June 20, 2017 | | Comments 0
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Is this the survey we really want?

Moving on to the type of pain that can only be inflicted at the federal level, a couple of things that might require an increase in your intake of acid-reducing supplements…

As it appears that CMS doesn’t love that dirty water (and yes, my friends, that is a shameless local plug, but it is also a pretty awesome tune), now their attentions are turning to the management of aerosolizing and other such water systems as a function of Legionella prevention. Now, this is certainly not a new issue with which to wrestle, which likely means that the aim of this whole thing, as indicated in the above notification—“Facilities must develop and adhere to policies and procedures that inhibit microbial growth in building water systems that reduce the risk of growth and spread of Legionella and other opportunistic pathogens in water”—is something with which we are abundantly familiar. But I will admit to having been curious about the implied prevalence in healthcare facilities as that’s the type of stuff that typically is pretty newsworthy, so I did a quick web search of “Legionella outbreaks in US hospital.” I was able to piece together some information indicating that hospitals are not doing a perfect job on this front, but the numbers are really kind of small in terms of cases that can be verifiably traced back to hospitals. When you think about it, the waters could be a bit muddy as Legionella patients that are very sick are probably going to show up at your front door and there may be a delay in diagnosis as it may not be definitively evident that that’s what you’re dealing with. At any rate, sounds like a zero-tolerance stance is going to be, but the Survey & Certification letter does spell out the instructions for surveyors:

Surveyors will review policies, procedures, and reports documenting water management implementation results to verify that facilities:

 

  • Conduct a facility risk assessment to identify where Legionella and other opportunistic waterborne pathogens (e.g., Pseudomonas, Acinetobacter, Burkholderia, Stenotrophomonas, nontuberculous mycobacteria, and fungi) could grow and spread in the facility water system.
  • Implement a water management program that considers the ASHRAE industry standard and the CDC toolkit, and includes control measures such as physical controls, temperature management, disinfectant level control, visual inspections, and environmental testing for pathogens.
  • Specify testing protocols and acceptable ranges for control measures, and document the results of testing and corrective actions taken when control limits are not maintained.

I have little doubt that you folks already have most, if not all, of this stuff in place, but it might not be a bad idea to go back and review what you do have to make sure that everything is in order. And if you are interested in some of the additional information (including some numbers) available, the following links should be useful:

Moving on to the world of emergency management, during the recent webinar hosted by CMS to cover the Emergency Preparedness final rule, one of the critical (at that time, more or less unanswered) questions revolved around whether we could expect some Interpretive Guidelines (basically, instructions for surveyors in how to make their assessments) for the EP Final Rule. And to what to my wondering eyes should appear, but those very same Interpretive Guidelines.  I will feely admit that the setup of the document is rather confusing as there are a lot of different types of providers for which the Final Rule applies and not all the requirements apply to all of the providers, etc., so it is a bit of a jumble, to say the least. That said, while I don’t think that I am sufficiently well-versed with the specific EM requirements of the various and sundry accreditation organizations (HFAP, DNV, CIHQ, etc.), I can say that those of you using TJC for deemed status purposes should be in pretty good shape as it does appear that one of the early iterations of the TJC EM standards was used in devising the Final Rule, so the concepts are pretty familiar.  A couple of things to keep in mind in terms of how the CMS “take” might skew a little differently are these:

 

  • You want to make sure you have a fairly detailed Continuity of Operations Plan (CoOP); this was a hot button topic back in the immediately post-9/11 days, but it’s kind of languished a bit in the hierarchy of emergency response. While the various and sundry performance elements in the TJC EM chapter pretty much add up to the CoOP, as a federal agency, it is likely that CMS will be looking for something closer to the FEMA model (information about which you can find here), so if you have a CoOP and haven’t dusted it off in a while, it would probably be useful to give it the once over before things start heating up in November…
  • As a function of the CoOP, you also want to pay close attention to the delegation of authority during an emergency, primarily, but not exclusively the plan of succession during an emergency (I found the following information useful and a little irreverent—a mix of which I am quite fond). It does no good at all for an organization to be leaderless in an emergency—a succession plan will help keep the party going.
  • Finally, another (formerly) hot button is the alternate care site (ACS), which also appears to be a focus of the final rule; the efficacy of this as a strategy has been subject to some debate over the years, but I think this one’s going to be a source of interest as they start to roll out the Interpretive Guidelines. At least at the moment, I think the key component of this whole thing is to have a really clear understanding (might be worth setting up a checklist, if you have not already) of what you need to have in place to make appropriate use if whatever space you might be choosing. I suspect that making sure that you have a solid evaluation of any possible ACS in the mix: remember, you’re going to be taking care of “their” (CMS’) patients, so you’d better make sure that you are doing so in an appropriate environment.

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Filed Under: CDC/infection controlCMSEnvironment of careEnvironmental protectionHospital safety

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Steve MacArthur About the Author: Steve MacArthur is a safety consultant based in Bridgewater, Mass. He brings more than 30 years of healthcare management and consulting experience to his work with hospitals, physician offices, and ambulatory care facilities across the country. He is the author of HCPro's Hospital Safety Director's Handbook and is contributing editor for Briefings on Hospital Safety. Contact Steve at stevemacsafetyspace@gmail.com.

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