June 23, 2020 | | Comments 0
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And it makes me wonder…sure does!

And it’s not just a bustle in your hedgerow, so alarm might be warranted…

Lately, I’ve been using this space to muse on the potential for changes to the survey process, particularly as a function of the inclusion of outpatient clinic settings and the impact of life safety surveyor attention to these facilities might have on survey results. If your immediate thought was “more findings in the physical environment,” I fear you are more correct than you might have wanted to be.

While I don’t have access to the official results just yet (the wheels of bureaucracy grind ever slowly), I was able to be front and center last week for a full federal Conditions of Participation survey. The most notable aspect of the survey (for me) was the attention paid to outpatient clinics being managed as business occupancies by the life safety portion of the survey process. There was a lot of focused document review for these offsite locations, with the expectation that the degree/level of exactitude in the documentation for your main campus is to be extended to the outpatient settings. Inventory lists of devices, making sure sensitivity testing is being done (with specific values—not just a pass/fail note for each); focused attention on how spare sprinkler heads are being managed—including ensuring that the correct wrench or wrenches are in place; quarterly fire drills (and yes, you read that correctly; it seems that the days of annual fire drills in business occupancies is drawing to a close), etc.

Those of you managing your outpatient settings through your own processes will have a leg up on the process, but if you rely on documentation provided by landlords, etc., you probably want to start kicking those tires and having the discussions now. The other piece of this is that the expectation is that any requested documentation would be readily (pretty darn close to immediately) available for review by the surveyor, so you may want to consider how you are managing that process. Do you have site-based binders or do you provide electronically? The surveyors definitely don’t want to hear that (for whatever reason) the documentation is not available.

As a final thought for this week, in light of this week’s coverage, you may want to give some thought as to how you might memorialize the ligature resistance risk assessment in the outpatient areas (don’t forget to make it thoughtful). As you can see from the link, the FAQ is aimed at the “hospital and hospital clinics” settings, so I think we can see where this could (and, let’s face it, probably will) go.

Until next time, I hope this finds you well and somehow managing the current currents—not sure what it will look like when we finally get past these rapids, but I hope that we all get through together!

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Filed Under: CMSLife Safety Code

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Steve MacArthur About the Author: Steve MacArthur is a safety consultant with The Greeley Company in Danvers, 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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