Search Results for 'water management'

The Fountains of Youth and Water Management Programs

As a follow to last week’s item about water management programs, I know a lot of folks are not using their drinking fountains (or as we know them in the Boston areas, bubblers—pronounced “bubblahs”—I was hoping to find an audio link, but if you doubt the veracity of that pronunciation, this sort of backs it up). How are you managing those as a function of your water management program?  I’ve seen a lot of these devices sitting idle (and not just in healthcare) and looks like they may be sitting that way for a while. Are you periodically having someone go around to operate them or have you modified other practices to keep an eye on these? Not quite sure why it took me so long to think about this—perhaps it’s the ever-growing drinking fountains covered in plastic. The other question I had in this regard is whether any of you are using this as an opportunity to remove them completely? Depending on the design of your building, these are sometimes placed in a way that reduces the clear width of an egress pathway or two. This might be the best opportunity evah to get rid of them.

Of course, the other dynamic that comes into play (though perhaps less in healthcare than in other industries) is the whole notion of how to manage facilities that are experiencing reduced utilization. Perhaps you have a business office or the equivalent, and you have folks working remotely or some other variation on the theme of forced vacancy. If that’s the case (or could become the case if COVID persists), then you might find the following information worth checking. Fortunately, resources continue to provide guidance in this regard and I don’t think there’s anyone among us that would wish to endure a breakout of waterborne pathogens in the midst of the current climate.

Check out the following resources:

Hope all is well and you folks are staying safe. See you next time!

Madman Across the Water Management Program

This week brings us something of an unexpected development in the management of the physical environment as our friends in Chicago are seeking comments on a proposed standards revision that more clearly indicates the required elements for water management programs. I don’t know that I was expecting this change, though I suppose it falls under the “one outbreak is one too many” category, nor was I expecting the solicitation of commentary from the field (I look forward to seeing the results of the comment period). It would seem that the proposed performance element is based very closely on the CDC recommendations, which clearly take into consideration the guidance from ASHRAE 188 Legionellosis: Risk Management for Building Water Systems and ASHRAE 12 Managing the Risk of Legionellosis Associated with Building Water Systems, so it doesn’t appear that we’re breaking new ground here.

Additionally, we know from past discussions that CMS has been pretty focused on the risks associated with building water systems (most recently, here, but there are others), so this may be a case of ensuring that everyone is paying attention to the areas of (presumably) greatest risk. And, as near as I can tell, none of the existing COVID-related blanket waivers exempts folks from managing the risks associated with building water systems, so hopefully you’ve been staying with your identified frequencies for testing, etc. And if you haven’t, you probably should be identifying a game plan for ensuring that those risks are being appropriately managed.

Clearly, there’s a little time before these “changes” go into effect (the comment period ends November 16, 2020), but since this is pretty much what CMS has been looking for since 2017 or so, you want to have a solid foundation of compliance moving forward. I recognize with everything else going on at the moment, this might not be a priority, but this is one of those concerns in which proactivity will keep you out of compliance jail.

Until next time, hope you are all well and staying safe!

Don’t get soaked by your water management program!

I don’t know about you, but lately I’ve been finding the most interesting stuff being published in Perspectives are the articles entitled “Consistent Interpretation” because I am fascinated by the data they are collecting that drives taking particular note of the standard or performance element being featured. For example, the January 2020 issue covers the intricacies of managing the risks associated with waterborne pathogens, a topic that I’ve been keeping an eye on if only because of the attentions paid to that topic by our friends at CMS (if you’ve lost track of where they are in the fray, feel free to make the jump—but don’t forget to come back!). I figure there are just enough peculiarities involved for this to wreak some havoc during accreditation surveys, and while there are ways for survey findings to be generated, it would appear (based on the just under 4% citation rate during the first half of 2019) that you folks out there in the field are making pretty good headway.

So, where things can go awry include: Not having a water management plan to deal with waterborne pathogen risks (not sure how someone would have missed that, but perhaps it was a question of a slower than normal implementation track); failing to include a new piece of equipment (for instance, a brand new cooling tower) in the program (I should think the time for risk assessment and inclusion is during the commissioning of new equipment); failing to maintain the water in the system in accordance with the levels called for in the water management plan; failing to document scheduled testing and monitoring; and failing to establish acceptable ranges and/or control measures to be taken when levels are out of range.

It would seem that decorative water features, ice machines, and water dispensers were in the mix as well, including issues with equipment not being maintained in accordance with the manufacturers’ instructions for use, but in looking at all the different ways water management concerns could be cited, I suspect a lot of the cited conditions (you can find more specifics in the January Perspectives) were not widely observed.

That said, since a lot of the nuts and bolts implementation of water management programs may be accomplished by “others,” I think that going forward, the surveyors will be especially attentive to reviewing your water management plan and any deliverables from testing and monitoring activities. There are a lot of moving parts in this endeavor; best to be ahead of the curve and keep a close eye on those reports.

Water is wet: How about your ORs?

Howdy folks, as our friends from Chicago return to the field, a couple of items have come to my attention that I felt were worth sharing. There’s also an updated resource that we’ve mentioned in the past (though it seems that there are always many things that we’ve mentioned in the past—go figure).

First up, as we know from our diligent perusal of the intricacies of NFPA 99, Section 6.3.2.2.8.4 indicates that “(o)perating rooms shall be considered to be a wet procedure location, unless a risk assessment conducted by the health care governing body determines otherwise.” Consequently, the Life Safety surveyors are asking to see the risk assessment that determined otherwise or validation that your ORs are appropriately protected in accordance with the requirements for wet locations (isolated power, etc.). In previous discussions, I did note that “health care governing body” would seem to indicate that the assessment needs to include, at least to some degree—it doesn’t specify—hospital leadership. My general thought is that if your ORs aren’t considered wet locations and weren’t designed that way, you should be able to use the initial design/build aspect of the ORs to represent an assessment of those risks and, nominally, as construction activity, would have involved hospital leadership. I guess that then begs the question of how often you would need to revisit the assessment. It might be a(nother) good use of the annual evaluation process; I’m a big fan of using that process to “plant” things where you know they are likely to be viewed during survey. Much as the comments section of the eSOC is a good place to memorialize waivers, equivalencies, and the like, the annual evaluation is a good place to revisit important historical decisions. At any rate, it appears that wet locations are high on the “ask list,” so be prepared.

Another consideration that appears to be on the table is a risk assessment regarding what type(s) of fire extinguishers are in your ORs (could surgical fire management be a theme?). Our friends from the Windy City have something to say about this, and it appears that there was a recent update (though what got updated is not immediately apparent) to the FAQ, so probably worth a visit. I don’t doubt that these elements came into play when extinguishers were first chosen, but (again!) it never hurts to review…

Lastly this week, while this hasn’t necessarily been a survey hot topic, somehow it feels like water management programs are going to start to become more heavily surveyed. I think we can agree that this is a significant risk to be managed and while there is minimal evidence that these risks are not being appropriately managed in U.S. hospitals, any time something “new” comes along, it tends to represent a shift in survey focus. In the past, I’ve recommended checking out Matt Freije’s work at HC Info for really useful information on water management concerns. He does a great job of keeping an eye on water management across the globe, but also keeps an eye on our friends. If you’ve not settled into a water management program yet (and you really do need to get on it), it is definitely worth checking out the HC Info website.

On that note, I will bid you adieu for now; hope you all are doing well and staying safe. See you next week!

Like water for opportunistic organisms: Protecting patients through utility systems

As a wise individual once noted, “water always wins” (at risk of betraying my nerd status, you can find the entire quote here), and it seems like water in its numerous forms is giving facilities professionals a run for their money this year. From mold in an OR in the Northwest to the constant battle (or so it seems) with Legionella prevention, this is as challenging a time as I can recall for facilities. And that doesn’t even take into account the ongoing impact of minor intrusions—leaks, condensation, overflowing toilets—it is an almost endless list of troubles.

My intent was to provide the above as information, with my usual encouragement to leverage point-of-care/point-of-service staff in the early identification of trouble spots, but I’m also thinking that perhaps someone out there in the field has been able to develop an effective plan for the proactive management of water woes. Certainly, I know of folks with fairly predictable “rainy seasons” and then there are those locations in which rain is a constant threat, not to mention the intrusion of humidity by various (and sometimes nefarious) means. So, what do you do that works (recognizing that this is not a one size fits all proposition)? Do you have any useful/effective strategies you can share with the blogosphere? I generally only hear about stuff that doesn’t work, so it would be a treat indeed to tout someone’s intuitive brilliance.

As a final note for this week, those of your laboring under the yoke of TJC accreditation might do well to give the August issue of Perspectives a look (it’s become less of a regularly useful read for me, but every once in a while). In the Consistent Interpretation column/article, there’s a lot of discussion (under the guise of the Infection Control standards) of PPE use/availability/education, etc. Again, the findings are falling under the IC standards from a past survey result standpoint, but I don’t think it’s a stretch for some (or almost any) of these to be applied as Hazardous Materials & Wastes Management findings. Again, not everything applies, but I think if we’ve learned nothing else over the years, it’s the funky application of survey concepts from one are of scrutiny to another. Stranger things have happened…

Try to keep things cool over the second half of the summer!

It’s been a quiet week in Lake Hazard-be-gone: Water and Legionella

Not a ton of “hair on fire” stuff in the news this week, so (yet again), a quick perusal of something from the “things to consider” queue.

It seems likely that Legionella and the management of water systems is going to continue to have the potential for becoming a real hot-button issue. I suppose any time that CMS issues any sort of declarative guidance, it moves things in a (potentially) direction of vulnerability for healthcare organizations. That said, it might be worth picking up the updated legionellosis standard from ASHRAE to keep up with the current strategies, etc. I don’t know that there’s any likelihood of eradication of Legionella in the general community (by the way—and I’m sure this is the case, but it never hurts to reiterate—those of you with responsibilities for long-term care facilities are definitely in a bracket of higher vulnerability). But there remains a fair amount of risk in the community, as evidenced by the most recent slate of outbreaks. Water is definitely the common denominator, but beyond that, this can happen anywhere at any time, so vigilance is always the end game when it comes to preventive measures.

As a final thought for the week, I wanted to share a blog item (not mine) that I found very interesting as food for thought (the concept is very powerful, though you may have a tough time convincing your boss to embrace it, as I think you’ll see): treating failure like a scientist. You can find the whole post here, but the short take is that you may have a positive or a negative result of whatever strategy you might employ—each of which should be considered data points upon which you can make further adjustments. Not everything works the way you thought it would, but rather discarding something outright if it doesn’t succeed, try to figure out the lesson behind the failure to make a better choice/strategy/etc. moving forward. The blog covers things more elegantly than I did here, but I guess my closing thought would be to have the courage (maybe “luxury” is the better term) to really learn from your mistakes—if we were perfect, there would never be a need for improvement.

While I hate to do anything to muddy the waters…with paper clips!

Or ear buds…

In the absence of anything particularly controversial on the regulatory front, I tend to go back and cover “old” ground just to see if there are any new resources, altered realities, etc. So, last week I was doing some work that involved helping folks with their ligature risk assessment and was pondering the availability of ligature-resistant fire alarm notification appliances. This pondering led me to my usual primary source for such things, The Design Guide for the Built Behavioral Health Environment (now an offering from the Facilities Guidelines Institute); we’ve discussed the particulars of the Design Guide on any number of occasions, most recently back in late 2016, and hopefully by now everyone has obtained a copy for their e-library. At any rate, I was poking around looking for ligature-resistant fire alarm notification appliances and, lo and behold, I couldn’t find any.

So (as I am wont to do) I headed off to the Googlesphere to see what might be out and about and (in yet another lo and behold moment) found the latest edition of the New York State Office of Mental Health’s Patient Safety Standards, Materials and Systems Guide. As near as I can tell from the webpage, this is the 19th edition of this particular guide, though I will tell you that this is my first encounter and I think it’s pretty spiffy (I’m guessing you folks in the Empire State knew about this and kept it to yourselves…). One of the most interesting elements is that it covers what they recommend (including whether they’ve found the products, etc., to be effective based on the acuity of the setting), but they also list stuff that they have tested and found does not work as advertised (I will admit to being fascinated with the idea that some of these ligature-resistant products can be defeated by strategies as simple as paper clips and/or ear buds—I guess necessity remains the mother of invention). Admittedly, there could be different philosophies in other jurisdictions, but I can really appreciate the thought, analysis, and general effort that went in to this resource and I think the risks/benefits/alternatives are sufficiently clear cut that you could communicate the issues very effectively to those reluctant surveyor types. At any rate, I encourage you (yet again) to add this one to your resource library.

I’ve also learned that as folks work through the various and sundry parameters of the regulatory guidance sets floating around, folks have been considering the management of risks in relatively unsecured (at least in terms of ligature-resistance) common areas (lobbies, stairwells, offices), which (surprise, surprise surprise!) got me to thinking…

I think the appropriate strategy for these other areas needs to start with whatever clinical assessment/determination would need to occur before patients would be able to access unsecured common areas; to my mind, patients that are legitimately at risk of self-harm either need to have services come to them on the secured units or they are sufficiently escorted (sufficiently meaning enough folks to control a situation should it start to get out of hand). By nature, every organization has areas of greater and lesser levels of security, so the “burden of the process” (if you will) is to ensure that patients are not unilaterally exposed to risks greater than their (or, indeed, our) capacity to manage them. While the minimization of physical risk is a safety “function,” ensuring that patients are managed in an appropriate environment is a clinical “function” based on the needs/condition, etc., of the patients. For example, if a patient is clinically “well” enough to have access to the advocate beyond the advocate coming to see them on the unit, then my expectation would be that that determination would be made by the clinical folks, with full knowledge of the involved risks. I think (at least until CMS or someone else provides additional/different interpretations) that going with the stratification used by The Joint Commission, which for all intents and purposes parses out into inpatient psychiatric unit environments, acute care inpatient environments and emergency department environments, should remain the focus of your assessment and risk management activities. After all, the clinical management of the patient must work in concert with efforts to decrease risk in the environment and vice versa—everyone working together is the only thing that’s going to bring us success (which is rather a common strategy…).

What it is ain’t exactly clear: Hazardous materials management and the SAFER matrix

I was recently asked to ponder the (relative—all things are relative) preponderance of findings under the Hazardous Materials and Wastes Management standard (EC.02.02.01 for those of you keeping track). For me, the most interesting part of the question was the information that (as was apparently revealed at the Joint Commission Executive Briefings sessions last fall) findings under EC.02.02.01 frequently found their way to the part of the SAFER matrix indicating a greater likelihood of causing harm (the metric being low, moderate, and high likelihood of harm) than some of the other RFIs being generated (EC.02.06.01, particularly as a function of survey issues with ligature risks, also generates those upper harm-level likelihood survey results). Once upon a time, eyewash station questions were among the most frequently asked (and responded to in this space), so it’s almost like replaying a classic

Generally speaking, the findings that they’ve earmarked as being more likely to cause harm are the ones relating to eyewash stations (the most common being the surveyors over-interpreting where one “has” to have an eyewash station the remainder pretty much fall under the maintenance of eyewashes—either there’s a missing inspection, access to the eyewash station is obstructed during the survey, or there is clearly something wrong with the eyewash—usually the protective caps are missing or the water flow is rather anemic in its trajectory). All of those scenarios have the “potential” for being serious; if someone needs an eyewash and the thing doesn’t work properly or it’s been contaminated, etc., someone could definitely be harmed. But (and it is an extraordinarily big “but”) it’s only when you have an exposure to a caustic or corrosive chemical, which loops us back to the over-interpretation. OSHA only requires emergency eyewash equipment when there is a risk of occupational exposure to a corrosive chemical (the ANSI standard goes a bit further by indicating eyewash equipment should be available for caustic chemicals as well as corrosives). A lot of the findings I’ve seen have been generated by the clinical surveyors, who are frequently in the company of hospital staff that aren’t really clear on what the requirements are (you could make the case that they should, if only from a Hazard Communications standard standpoint, but we’ll set that aside for the moment), so when the clinical surveyor says “you need an eyewash station here” and writes it up, the safety folks frequently don’t find out until the closeout (and sometimes don’t find out until the survey report is received). The “problem” that can come to the fore is that the clinical folks don’t perceive the eyewash finding as “theirs” because it’s not a clinical finding, so they really don’t get too stressed about it. So, the surveyor may ask to see the SDS for a product in use and if the SDS indicates that the first aid for eye exposure is a 15- or 20-minute flush with water, then they equate that with an eyewash station, which in a number of instances, is not (again, strictly speaking from a regulatory standpoint) “required.” Sometimes you can make a case for a post-survey clarification, but successful clarifications are becoming increasingly rare, so you need to have a process in place to make your case/defense during the survey.

The other “batch” of findings for this standard tend relate to the labeling of secondary containers (usually the containers that are used to transport soiled instruments); again, in terms of actual risk, these conditions are not particularly “scary,” but you can’t completely negate the potential, so (again) the harm level can be up-sold (so to speak).

In terms of survey prep, you have to have a complete working knowledge of what corrosive chemicals are in use in the organization and where those chemicals are being used (I would be inclined to include caustic chemicals as well); the subset of that is to evaluate those products to see if there are safer (i.e., not corrosive or caustic) alternatives to be used. The classic finding revolves around the use of chemical sprays to “soak” instruments awaiting disinfection and sterilization—if you don’t soak them, then the bioburden dries and it’s a pain to be sure it’s all removed, etc.; generally, some sort of enzymatic spray product is used—but not all of them are corrosive and require an eyewash station. Then once you know where you have corrosives/caustics, you need to make sure you have properly accessible eyewash equipment (generally within 10 seconds of unimpeded travel time from the area of exposure risk to the eyewash) and then you need to make sure that staff understand what products they have and why an eyewash is not required (strictly speaking, there really aren’t that many places in a hospital for which an eyewash station would be required) if that is the case—or at least make sure that they will reach out to the safety folks if a question should come up during survey. Every once in a while there’s a truly legit finding (usually because some product found its way someplace where it didn’t belong), but more often than not, it’s not necessary.

You also have to be absolutely relentless when it comes to the labeling of secondary containers; if there’s something of a biohazard nature and you put it in a container, then that container must be properly identified as a biohazard; if you put a chemical in a spray bottle, bucket, or other container, then there needs to be a label (there are exceptions, but for the purposes of this discussion, it is best managed as an absolute). Anything that is not in its original container has to be labeled, regardless of what the container is, the reason for doing it, etc. The hazard nature of the contents must be clear to anyone and everyone that might encounter the container.

At the end of the day (as cliché an expression as that might be), it is the responsibility of each organization to know what’s going on and to make sure that the folks at the point of care/point of service have a clear understanding of what risks they are likely to encounter and how the organization provides for their safety in encountering those risks. We are not in the habit of putting people in harm’s way, but if folks don’t understand the risks and (perhaps most importantly) understand the protective measures in place, the risk of survey finding is really the least of your worries.

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.

What we have here is a failure to communicate, or is it a water failure? Sewer failure?

Another survey finding that’s been bubbling up to the top lately relates to your utility system disruption/failure response plans. EC.02.05.01, EP #9 requires hospitals to have written procedures for responding to utility system disruptions. I’ve seen a number of folks tagged for not having the full “suite” of response procedures; if you have a utility system, then you need to have a written procedure for responding.

Now I would think that as a function of your incident command structure, (which is, like, totally compliant with the requirements of the National Incident Management System), you should be able to appropriately manage utility disruptions. However, I guess that sort of begs the question: Do you stand up your IC for utility systems issues or is there a reluctance (or something similar to that) to pull the trigger when push comes to a little bigger push? And, once again, it comes down to how (and perhaps more importantly, how well) you educate/communicate/simplify your frontline folks.

My general experience, fortunately, has been that disruptions to single systems tend to be rather more transient than not–something that can be “endured” until we get things back in order. And I think an important consideration when it comes to endurance is having a simple structure, based on what one might consider “normal” operations. This way, staff don’t have to worry so much about getting from Point A to Point Z because they are sufficiently familiar with B, C, D, and so on. They can respond quickly and appropriately, regardless of what’s going on (or isn’t going on, which I guess is a good indicator of a disruption).

So, do you have written plans for each of your utility systems? When’s the last time you had a chance to practice on some of the more esoteric systems? I’d love to hear what folks are doing, and I suspect that I am by no means the only one.