RSSAll Entries in the "CMS" Category

CMS Ligature Risk Update: Not quite finished…

Cast aside the doubt that nothing good came come this way again!

On July 20, 2018, CMS issued further information regarding its expectations for ensuring that behavioral health patients are being provided a safe and appropriate environment. There had been some indication that CMS might be undertaking their own analysis of the current state of things, but it appears that CMS is going to incorporate the outcomes of The Joint Commission’s (TJC) suicide panel (in which CMS representatives participated) into a comprehensive ligature risk interpretive guidance. The memorandum does not indicate when we can expect the finalized interpretive guidance, but things do seem to be moving at a pretty good clip, so I’m thinking (maybe, just maybe), we’ll see that information before the end of the year. As a point of information (and you know I’m all about the points), the Joint Commission guidance cited in the CMS memorandum can be found here: and some clarifying FAQs issued by TJC last month (but not specifically referenced in the CMS memorandum) can be found here: (the information specific to ligature risks is about half way down the page). I know we’ve covered this over the past few months, but I can never be sure at which point in the conversation folks tune in, so I figured it doesn’t hurt to have links for what is current (at the moment…).

For those of you who have not yet tackled all of the particulars relating to the guidance issued from Joint Commission (mostly because you do not use TJC for deemed status accreditation purposes), I do think that the compliance path appears to be fairly reasonable and straightforward from an implementation standpoint. That said, until the interpretive guidance is finalized by CMS, there will likely continue to be some surveyor interpretation in the mix, particularly on the part of those accreditation and regulatory organizations other than Joint Commission (DNV, CIHQ, HFAP, state agencies, etc.). Which means it will be incumbent upon pretty much all hospitals to know where they stand relative to TJC recommendations, particularly as a function of how the strategies and facilities modifications they’ve made meet the intent of the recommendations. Some recent non-TJC survey activities indicate that the “other” accreditation organizations are starting to focus on this topic and, right now, are very much where TJC was in early 2017 when surveyors were inclined to identify anything and everything as a potential, unmanageable risk. And lots of re-surveys following in the wake of those determinations

Beyond a familiarity/assessment relative to the TJC recommendations, the “other” piece of which you need to be mindful is that whatever fixes they identify need to be completed before survey or there will likely be some back and forth relative to Immediate Threat, the need for re-survey, etc.  As we’ve discussed in the past (and this surely goes beyond ligature-resistant hardware), a lot of folks with a significant number of fixes are very much at the mercy of the supplies of needed hardware, etc. At a minimum, hospitals that haven’t completed their “laundry list” of fixes must have a risk assessment in place that outlines not only what is to be done from a facilities standpoint, but what strategies are in place to ensure that the risk to patients is being properly managed in the interim (this is very similar to the survey methodology dealing with Interim Life Safety Measures). As I’ve told folks time and again, you don’t get credit for doing the math in your head—at the end of the day, when you have a survey team “in the house,” the only “good” risk assessment is a risk assessment that is fully documented, approved by the appropriate organizational authorities, etc. If you don’t have an assessment ready to go for survey, it’s likely to be a very tough slog.

At any rate, it does appear that this one is going to be winding down in terms of survey activity, which will bring no small measure of relief to the survey preparation process, but it does beg the question of whether this is the last big environmental dope-slap or if there’s something else waiting in the wings to make us crazy. Any thoughts?

Hanging on in quiet desperation is the safety way: Thought of something more to say!

Recognizing that authorities having jurisdiction (AHJ) always reserve the right to disagree with any decision you’ve ever made or, indeed, anything they (or any other AHJ) have told you in the past, how long are existing waivers, guidance and/or equivalencies good for? Answer: It depends (with more permutations that you can shake a stick at…).

Last week, we chatted a little bit about the whole water management thing, including mention of what CMS is telling surveyors to look for, but I thought it might be useful to extract some of the specifics from that missive (if you missed it last week, it’s here). So, here we have:

Expectations for Healthcare Facilities

CMS expects Medicare and Medicare/Medicaid certified healthcare facilities to have water management policies and procedures to reduce the risk of growth and spread of Legionella and other opportunistic pathogens in building water systems.

Facilities must have water management plans and documentation that, at a minimum, ensure each facility:

  • Conducts 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.
  • Develops and implements a water management program that considers the American Society of Heating, Refrigerating, and Air-Conditioning Engineers (ASHRAE) industry standard and the CDC toolkit.
  • Specifies testing protocols and acceptable ranges for control measures, and document the results of testing and corrective actions taken when control limits are not maintained.
  • Maintains compliance with other applicable federal, state, and local requirements.

Note: CMS does not require water cultures for Legionella or other opportunistic waterborne pathogens. Testing protocols are at the discretion of the provider.

Healthcare facilities are expected to comply with CMS requirements and Conditions of Participation to protect the health and safety of its patients. Those facilities unable to demonstrate measures to minimize the risk of LD are at risk of citation for noncompliance.

Expectations for Surveyors and Accrediting Organizations

Long-term care (LTC) surveyors will expect that a water management plan (which includes a facility risk assessment and testing protocols) is available for review but will not cite the facility based on the specific risk assessment or testing protocols in use. Further LTC surveyor guidance and process will be communicated in an upcoming survey process computer software update. Until that occurs, please use this paragraph as guiding instructions.

Just so you know, I chose to use some of the text in bold font because I think that’s probably the most important piece of this for folks moving forward (kind of makes me think that, just perhaps, there have been citations for folks not actively pursuing water cultures). But it does establish the expectation that a piece of the required risk assessment is going to include something that relates to whether you choose to culture, how often, and how you came to make that determination. I think this helps folks manage some of the ins and outs of this process, but I still feel like this could end up being a source of consternation as surveyors “kick the tires” in the field.

 

Wagging the dog: Can Accreditation Organizations influence each other?

In last week’s issue of HCPro’s Accreditation Insider, there was an item regarding the decision of the folks at the Healthcare Facilities Accreditation Program (HFAP) to update their Infection Control standards for acute care hospitals, with the intent of alignment with CMS expectations (you can find the article here) We’ve certainly covered the concerns relative to Legionella and the management of risks associated with aerosolizing water systems and this may only be a move to catch up on ground already covered by other accreditation organizations (our friends in Chicago already require the minimization of pathogenic biological agents in cooling towers, domestic hot- and cold-water systems, and other aerosolizing water systems), but I’m thinking it might also be something of a “tell” as to where survey focus might be drifting as we embark upon the second half of 2018. Certainly, waterborne pathogens are of critical importance to manage as a function of patient vulnerability (ideally, we want folks to get better during their hospital stays), so it makes perfect sense for this to be on the radar to some degree. At this point, the memorandum from CMS outlining their concerns has been with us for about a year, with an immediate effective date, so hopefully you are well-entrenched in managing those water systems. If this one is still on your to-do list, I think it’s probably advisable to making it a priority to get it to your “to-done” list. But you should definitely check out the latest “clarification” from CMS. While the memo indicates that this does not impose any new expectations or requirements, it does make it a little clearer as to what surveyors are supposed to be checking.

As I think Mr. Gershwin once opined about summer and the easiness of living, it would be nice to be able to set a spell and take one’s shoes off, but vigilance is always the order of the day.

On a somewhat lighter note, I just finished reading Our Towns – A 100,000 Mile Journey Into The Heart of America, which outlines the efforts of a number of (mostly smallish) municipalities across the United States in positioning themselves for a positive future (positive positioning—I kind of like that). The focus is mostly on the socioeconomics of different parts of the country, with a focus on how diversity can be employed in bettering a community (that’s probably a little ham-handed as a descriptor, but you can find an excerpt here if you like). As my work allows me to travel to a lot of places, while I haven’t been to a lot of the same destinations as the Fallows, I do recognize a lot of the stories and a lot of the challenges facing folks lately (and I think you might, too). I would describe the tone of the book as hopeful, so if you’re looking for something to read at beach/pond/summer cottage, etc., you might consider giving Our Towns a shot.

 

Emergency Management Monkeyshines: All Things Must Pass…

Sometimes like a kidney stone, but nonetheless…

Before we dive into this week’s “content,” I have a thought for you to ponder as to the nature of basing future survey results on the results of surveys past (rather Dickensian, the results of surveys past): Recognizing that authorities having jurisdiction (AHJ) always reserve the right to disagree with any decision you’ve ever made or, indeed, anything they (or any other AHJ) have told you in the past, how long are existing waivers and/or equivalencies good for? Hopefully this ponderable will not visit itself upon you or your organization, but one must be prepared for any (and every) eventuality. Which neatly brings us to:

In digging around past emails and such, I noticed that I had not visited the Department of Health and Human Services Healthcare Emergency Preparedness Gateway in rather a while and what to my wondering eyes should appear but some updated info and a link to CMS that I think you’ll find useful. So, the current headlines/topics:

  • Considerations for the Use of Temporary Care Locations for Managing Seasonal Patient Surge
  • Pediatric Issues in Disasters Webinar
  • 2017 Hurricane Response – Resources for Children with Special Health Care Needs
  • Supporting Non-resident/Foreign Citizen Patients
  • A new issue of The Exchange newsletter
  • A link to the CMS Emergency Preparedness Final Rule surveyor training (you can find the information available to providers here). Unfortunately, the post-test is not available to providers, but sometimes it’s like that.

It is my intent over the next little while to check out the education package, so I will let you know if I have any grave reservations about the content, etc., or if I think you need to earmark it for priority viewing.

So, kind of brief this week, but I’m sure there’ll be more to discuss in the not too distant future. And so, with the end of wintah on the horizon, I wish you a moderately temperate week!

There’s no such thing as someone else’s code: Infection control and the environment (again…)

Periodically, I field questions from folks that require a little bit (well, perhaps sometimes more than a little) of conjecture. Recently, I received a question regarding the requirements in ASHRAE 170-2008 regarding appropriate pressure relationships in emergency department and radiology waiting rooms (ASHRAE 170-2008 says those areas would be under negative pressure, with the caveat that the requirement applies only to “waiting rooms programmed to hold patients awaiting chest x-rays for diagnosis of respiratory disease”).

Right now, that particular question is kind of the elephant in the room from a regulatory perspective; there is every indication that The Joint Commission/CMS are working their way through ASHRAE 170-2008 and have yet to make landfall on this particular requirement—as far as I know—feel free to disabuse me of that notion. The intent of the requirement (as I interpret it) is to have some fundamental protections in place to ensure that an isolated respiratory contagion does not have the capacity of becoming a legitimate outbreak because of inadequate ventilation. Now, you could certainly use the annual infection control program risk assessment to identify whether your waiting rooms are “programmed to hold patients awaiting chest x-rays for diagnosis of respiratory disease” based on the respiratory disease data from the local community (and you might be able to obtain data from a larger geographic area, which one might consider a “buffer zone”).

Best case scenario results in you being able to take this completely off the table from a risk standpoint, next best would be that you introduce protocols for respiratory patients that remove them from the general waiting rooms (depending on the potential numbers, you may not have the space for it), worst case being that you have to modify the current environment to provide appropriate levels of protection. The notation for this requirement does provide some relief for folks with a recirculating air system in these areas, which allows for HEPA filters to be used instead of exhausting the air from these spaces to the outdoors, providing the return air passes through the HEPA filters before it introduced into any other spaces.

Knowing what I do about some of the ventilation challenges folks have, I suspect that it may make more sense to pursue the HEPA filtration setup than it would be to try to bring each of the spaces under negative pressure, but (going out on a limb here) that might be a question best answered by a group of knowledgeable folks (including an individual of the mechanical engineering persuasion) as a function of the (wait for it…) risk assessment process.

Ultimately, it comes down to what the Authority Having Jurisdiction chooses to enforce; that said, it might be worth having someone work through your state channels or by putting the question to the Standards Interpretation Group at Joint Commission (I suspect that their response would not be not particularly instructive beyond the usual “do a risk assessment” strategy, but there is a new person running the Engineering group at TJC, so perhaps something a little more helpful might be forthcoming). At any rate, as noted above, I’ve not heard of this being cited, but I also know that if there’s an outbreak tied to inadequate ventilation somewhere, this could become a hot topic pretty quickly (probably not as hot as ligature risks at the moment, but you never know…).

You don’t have to be a weather(person)man to tell: Kicking off survey year 2018!

Your guess is as good as mine…

Just a couple of brief items (relatively—you know how I do go on, but I will try) of interest. I don’t know that there’s a common theme besides an effort to anticipate in which direction the survey winds might blow in 2018:

  •  Previously in this space, I’ve mentioned the work of Matt Freije and his team at HCInfo as they have done yeoman’s (yeoperson’s?) work in the field of water systems management and the “fight” against In response to last year’s letter of intent by CMS to take a more focused look at how hospitals and nursing homes are providing appropriately safe water systems for their patients, Mr. Freije has developed a checklist to help folks evaluate their current situations and has posted the checklist online for comment, suggestions, etc. I’m having a hard time thinking that this might not become something of a hardship for folks arriving late to the party, so if you’ve not yet embraced poking around this subject (and even if you have), you’d do well to check out the checklist.
  •  A couple of inspection items relative to the ongoing rollout of the various and sundry changes wrought by the adoption of the 2012 Life Safety Code®, some of which have yet to migrate in detail to the accreditation organization publications (at least the ones that I’ve seen), but have popped up during recent CMS surveys:
    • Make sure you fire alarm circuit breakers are clearly marked in red (check out NFPA 72 10.5.5.2 for the skinny on this).
    • Make sure your ILSM/fire watch policy/process reflects the appropriate AHJs—you need to make sure that you know for sure whether your state department of public health, et al, want to be notified. They do in California, and probably elsewhere.
    • In NFPA 25, chapters 5 and 13 indicate some monthly inspections of gauges, valves for condition, appropriate position (open or closed) and normal pressures—again, they’re not specifically listed in the accreditation manuals yet, but I suspect that they’ll be coming to a survey report near you before too long.
    • A final note for the moment in this category, NFPA 70 (2011 edition) 400.10 indicates that “flexible cords and cables shall be connected to devices and to fittings so that tension is not transmitted to joints of terminals.” Keep an eye on power strips, particularly in your IT and communications closets for those dangling power strips (and some of them aren’t so much dangling as they are pulled across open spaces, etc. I suspect you know what I mean.) I know the folks who manage this stuff think that we are just being pains in the butt, but now you may have a little codified leverage.
  •  In my post a couple of weeks ago, I don’t think I played the personal protective equipment (PPE) card with sufficient gravity; part of folks’ understanding of the hazards of using chemicals is recognizing the importance of actually using appropriate PPE as identified on the product SDS. When you think about it, the emergency eyewash station is not intended to be the first line of defense in the management of exposures to chemical hazards, but rather what happens when there is an emergency exposure. If the use of PPE is hardwired into the process, then the only time they’ll need to use the eyewash equipment is when they do their weekly testing. At that, my friends, is as it should be.

 

It’s knowing (hoping) that this can’t go on forever: A little bit of regulatory mishegas…

It being only the third week of the New Year, it’s a little early for any trends to fully manifest themselves, so a couple of odds and ends to get you caught up on (or, upon which to get you caught up, for any hard-core grammarians in the crowd…).

The latest issue of Health Facilities Management has a couple of articles (and a risk assessment available to ASHE members—gotta love a new risk assessment) that should prove of some value/interest over the next little bit:

  •  ASHE issues update on CMS ligature-risk policy – this is basically a recap of the CMS memo issued in December (details here) but also includes mention of an environmental ligature risk tool (updated to include a worksheet for EDs) that is available to ASHE members. I’m not sure if the “hand in glove” relationship between ASHE and TJC will remain the same with the departure of George Mills, but there is every reason to feel that ASHE’s position as an advocacy group will continue. In that light, probably a good idea to check out the ligature risk tool and adopt any elements that you may not have yet considered. I still feel that you have to rule everything in as a risk until you can start ruling stuff out, but I also think that we should be checking out any and all available resources.
  • An interesting article on airflow in the OR; to be honest, I love this kind of digging around into the corners of what makes the surgical environment such a bear from a compliance standpoint and where regulatory scrutiny might be headed as a function of increasing attention to the infection control impact of the environment. I’m not suggesting you have to mimic the study, but it might help you anticipate some pointed survey questions or requests.
  • Also in the latest issue of HFM, there’s an update on the CMS interpretations relative to rolling latches and related concerns as well as a request for volunteers to assist in gathering information, policies, etc. on how folks are keeping things quiet at night.

Moving on to our friends from Chicago, in the continuing unfolding of information regarding the management of ligature risks, the latest issue of Joint Commission Online includes further guidance relating to “other” (my quotation marks) behavioral health environments such as residential treatment, partial hospitalization, intensive outpatient and outpatient treatment programs. The guidance indicates that these settings are not required to be ligature resistant, but then goes on to indicate that a risk assessment should be conducted in these environments, and then policies and procedures implemented to address how to manage patients in these settings that may experience and increase in symptoms that could result in self-harm or risk of suicide. The piece also indicates that the expert panel met again in December and there will be additional guidance relating to suicide risk assessment and safe monitoring of high-risk patients. And so the conversation continues…

An invitation to the regulatory dance—and the band keeps playing faster…

About a year ago, we chatted a bit about the likely changes to the regulatory landscape under a new administration, most of which (at least those related to the changing of the guard) never really materialized to any great extent. But one thing held true—and continues as we embark upon the good ship 2018—the focus on management of the physical environment is very much at the forefront of preparatory activities.

We also chatted a bit about The Joint Commission’s previous exhortations to healthcare leaders to focus more attention on the management of the physical environment (I was going to provide a link to TJC’s leadership blog regarding our little world, but it appears that the page is not so easily found, though I’m sure it has nothing to do with revisionist history…). But it does appear that there’s no reason to think that the number (and probably types) of survey findings in the environment are going to be anything but steady, though hopefully not a steady increase. Remember, we still have two years in the survey cycle before everyone gets to have undergone their first survey with the loss of the rate-based performance elements.

Which brings us squarely to 2018 and our continuing storm of regulatory challenges; I had made a list of stuff that I believed would play some role of significance in 2017 and (strangely enough) appear to be poised to do the same in the coming year (or two…or three?!?):

 

  1. Physical environment standards remain among the most frequently cited during TJC surveys (Nine of the 10 most frequently cited standards for the period January through June 2017). Please check out the September 2017 issue of Joint Commission Perspectives for the details! Just so you know (and I do believe that I’ve mentioned this in the past), I “count” IC.02.02.01 as a physical environment standard. Yes, I know it’s under the Infection Control chapter, but disinfection, the management of equipment and supplies? That all happens in the environment!
  2. CMS, in its report card to Congress, identified the physical environment as the largest “gap” of oversight during all accreditation organization surveys
  3. Also in its report card to Congress, CMS singled out TJC as lagging behind its competition when it comes to improving identification of deficiencies relative to the Conditions of Participation. I firmly believe that the report card to Congress was the proverbial “spark” that fanned the flames of regulatory focus in the environment. I don’t know when we can expect an updated edition of the report card (I suspect that it may be a while), but knowing that CMS is “concerned” can only mean continued focus…
  4. CMS adoption of the 2012 Life Safety Code® (effective survey date of November 1, 2016) definitely did create some level of confusion and uncertainty that always accompanies “change.” And 2017 demonstrated very clearly that it’s not just “us” that have to learn the practical application of the new stuff—the surveyors have to catch up as well! I am definitely starting to see the impact of the adoption of the 2012 Health Facilities Code (NFPA 99)—if you don’t have a copy in your library, it might just be time.
  5. TJC is in the process of revising its Environment of Care and Life Safety chapters to more closely reflect CMS requirements. January 2018 continues the rollout of the standards/performance elements updates—and they’re still not done. As we’ve discussed over the last few weeks, there’s still a lot of shifting requirements (some we always knew were in place, others merely rumored).
  6. Recent TJC survey reports indicate an increasing focus (and resulting vulnerabilities) on outpatient locations, particularly those engaging in high-level disinfection and/or surgical procedures. The physical environment in all areas in which patients receive care, treatment, and services are generating up to 60% of the total physical environment findings in recent surveys. That was just as true in 2017 as in 2016—each care location in the organization has to be prepared for multi-day scrutiny.
  7. CMS published its final rule on Emergency Preparedness (including Interpretive Guidelines, effective November 2016, with full implementation of requirements due November 2017). While organizations in compliance with current TJC Emergency Management standards will be in substantial compliance with the new rule, there will be some potential vulnerabilities relative to some of the specific components of the rule. The key sticking points at the moment appear to relate to the Continuity of Operations Plan (COOP) and the processes for delegating authority and leadership succession planning during extended events.
  8. Introduction of TJC’s SAFER matrix, which did indeed result in every deficiency identified during the survey process being included in the final survey report. Formerly, there was a section called Opportunities For Improvement for the single findings that didn’t “roll up” into a Requirement For Improvement. With the SAFER matrix, everything they find goes into the report. And there did seem to be a preponderance of findings “clustered” (make of that descriptor what you will) in the high risk sections of the matrix.
  9. As a final “nail” in the survey process coffin, effective January 2017, TJC will no longer provide for the clarification of findings once the survey has been completed. While this didn’t result in quite the devastation in the process as it might have first appeared (mostly because I think it forced the issue of pushing back during the survey), it also appears that clarification only during survey was not the hard line in the sand it appeared to be when this first “dropped.” That said, there very definitely seems to be a reluctance on the part of the folks at the Standards Interpretation Group (SIG) to “reverse the call on the field” once the survey team has left the building; just as there is a reluctance to vacate physical environment findings once the LS surveyor has hit the bricks. If you feel that a finding is not valid, there is no time like the present when it comes to the pushback.
  10. One unexpected “change” during 2017: The focus on ligature risks in the various environments in which behavioral health patients receive care, treatment, and/or services. We’ve discussed the particulars fairly extensively in this space and while I didn’t see it “coming,” it has certainly leaped to the top of the concern pile. The recent guidance from the regulators has (perhaps) helped to some degree, but this one feels a lot like the focus on the procedural environment over the past couple of years. I don’t think they’re done with this by any stretch…

 

In my mind, still working from the perspective of CMS calling out the physical environment as an area of concern, the stuff noted above indicates the likely result that the next 12-24 survey months will show a continued focus on the physical environment by the entire survey team (not just the Life Safety surveyor) and a likely continued plateau or increase in findings relating to the physical environment. I still believe that eventually the regulatory focus will drift back more toward patient care-related issues, but right now the focus on the physical environment is generating a ton of findings. And since that appears to be their primary function (generating findings), there’s always lots to find in the environment.

As I like to tell folks (probably ad nauseum, truth be told), there are no perfect buildings/environments, so there’s always stuff to be found—mostly fairly small items on the risk scale, but they are all citable. The fact of the matter is that there will be findings in the physical environment during your next survey, so the focus will shift to include ensuring that the corrective action plans for those findings are not only appropriate, but also can demonstrate consideration of sustained compliance over time. Preparing for the survey of the physical environment must reflect an ongoing process for managing “imperfections”—not just every 36 (or so) months, but every day.

But I never wave bye-bye: Closing out 2017 with some LSC goodies…

As noted last week, this week’s foray looks into the changes to the Life Safety chapter that will be onboarding at the turn of the new year (the details can be found here). I think (for the most part), there is nothing particularly earth-shattering in the new requirements: really just a mix of updating the NFPA standards edition numbers, some increased granularity relative to fire alarm systems, and a couple of opportunities for some quick risk assessments/evaluations to ensure that what you had is not going to get you into survey difficulty. Also (and I guess only time will tell us how important this is going to be), it is important to continue to monitor the practical applications of Chapter 43, especially when one is in the throes of changing utilization to the point of a shift in occupancy classifications. My not-insubstantial gut tells me that this has great potential for consternation in the field, including the ongoing impact of inconsistent (bordering on draconian) interpretations. Certainly some of the granularity indicated below will lessen some of the over-interpretation woes (definitive reads on square footage should help), but those hard lines drawn in the sand can also represent some challenges as you are planning and executing renovation, etc., projects. In my experience, there aren’t too many projects that remain the same (in terms of scope) through the design and build phases, so you may find yourself paying more attention to expanding project footprints.

And so:

LS.02.01.10

  • Building undergoing change of use or occupancy must be in compliance with 101-2012:43.7 (certain exceptions, as always, apply); likewise, any additions must comply with the requirements for new.
  • Any of you with non-sprinklered smoke compartments undergoing major rehabilitation are putting sprinklers in (I hope); major rehabilitation involves more than 50% of the area of the smoke compartment or 4500 square feet—whichever comes first.
  • Multiple occupancies in a building must observe the most stringent occupancy requirements—so keep those occupancy separations well-defined and tight; also, outpatient surgical departments must be classified as ambulatory healthcare regardless of the number of patients served. Those of you at organizations considering going to provider-based models need to keep those surgical procedure locations under close watch.

 

LS.02.01.20

  • Make sure your horizontal sliding doors that are not automatic closing are limited to a single leaf and have a latch or other mechanism to prevent the door from rebounding; also, there are some specific requirements for horizontal doors serving an occupant load of 10 or fewer, including operability from either side without special knowledge or effort and a couple other things. 101-2012: 18/19.2.2.2.10.2 will help you with the details.
  • Make sure that every corridor provides access to at least two approved exits; no passing through any intervening rooms or spaces other than corridors or lobbies.
  • Have you included a look at door widths in your ongoing rated door program? Existing exit access doors have to be at least 32 inches in clear width, though you can hold on to your 28-inch doors if you’re not evacuating by bed, gurney, or wheelchair. New exit access doors have to be at least 41½ inches in clear width (psych hospitals have to be at least 32 inches wide). Doors not subject to patient use, exit stairway enclosures or serving newborn nurseries can hold the line at 32 inches. Door pairs with an inactive leaf must have the inactive leaf secured with automatic flush bolts. There are a few other pieces of this, so make sure you transfer/transmit the particulars to the folks inspecting the doors.
  • Existing exit access doors and exit doors are of the swinging type and are at least 32 inches in clear width. Exceptions are provided for existing 34-inch doors and for existing 28-inch doors where the fire plan does not require evacuation by bed, gurney, or wheelchair.
  • Travel distances to exits are measured in accordance with NFPA 101-2012: 7.6.

 

LS.02.01.30

  • Laboratories using quantities of flammable, combustible, or hazardous materials that are considered a severe hazard are in accordance with NFPA 101-2012: 8.7 and NFPA 99 requirements. I’m thinking most of you are probably not in position of severe hazardousness, but if you’re thinking what I’m thinking, a little risk assessment should solidify any of the particulars.

 

LS.02.01.34

  • Make sure your fire alarm system is up to snuff relative to the applicable requirements of NFPA 70 National Electric Code and NFPA 72 National Fire Alarm Code—probably worth a conversation and some verification by your fire alarm inspection, testing, and maintenance folks. This includes a more than passing familiarity with placement and types of devices, ensuring an alternative power supply for alarm systems, etc. Make sure that manual and automatic initiation of the fire alarm system is in accordance with the noted requirements, including pull stations. Also, make sure your alarm zones are not larger than 22,500 square feet (for some reason, I think that this might provide some angst for folks…) and spaces open to corridors are provided with appropriate smoke detection.

 

LS.02.01.50

  • Make sure that any spots containing equipment using gas or gas piping are up to snuff with NFPA 54 National Fuel Gas Code and electrical complies with NFPA 70. You can maintain existing installations that are not fully compliant as long as there are no life-threatening hazards.
  • Make sure those pesky heating devices are in appropriate compliance—with both code and your organizational policy.
  • Equipment using gas or gas piping complies with NFPA 54-2012, National Fuel Gas Code; electrical wiring and equipment complies with NFPA 70-2012, National Electric Code. Existing installations can continue in service provided there are no life-threatening hazards.
  • If you have fireplaces in your facility, there are specific considerations, including carbon monoxide detection; 101-2012: 9.2.2 will give you the lowdown.
  • 101-2012 9.4 will get you the straight dope on escalators, dumbwaiters, and moving walks—and don’t forget to consult ASME/ANSI A17.1 for new and ASME/ANSI A17.3 for existing equipment.

 

LS.02.01.70

  • If you’re hanging draperies, curtains (including cubicle and shower curtains), and loosely hanging fabric in non-sprinklered compartments, then 101-2012: 10.3.1 is the compliance source. Of course, if you have sprinklers, there are exceptions…
  • No sprinkler protection? Upholstered furniture purchased on or after July 5, 2016 must meet Class 1 or char length and heat release criteria—101-2012: 10.3.2.1 and 10.3.3; mattresses purchased on or after 7/6/2016 must meet 101-2012 10.3.2.2 and 10.3.4
  • If you have a new engineered smoke control system, it must be tested in accordance with NFPA 92-2012, Standard for Smoke Control Systems. If you have an existing engineered smoke control system, it must be tested in accordance with established engineering principles.

 

Since I don’t want you to be completely comatose for your New Year’s celebrations, I will cover the ambulatory occupancy changes sometime in January (please feel free to prod me if you’d rather I do it sooner than later). And on that note, I wish each and every one of you safe celebrations and a most prosperously compliant New Year!

On the nth day of Christmas, CMS gave to me: Ligature risks revisited

As you will no doubt recall, back at the beginning of November, The Joint Commission released guidance relative to survey expectations and ligature risks, splitting things into guidance for behavioral health units/hospitals and then some separate items for expectations in non-behavioral health settings (emergency departments, inpatient units). The information release indicated that there were some folks from CMS involved in the (what will apparently be ongoing) discussion on what healthcare organizations can expect over the next little while as the challenges of managing all variations of the behavioral health patient population. What wasn’t clear at the time (at least to me—and it’s still not) was whether CMS’ participation in that process could be interpreted as an at least tacit endorsement of the guidance statements.

And now (well, this past week), CMS issued its own thoughts relative to its expectations, including indication that more will be forthcoming (in approximately six months’ time, so let’s just say sometime next summer). The Survey & Certification memorandum outlines the current slate of expectations (yours and theirs), starting with the pretty much unassailable notion that: “Ligature risks compromise Psychiatric Patients’ right to receive care in a safe setting.” I think we can all agree that that is a reasonable assertion with which to start a conversation.

The memo also goes on to outline the CMS definition of a ligature risk: “(a) ligature risk (point) is defined as anything which could be used to attach a cord, rope, or other material for the purpose of hanging or strangulation. Ligature points include shower rails, coat hooks, pipes, and radiators, bedsteads, window and door frames, ceiling fittings, handles, hinges and closures.” For me, the only surprise was that the example list didn’t say “include, but are not limited to.” I’m used to the regulatory rapscallions leaving themselves an “out” when it comes to this kind of stuff. While the list is pretty comprehensive, I think it stops a little short of all-inclusive, but perhaps as a function of the designated behavioral health environment, it will do. Which leads to the next highlight: this particular guidance is “primarily aimed at Psychiatric units/hospitals.” I guess that means that guidance for non-BH areas like regular emergency departments and acute-care hospital inpatient units that might have to manage behavioral health patients—maybe in the summer, but not really clear on that. It will be interesting to see how future guidance will dovetail (or not) with the TJC stuff.

So, as we wait for the next installment, it appears that it will be left in the hands of the folks on the ground (CMS regional offices, state survey agencies, accreditation organizations) to “the identification of ligature and other safety risk deficiencies, the level of citation for those deficiencies, as well as the approval of the facility’s corrective action and mitigation plans to minimize risk to patient safety and remedy the identified deficiencies.” At least for the moment, we know how TJC is going after this issue, but everything else is somewhat in the land of gray.

A couple of other items covered include time frame for correction of deficiencies (you have to fix things in the time frame identified by the surveying body, unless it is determined that it is not reasonable to expect compliance within the designated time frame, then only CMS can grant additional time for correction); the specific direction that ligature risks do not qualify for Life Safety Code® (LSC) waivers (because ligature risks are not LSC deficiencies); and if you do get to take additional time for corrective actions, monthly electronic progress reports—including substantiating evidence of progress towards compliance—will be the task. It would seem that the monthly check-in, particularly as a function of providing “substantiating evidence of progress” will help to keep the fires of progress burning bright in the hearts and minds of folks charged with making the necessary corrections. As a function of that, I’ve heard of some anecdotal accounts of surveyors indicating that there is a six-month grace period for corrective actions as long as you can substantiate that the corrections will take that long, but the word from Chicago is that is not the case. I have certainly witnessed long lead times for procurement of ligature-resistant door hardware and such, but that’s not enough to delay the reporting of progress process.

The Survey & Certification memorandum includes an attachment that outlines the current guidance to surveying agencies/organizations. I would encourage you all to give that a thorough look-see (and perhaps a dramatic reading instead of the traditional “’Twas the night before Christmas”—bet it puts the kiddies to sleep PDQ). Doubtless, I will weigh on some of the particulars as they leap out at me (much like those leaping lords) in the coming weeks, but I think I’ve gone on long enough for the moment. That said, I will leave you with these two passages from the guidance attachment:

  •  “In order to provide care in a safe setting, hospitals must identify patients at risk for intentional harm to self or others, identify environmental safety risks for such patients, and provide education and training for staff and volunteers.”

 

  • “Although all risks cannot be eliminated, hospitals are expected to demonstrate how they identify patients at risk of self-harm or harm to others and steps they are taking to minimize those risks in accordance with nationally recognized standards and guidelines.”

Certainly nothing we haven’t talked about in the past in regards to an endless supply of subjects, but kind of interesting to see this included in a missive from the palace…