of these United States, I see a fair amount of holiday decorations that have been treated with flame retardant sprays of various manufacture as folks try to provide a cheery environment for patients and not run afoul of the safety Grinches (and I use that term with all due respect and affection, having been a Grinch myself once or twice in the past). I don’t know if we’ll be able to say “as Maine goes, so goes the nation,” but this might have some interesting impact on the field-treating of combustible decorations.

As our final note this week, data from the U.S. Nurses’ Health Study II suggests that there is an increased risk of Chronic Obstructive Pulmonary Disease (COPD) among nurses with frequent exposure (at least once a week) to disinfectants in certain tasks (cleaning of surfaces, etc.): https://www.ersnet.org/the-society/news/nurses-regular-use-of-disinfectants-is-associated-with-developing-copd . The study indicates some of the “culprits” as glutaraldehyde, bleach, hydrogen peroxide, alcohol, and quaternary ammonium compounds. The article on the link also indicates that a recent European study of folks working as cleaners also showed an increased risk for COPD (somehow, not a surprising revelation to me). I think the bottom line on this (and perhaps our charge moving forward) is (and the article doesn’t really mention this) ensuring that folks are using appropriate PPE when they are using those types (or any type) of disinfectant products. PPE is always a tough thing to “sell” to folks, and while I think folks do understand that there are risks involved (just as there are risks associated with all sorts of behaviors—smoking springs to mind), there does seem to be a reluctance to take proper precautions every time one engages in these types of activities. I know this stuff isn’t particularly “sexy” when it comes to the topics of the day, but reinforcing basic protective measures can’t be a completely lost cause, can it?

 

 

Lazy days of autumn: CMS does emergency management (cue applause)!

I suppose you could accuse me of being a little lazy in this week’s offering, but I really want you to focus closely on what the CMS surveyors are instructed to ask for in the Emergency Management Interpretive Guidelines (more on those here; seems like forever ago), so I’ve done a bit of a regulatory reduction by pulling out the non-hospital elements (I still think they could have done a better job with sorting this out for the individual programs) and then pulling out the Survey Procedures piece—that’s really where the rubber meets the road in terms of how this is going to be surveyed, at least at the front end of the survey process.

I suspect (and we only have all of recorded history to fall back on for this) that as surveyors become more comfortable with the process, they may go a little off-topic from time to time (surprise, surprise, surprise!), but I think this is useful from a starting point. As I have maintained right along, I really believe that you folks have your arms around this, even to the point of shifting interpretations. This is the stuff that they’ve been instructed to ask for, so I think this is the stuff that you should verify is in place (and, really, I think you’ll find you’re in very good shape). There’s a fair amount of ground to cover, so I will leave you to it—until next week!

BTW, I purposely didn’t identify which of the specific pieces of the Final Rule apply to each set of Survey Procedures. If there is a hue and cry, I will be happy to do so (or you can make your own—it might be worth it to tie these across to the requirements), but I think these are the pieces to worry about, without the language of bureaucracy making a mess of things. Just sayin’…

Survey Procedures

  • Interview the facility leadership and ask him/her/them to describe the facility’s emergency preparedness program.
  • Ask to see the facility’s written policy and documentation on the emergency preparedness program.
  • For hospitals and critical access hospitals (CAH) only: Verify the hospital’s or CAH’s program was developed based on an all-hazards approach by asking their leadership to describe how the facility used an all-hazards approach when developing its program.

Survey Procedures

  • Verify the facility has an emergency preparedness plan by asking to see a copy of the plan.
  • Ask facility leadership to identify the hazards (e.g., natural, man-made, facility, geographic, etc.) that were identified in the facility’s risk assessment and how the risk assessment was conducted.
  • Review the plan to verify it contains all of the required elements.
  • Verify that the plan is reviewed and updated annually by looking for documentation of the date of the review and updates that were made to the plan based on the review.

 

Survey Procedures

  • Ask to see the written documentation of the facility’s risk assessments and associated strategies.
  • Interview the facility leadership and ask which hazards (e.g., natural, man-made, facility, geographic) were included in the facility’s risk assessment, why they were included and how the risk assessment was conducted.
  • Verify the risk assessment is based on an all-hazards approach specific to the geographic location of the facility and encompasses potential hazards.

Survey Procedures

Interview leadership and ask them to describe the following:

  • The facility’s patient populations that would be at risk during an emergency event
  • Strategies the facility (except for an ASC, hospice, PACE organization, HHA, CORF, CMHC, RHC, FQHC and end stage renal disease (ESRD) facility) has put in place to address the needs of at-risk or vulnerable patient populations
  • Services the facility would be able to provide during an emergency
  • How the facility plans to continue operations during an emergency
  • Delegations of authority and succession plans

Verify that all of the above are included in the written emergency plan.

Survey Procedures

Interview facility leadership and ask them to describe their process for ensuring cooperation and collaboration with local, tribal, regional, state, and federal emergency preparedness officials’ efforts to ensure an integrated response during a disaster or emergency situation.

  • Ask for documentation of the facility’s efforts to contact such officials and, when applicable, its participation in collaborative and cooperative planning efforts.
  • For ESRD facilities, ask to see documentation that the ESRD facility contacted the local public health and emergency management agency public official at least annually to confirm that the agency is aware of the ESRD facility’s needs in the event of an emergency and know how to contact the agencies in the event of an emergency.

Survey Procedures

Review the written policies and procedures which address the facility’s emergency plan and verify the following:

  • Policies and procedures were developed based on the facility- and community-based risk assessment and communication plan, utilizing an all-hazards approach.
  • Ask to see documentation that verifies the policies and procedures have been reviewed and updated on an annual basis.

Survey Procedures

  • Verify the emergency plan includes policies and procedures for the provision of subsistence needs including, but not limited to, food, water and pharmaceutical supplies for patients and staff by reviewing the plan.
  • Verify the emergency plan includes policies and procedures to ensure adequate alternate energy sources necessary to maintain:

o Temperatures to protect patient health and safety and for the safe and sanitary storage of provisions;

o Emergency lighting; and,

o Fire detection, extinguishing, and alarm systems.

  • Verify the emergency plan includes policies and procedures to provide for sewage and waste disposal.

 

Survey Procedures

  • Ask staff to describe and/or demonstrate the tracking system used to document locations of patients and staff.
  • Verify that the tracking system is documented as part of the facilities’ emergency plan policies and procedures.

 

Survey Procedures

  • Review the emergency plan to verify it includes policies and procedures for safe evacuation from the facility and that it includes all of the required elements.
  • When surveying an RHC or FQHC, verify that exit signs are placed in the appropriate locations to facilitate a safe evacuation.

 

Survey Procedures

  • Verify the emergency plan includes policies and procedures for how it will provide a means to shelter in place for patients, staff and volunteers who remain in a facility.
  • Review the policies and procedures for sheltering in place and evaluate if they aligned with the facility’s emergency plan and risk assessment.

 

Survey Procedures

  • Ask to see a copy of the policies and procedures that documents the medical record documentation system the facility has developed to preserves patient (or potential and actual donor for OPOs) information, protects confidentiality of patient (or potential and actual donor for OPOs) information, and secures and maintains availability of records.

 

Survey Procedures

  • Verify the facility has included policies and procedures for the use of volunteers and other staffing strategies in its emergency plan.

 

Survey Procedures

  • Ask to see copies of the arrangements and/or any agreements the facility has with other facilities to receive patients in the event the facility is not able to care for them during an emergency.
  • Ask facility leadership to explain the arrangements in place for transportation in the event of an evacuation.

 

Survey Procedures

  • Verify the facility has included policies and procedures in its emergency plan describing the facility’s role in providing care and treatment (except for RNHCI, for care only) at alternate care sites under an 1135 waiver.

 

Survey Procedures

  • Verify that the facility has a written communication plan by asking to see the plan.
  • Ask to see evidence that the plan has been reviewed (and updated as necessary) on an annual basis.

 

Survey Procedures

  • Verify that all required contacts are included in the communication plan by asking to see a list of the contacts with their contact information.
  • Verify that all contact information has been reviewed and updated at least annually by asking to see evidence of the annual review.

 

Survey Procedures

  • Verify that all required contacts are included in the communication plan by asking to see a list of the contacts with their contact information.
  • Verify that all contact information has been reviewed and updated at least annually by asking to see evidence of the annual review.

 

Survey Procedures

  • Verify the communication plan includes primary and alternate means for communicating with facility staff, federal, state, tribal, regional and local emergency management agencies by reviewing the communication plan.
  • Ask to see the communications equipment or communication systems listed in the plan.

 

Survey Procedures

  • Verify the communication plan includes a method for sharing information and medical (or for RNHCIs only, care) documentation for patients under the facility’s care, as necessary, with other health (or care for RNHCIs) providers to maintain the continuity of care by reviewing the communication plan.

o For RNCHIs, verify that the method for sharing patient information is based on a requirement for the written election statement made by the patient or his or her legal representative.

  • Verify the facility has developed policies and procedures that address the means the facility will use to release patient information to include the general condition and location of patients, by reviewing the communication plan

 

Survey Procedures

  • Verify the communication plan includes a means of providing information about the facility’s needs, and its ability to provide assistance, to the authority having jurisdiction, the Incident Command Center, or designee by reviewing the communication plan.
  • For hospitals, CAHs, RNHCIs, inpatient hospices, PRTFs, LTC facilities, and ICF/IIDs, also verify if the communication plan includes a means of providing information about their occupancy.

 

Survey Procedures

  • Verify that the facility has a written training and testing (and for ESRD facilities, a patient orientation) program that meets the requirements of the regulation.
  • Verify the program has been reviewed and updated on, at least, an annual basis by asking for documentation of the annual review as well as any updates made.
  • Verify that ICF/IID emergency plans also meet the requirements for evacuation drills and training at §483.470(i).

 

Survey Procedures

  • Ask for copies of the facility’s initial emergency preparedness training and annual emergency preparedness training offerings.
  • Interview various staff and ask questions regarding the facility’s initial and annual training course, to verify staff knowledge of emergency procedures.
  • Review a sample of staff training files to verify staff have received initial and annual emergency preparedness training.

 

Survey Procedures

  • Ask to see documentation of the annual tabletop and full scale exercises (which may include, but is not limited to, the exercise plan, the AAR, and any additional documentation used by the facility to support the exercise.
  • Ask to see the documentation of the facility’s efforts to identify a full-scale community based exercise if they did not participate in one (i.e., date and personnel and agencies contacted and the reasons for the inability to participate in a community based exercise).
  • Request documentation of the facility’s analysis and response and how the facility updated its emergency program based on this analysis.

 

Survey Procedures

  • Verify that the hospital, CAH, and LTC facility has the required emergency and standby power systems to meet the requirements of the facility’s emergency plan and corresponding policies and procedures
  • Review the emergency plan for “shelter in place” and evacuation plans. Based on those plans, does the facility have emergency power systems or plans in place to maintain safe operations while sheltering in place?
  • For hospitals, CAHs, and LTC facilities which are under construction or have existing buildings being renovated, verify the facility has a written plan to relocate the EPSS by the time construction is completed

For hospitals, CAHs, and LTC facilities with generators:

  • For new construction that takes place between November 15, 2016 and is completed by November 15, 2017, verify the generator is located and installed in accordance with NFPA 110 and NFPA 99 when a new structure is built or when an existing structure or building is renovated.  The applicability of both NFPA 110 and NFPA 99 addresses only new, altered, renovated or modified generator locations.
  • Verify that the hospitals, CAHs and LTC facilities with an onsite fuel source maintains it in accordance with NFPA 110 for their generator, and have a plan for how to keep the generator operational during an emergency, unless they plan to evacuate.

 

Survey Procedures

  • Verify whether or not the facility has opted to be part of its healthcare system’s unified and integrated emergency preparedness program. Verify that they are by asking to see documentation of its inclusion in the program.
  • Ask to see documentation that verifies the facility within the system was actively involved in the development of the unified emergency preparedness program.
  • Ask to see documentation that verifies the facility was actively involved in the annual reviews of the program requirements and any program updates.
  • Ask to see a copy of the entire integrated and unified emergency preparedness program and all required components (emergency plan, policies and procedures, communication plan, training and testing program).
  • Ask facility leadership to describe how the unified and integrated emergency preparedness program is updated based on changes within the healthcare system such as when facilities enter or leave the system.

 

To close out this week’s bloggy goodness, Diagnostic Imaging just published a piece on emergency preparedness for radiology departments that I think is worth checking out: http://www.diagnosticimaging.com/practice-management/emergency-preparedness-radiology . Imaging services are such a critical element of care giving (not to mention one of the largest financial investment areas of any healthcare organization) that a little extra attention on keeping things running when the world is falling (literally or figuratively) down around your ears. I think we can make the case that integration of all hospital services is likely to be a key element of preparedness evaluation in the future—this is definitely worthy of your consideration.

Fall On Me: Keeping Emergency Management Changes in Perspective

As I was ruminating on a topic for this week’s conversation, the October issue of Perspectives came zipping over the electronic transom, and I think there is just enough stuff here to cobble together a relatively cogent offering to you all out there in the blogosphere (that’s right—after 10+ years, I’m working on cogency—who’d a thunk…)

First up is the announcement of proposed changes to the Emergency Management chapter (I say proposed, because the indication is that these changes still require approval by CMS) with an intended survey implementation date of November 15, 2017 (when the Emergency Management final rule takes full effect). From my experiences with folks, I still don’t think they’re barking up a tree for which we cannot (collectively) provide a reasonable response, but if you’re interested in what they think they need to change in the standards, the list of additions includes consideration of:

  • Continuity of operations and succession plans
  • Documentation of collaboration with local, tribal, regional, state, and federal EM officials
  • Contact information on volunteers and tribal groups
  • Documented annual training of all new/existing staff, contractors, and volunteers
  • Integrated health care systems
  • Transplant hospitals

Again, I don’t see anything that strikes me as being particularly daunting, though there’s still a fair amount of angst relative to these changes (as is the case with anything that changes). I know there’s been some consternation relative to managing Memorandums of Understanding (or Memoranda, if that be your preference) and Alternate Care Sites, but I think the important thing to keep in mind is that the journey to the Final Rule started back when the 2008 TJC standards were in full bloom. And I suspect that those of you who have been doing this for a while recall those heady days of focus on MOU’s, ASC’S, COOP’s and the like, concepts that have really kind of faded into the operational ether as the efficacy of those approaches has yielded wildly inconsistent levels of preparation. For some folks, MOU’s, ASC’s and COOP’s are essential, but I’ve also seen evidence that when the feces is striking the rapidly rotating blades, it is often the group that shows up first with the closest thing to cash that has access to resources. When you think about it, things like MOU’s are only an agreement to do the best one can under the circumstances—that’s why the interface with local and regional EM authorities is so very important. At any rate, next we’ll chat a bit about what the CMS survey instructions involve and why I think you folks are going to be in pretty good shape. I am curious as to whether or not there is an intent to modify the emergency response exercise requirements to more closely mirror the Final Rule—I guess all in the fullness of time.

Moving on to other Perspectives topics, it would seem that last month’s Clarifications and Expectations column was indeed the last official communication under George Mills’ direction. The column is on hiatus for the moment—I guess we’ll have to wait and see whether November brings it back (though oy could certainly make the case that EC-EM-LS topics are taking up a fair amount of space in the monthly Perspectives, Clarifications and Expectations columns notwithstanding).

There is a new Sentinel Event Alert (#58!) regarding issues relating to inadequate hand-off communications; the reason I mention it here is that, while the focus in Perspectives is very much on the clinical side of things, I think there is more than a little crossover into the safety / physical environment realm. I’m just planting the seed here, but I suspect that I will have more thoughts on this in the coming little while.

Finally (for this week), there is a piece on Workplace Violence as a function of screening for early detection of risk to harm self or others. I suspect that this may be a harbinger of next steps as it relates to how organizations are managing at-risk patients, particularly as a function of the current focus on ligature risks. In recognition that all the risks that are not medically/clinically necessary have removed, if you don’t have a pretty robust screening process in place, it makes it very challenging to manage the risks that remain. At any rate, I’d keep an eye on this one—much as they’ve been peeling the Infection Control “onion” over the past couple of years, I think this is how they’re going to expand focus in the behavioral health realm.

But, as a subset of that, I did want to muse a bit on those instances when entities that were thought of as “friendly” turn out (under certain circumstances) to be not so much. I suspect that most of you saw the news item back in July regarding the nurse working in the ED of a hospital in Salt Lake City, UT, who was forcibly arrested by local police for not acquiescing to a request that was not allowed by organization policy (if you missed it, you can see some of the story here or here.) I mention this only to point out that the management of this stuff is not always simple (OK, it pretty much never is simple), but this does offer up yet another facet to how facilities safety and security professionals have to proactively advocate for staff (and patient) safety. Some of the images of the arrest are most harrowing and definitely beg the question of how this came to pass in this day and age (or maybe it’s not as questionable an outcome as perhaps it might once have been). At any rate, it’s always important to periodically review what I refer to as the “rules of engagement,” particularly when it comes to interacting with law enforcement folks. If our folks can’t be protected from our “friends,” then what shot do we have against an unknown/unknowable “foe.”