RSSAuthor Archive for Steve MacArthur

Steve MacArthur

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.

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

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

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

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

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

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

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

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

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

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

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

Top 10 Critical Process Vulnerabilities – Physical Environment

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

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

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

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

The top 10 are as follows:

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

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

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

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

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

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

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

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

Immediate Jeopardy: How much do you want to wager?

With best wishes to Alex Trebek!

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

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

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

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

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

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

Keeping an eye on things: Managing behavioral health patients

What, again?!?

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

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

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

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

 

It’s been a long time: Revisiting an EOC perennial

Setting the wayback machine for the dark ages of safety (well, 2011 or so), we come to the last time we covered the monitoring of temperature and/or humidity in surgical spaces, etc. (if you want to revisit those halcyon days, you can head here). The funny thing about this most ancient of history is that, since then, while there have been changes in applicable codes and references, the “new” stuff comes up a little short when it comes to providing guidance relating to monitoring temperature and humidity, particularly as a function of frequency (I suppose we could call it the frequency function if we were being excessively alliterative). The baseline response (catty though it may be) is that you should be monitoring conditions on as frequent a basis as is required to ensure appropriate conditions, given due consideration of the systems you have in place, any manufacturers’ recommendations (which are also not particularly helpful in determining monitoring frequencies), and regulatory guidance (ASHRAE 170; state mechanical code) as applicable.

Ultimately, this all comes down (back?) to the requirements as outlined in the Conditions of Participation, which gives us:

  • 482.41(c)(4) – There must be proper ventilation, light, and temperature controls in pharmaceutical, food preparation, and other appropriate areas.

So, you might well ask, what are those “other appropriate areas”? For that information, we need to head over to the State Operations Manual/Interpretive Guidelines, which is where the skeleton of the Conditions of Participation is fleshed out into the survey process.  And what do we find there? Take a look:

Interpretive Guidelines §482.41(c)(4) – There must be proper ventilation in at least the following areas:

  • Areas using ethylene oxide, nitrous oxide, glutaraldehydes, xylene, pentamidine, or other potentially hazardous substances;
  • Locations where oxygen is transferred from one container to another;
  • Isolation rooms and reverse isolation rooms (both must be in compliance with Federal and State laws, regulations, and guidelines such as OSHA, CDC, NIH, etc.);
  • Pharmaceutical preparation areas (hoods, cabinets, etc.);
  • Laboratory locations; and
  • Anesthetizing locations. According to NFPA 99, anesthetizing locations are “any area of a facility that has been designated to be used for the administration of nonflammable inhalation anesthetic agents in the course of examination or treatment, including the use of such agents for relative analgesia.” NFPA 99 defines relative analgesia as “A state of sedation and partial block of pain perception produced in a patient by the inhalation of concentrations of nitrous oxide insufficient to produce loss of consciousness (conscious sedation).” (Note that this definition is applicable only for Life Safety Code® purposes and does not supersede other guidance we have issued for other purposes concerning anesthesia and analgesia.)

Interesting to note that the list here does not quite match up with the totality of issues for which The Joint Commission is citing folks (clean and soiled utility rooms being first and foremost, though I know that it is merely an extrapolation of the ASHRAE 170 requirements). Also interesting to note that, sterile supply and processing is not specifically mentioned, but (again), I think we can see where the importance of maintaining those spaces drives out of ASHRAE 170.

But what’s the endgame when it comes down to the survey process? The general unhelpfulness of the answer will not surprise you:

  • Review monitoring records for temperature to ensure that appropriate levels are maintained
  • Review humidity maintenance records for anesthetizing locations to ensure, if monitoring determined humidity levels were not within acceptable parameters, that corrective actions were performed in a timely manner to achieve acceptable levels

So (still!) if you follow the temperature and humidity rabbit all the way back to the Interpretive Guidelines, we see that the surveyors are instructed to ask to see “records,” so it all comes down to what you can produce in terms of a deliverable that reflects that temperature and humidity levels are appropriate/acceptable and levels that were not within acceptable parameters (which they do not define, so you better have a sufficiently flexible definition) were dealt with in a “timely manner” (again, not defined, so it’s up to you, based on your risk assessment).

As a closing thought on this (for now), apparently there are some folks that have determined that they don’t have to monitor both elements (temperature and/or humidity) and if there is nothing else that you derive from this week’s missive, it is this: You gotta do both! You can determine the frequency (though I would recommend at least daily—if you recall, the question that started this conversation in 2011 was whether quarterly monitoring was sufficient), but you clearly want to be able to use performance data to make that determination (and from whence comes that data—regular monitoring). You can determine what is acceptable/appropriate (based on utilization, types of procedures, preference of surgical staff, etc.); you can determine what is a timely timeframe for corrective action (Timely Timeframe—that sounds like a name Stan Lee would’ve loved). But you gotta do the monitoring; to do otherwise risks too much if the CMSers darken your door (which is becoming a much more common occurrence).

One last quick note for this week: There seems to be a bit of a groundswell of survey findings relating to hand sanitizer dispensers not having drip trays. It would seem that there must have been some recent mention of this in surveyor education as there are some surveyors indicating that this is a new requirement, but the overarching requirement has been in place for rather a while. To whit (and, again, the State Operations Manual becomes then go-to resource):

  • 482.41(b)(9) (ii) The dispensers are installed in a manner that minimizes leaks and spills that could lead to falls; with the associated Survey Procedure being: “Determine whether the hospital maintains the ABHR dispensers in accordance with the manufacturer’s guidelines, or, if there are no manufacturer’s guidelines, that the hospital has adopted policies and procedures to ensure that the dispensers neither leak nor the contents spill.”

Now, nowhere in the regulatory canon does it discuss drip trays (though, when you come right down to it, how else are you going to manage the threat of leaks/drips, especially over hard-surface flooring?). But apparently drip trays have become the “gold standard” for leak/drip control, so you might want to keep an eye on this for the future. These things do tend to spread and who wants to be chasing this during a (or post) survey? Not me.

Eat, drink, and be safe: Some guidance on the care and feeding of staff

One of the more universal conditions I find is the whole issue of where staff can grab something to eat or drink in the midst of busy periods, particularly when staffing levels don’t necessarily dovetail with leaving the work space to go to the cafeteria, etc. And there’s always the specter of someone, somewhere having invoked the “You can’t eat there, it’s against TJC regulations” or “You can’t drink there, it’s against regulations” and so forth and so on. And what better strategy than to use a regulatory presence from outside the organization to be the heavy.

Many’s the time I’ve tried to convince folks that, from a regulatory perspective (with some fairly well-defined exceptions, like laboratories), there is nothing that approaches a general prohibition when it comes to the how, when, and where of eating and drinking in the workplace (and yes, I absolutely understand that prohibition is the easiest thing to “police,” but I think prohibitions also tend to “drive” more creative workarounds). And in the March 2019 edition of Perspectives, our friends in Chicago provide a couple of clarifications for folks, and if you think that there’s a risk assessment involved, then you would be correct.

So, the clarifications are two in number:

  • There are no TJC standards that specifically address where staff can have food or drink in the work areas.
  • You can identify safe spaces for food and drink as long as those locations  comply with the evaluation (read: risk assessment) of the space and your exposure control plan as far as risks of contamination from chemicals, blood, or body fluids, etc.

The guiding light in all of this, if you will, are the regulations provided by the Occupational Safety & Health Administration, and while they have a lot to say about such things (Bloodborne Pathogens and Sanitation), a careful analysis should yield a means of designating some spaces. I have seen a lot of designated “hydration stations,” particularly in clinical areas, to help keep folks hydrated over the course of the working day, so clearly some folks are working towards providing some flexibility based on a risk assessment. This is a good thing both in terms of staff support, but also in not drawing a line in the sand that they don’t have to. Prohibitions can bring about some of your toughest compliance challenges, so if you can work with folks to build in some flexibility, it could mean fewer headaches during rounding activities.

Making a checklist, making it right: Reducing compliance errors

As you may have noticed, I am something of a fan of public radio (most of my listening in vehicles involves NPR and its analogues) and every once in a while, I hear something that I think would be useful to you folks out in the field. One show that I don’t hear too often (one of the things about terrestrial radio is that it’s all in the timing) is called “Hidden Brain”, the common subject thread being “A conversation about life’s unseen patterns.” I find the programs to be very thought-provoking, well-produced, and generally worth checking out.

This past weekend, they repeated a show from 2017 that described Dr. Atul Gawande’s (among others) use of checklists during surgical (and other) procedures to try to anticipate what unexpected things could occur based on the procedure, where they were operating, etc. One of the remarks that came up during the course of the program dealt with how extensive a checklist one might need, with the overarching thought being that a more limited checklist tends to work better because it’s more brain-friendly (I’m paraphrasing quite a bit here) than a checklist that goes on for pages and pages. I get a lot of questions/requests for tools/checklists for doing surveillance rounds, etc. (to be honest, it has been a very long time since I’ve actually “used” a physical checklist; my methodology, such as it is, tends to involve looking at the environment to see what “falls out”). Folks always seem a little disappointed when the checklist I cough up (so to speak) has about 15-20 items, particularly when I encourage them not to use all the items. When it comes to actual checklists that you’re going to use (particularly if you’re going to try and enlist the assistance of department-level folks) for survey prep, I think starting with five to seven items and working to hardwire those items into how folks “see” the environment is the best way to start. I recall a couple of years ago when first visiting a hospital—every day each manager was charged with completing a five-page environmental surveillance checklist—and I still was able to find imperfections in the environment (both items that they were actually checking on and a couple of other items that weren’t featured in the five-pager and later turned out to be somewhat important). At the point of my arrival, this particular organization was (more or less) under siege from various regulatory forces and were really in a state of shock (sometimes a little regulatory trouble is like exsanguination in shark-infested waters) and had latched on to a process that, at the end of the day, was not particularly effective and became almost like a sleepwalk to ensure compliance (hey, that could be a new show about zombie safety officers, “The Walking Safe”).

At any rate, I think one of the defining tasks/charges of the safety professional is to facilitate the participation of point-of-care/point-of-service folks by helping them learn how to “see” the stuff that jumps out at us when we do our rounds. When you look at the stuff that tends to get cited during surveys (at least when it comes to the physical environment), there’s not a lot of crazy, dangerous stuff; it is the myriad imperfections that come from introducing people into the environment. Buildings are never more perfect than the moment before occupancy—after that, the struggle is real! And checklists might be a good way to get folks on the same page: just remember to start small and focus on the things that are most likely to cause trouble and are most “invisible” to folks.

Waste not, want not: The rest of the CMS Emergency Preparedness picture

Moving on to the rest of the guidance document (it still lives here), I did want to note one last item relative to emergency power: There is an expectation that “as part of the cooperation and collaboration with emergency preparedness officials,” organizations should confer with health department and emergency management officials, as well as healthcare coalitions to “determine the types and duration of energy sources that could be available to assist them in providing care to their patient population. As part of the risk assessment planning, facilities should determine the feasibility of relying on these sources and plan accordingly.

“NOTE: Hospitals, CAHs and LTC facilities are required to base their emergency power and stand-by systems on their emergency plans and risk assessments and including the policies and procedures for hospitals. The determination of the appropriate alternate energy source should be made through the development of the facility’s risk assessment and emergency plan. If these facilities determine that a permanent generator is not required to meet the emergency power and stand-by systems requirements for this emergency preparedness regulation, then §§482.15(e)(1) and (2), §483.73(e)(1) and (2),

  • 485.625(e)(1) and (2), would not apply. However, these facility types must continue to meet the existing emergency power provisions and requirements for their provider/supplier types under physical environment CoPs or any existing LSC guidance.”

“If a Hospital, CAH or LTC facility determines that the use of a portable and mobile generator would be the best way to accommodate for additional electrical loads necessary to meet subsistence needs required by emergency preparedness plans, policies and procedures, then NFPA requirements on emergency and standby power systems such as generator installation, location, inspection and testing, and fuel would not be applicable to the portable generator and associated distribution system, except for NFPA 70 – National Electrical Code.”

I think it is very clear that hospitals, et al., are going to be able to plot their own course relative to providing power during emergency conditions, but what’s not so clear is to what depth surveyors will be looking for you to “take” the risk assessment. I suspect that most folks would run with their permanently installed emergency generators and call it a day, but as healthcare organizations become healthcare networks become healthcare systems, the degree of complexity is going to drive some level of flexibility that can’t always be attained using fixed generator equipment. If anyone has any stories to share on this front (either recent or future), I hope you’re inclined to share (and you can reach out directly to me and I will anonymize your story, if you like).

Wrapping up the rest of the changes/additions, you’ll be pleased to hear that you are not required to provide on-site treatment of sewage or waste, but you need to have provisions for maintaining “necessary services.” Of course, the memo indicates that they are not specifying what “necessary services for sewage or waste management” might be, so a little self-definition would appear to be in order.

If your organization has a home health agency, then you need to make sure that the communication plan includes all the following: (1) Names and contact information for the following: (i) Staff. (ii) Entities providing services under arrangement. (iii) Patients’ physicians. (iv) Volunteers. I think that one’s pretty self-evident but may be worth a little verification.

Next up are some thoughts about providing education to folks working as contracted staff who provide services in multiple surrounding areas; the guidance indicates that it may not be feasible for these folks to receive formal training for each of the facilities emergency response plan/program. The expectation is that each individual (and this applies equally to everyone else in the mix) knows the emergency response program and their role during emergencies, but each organization can determine how that happens, including what constitutes appropriate evidence that the training was completed. Additionally, if a surveyor asks one of these folks what their role is during a disaster, then the expectation would be for them to be able to describe the plan and their role(s). No big surprise there (I suspect that validating the competency of point-of-care/service staff is going to be playing a greater role in the survey process—how many folks would they have to ask before somebody “fumbles”?)

The last item relates to the use of real emergency response events in place of the required exercises; I would have thought that this was (relatively) self-evident, but I guess there were enough questions from the field for them to specify that you can indeed use a real event in place of an exercise. Just make sure you have the documentation in order (I know I didn’t “have” to say that, but I figure if it’s important enough for CMS to say it, then who am I…). The timing would be one year from the actual response activation, so make sure you keep a close eye on those calendars (unless, of course, you have numerous real-life opportunities…).

I do think the overarching sense of this is positive, at least in terms of limiting the prescriptive elements. As is sometimes the case, the “responsibility” falls to each organization to be prepared to educate the surveyors as to what preparedness looks like—it has many similar components, but how things integrate can have great variability. Don’t be afraid to do a little hand-holding if the surveyors are looking for something to be done a certain or to look a certain way. You know what works best in your “house,” better than any surveyor!