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There’s always someone looking at you: More emergency preparedness!

Once again, we tread the halls of emergency preparedness in search of context for some recent developments. I guess it is not inappropriate that this has become a more frequently touched upon subject, but I am hopeful that the weather patterns of last summer remain a distant memory, though the current situation in Hawaii does give one pause as a function of shifting likelihoods. At any rate, sending positive thoughts and vibrations to the folks in our 50th state in hopes that the tectonic manifestations will slow to a reasonable level.

First up, a couple of words about the recent unveiling of NFPA 3000 Standard for an Active Shooter/Hostile Event Response (ASHER) Program. I have no doubt that any number of you have been working very diligently towards establishment of an ASHER Program within your organizations. And I suspect that you have encountered some of the same resistors when it comes time to try and actually conduct a practical exercise to see how effective (or not) the response might be (I can’t think of too many other exercise scenarios that could be more potentially disruptive to normal operations, but I think therein lies the most compelling reasons for wanting/needing to exercise this scenario). I’ve participated in/monitored a couple of these exercises and I will tell you firsthand that it’s tough to get really good results on that first try. Folks are nervous and tentative and there’ll be a whole host of folks who won’t be as inclined to participate in the exercise as you might want (and really don’t seem too concerned when they fall victim to the shooter—there is nothing quite like the indifference that can be experienced during these types of exercises), but you really must forge on. To my mind, beyond the likely survey scrutiny driven by the Sentinel Event Alert, this type of scenario falls squarely in the realm of “most likely to experience, least well prepared to respond” and the longer it takes to begin making substantive changes to your response plan—based on actual data generated through exercises—the further behind the curve it will be if there is an event in your community (an event that has become increasingly likely, pretty much no matter where you are).

As to the standard, I don’t know that NFPA 3000 brings anything particularly new to the party, but it does provide a codified reference point for a lot of the work we’re already doing. You need only to check out the table of contents for the standard to see some familiar concepts—risk assessment, planning/coordination, resource management, incident management, training, etc. I do think that where this will become most useful as a means of further integration of our preparedness and planning activities with those of our local community(ies). We need to be/get better prepared to respond to the chaos that is integral to such an event and hopefully this will provide common ground for continued program growth.

As an aside relative to all things EM, there is an indication that our friends from Chicago are starting to kick the tires a little more frequently when it comes to ensuring that all the required plan elements are in place. There is a truism that the survey tends to focus more on what has changed than on what has remained the same, as we’ve noted in the past, TJC has added a few things to the mix, so you want to make sure you have:

  • Continuity of operations planning, including succession planning and delegation of authority during emergencies
  • A process for requesting (and managing) an 1135 waiver to address care and treatment at an alternate care site
  • A plan/process for sheltering patients, staff, and visitors during an emergency, as applicable
  • Evidence that all your outlying clinic, etc., settings have participated in your emergency response exercises or actual events

I know there are instances in which some of these might not apply, but you need to be very diligent in outlining how and why these elements would not be applicable to your organization. I think the only one noted above that really could be dependent on your organization is if you don’t have any care locations outside of your main campus. But beyond that, all those other elements need to be in a place that the surveyors can find them. And don’t be afraid to reiterate the language in the applicable individual performance elements—fleshing out the process is a good idea, but you want them to be able to “see” how what you have in your plan reflects what is being required. I continue to maintain that hospitals do a very good job when it comes to emergency management, but there is also always room for improvement. I don’t want our improvement processes to get derailed by a draconian survey result, so make sure the “new” stuff has been captured and added to your Emergency Operations Plan (EOP).

Only dimly aware of a certain unease in the air: Thoughts on succession planning and other EManations

Lately, as I field questions from folks regarding potential survey vulnerabilities relating to emergency management, I keep coming back to the importance of succession planning. And, interestingly enough, I’ve found that succession planning can have a very big impact on other processes in the physical environment.

Certainly, the most critical aspect of succession planning revolves around insuring that you have sufficient numbers of prepared competent incident command staff—in this age of frequent shifts in organizational leadership, etc., you can hit some really lean times when it comes to having appropriately knowledgeable folks in the bunker with you during emergency response activities. And with this recent spate of emergency response activations lasting days instead of hours and weeks instead of days, you really need to have enough bench strength to move folks in and out of roles, getting them a little downtime, etc. I think it is only natural(ly unnatural) to rely on a fairly finite cadre of individuals who you know can “bring it,” regardless of what’s going on, but I think the challenge as we move forward is to expand on those core folks and move towards access to incident command staff across all shifts. If you think of it in terms of a basic continuity of operations plan (after all, you need folks to be able to continue operations), a seamless philosophy, etc., would seem the best strategy. And, to that end, I have a question for you folks out there in radioland—do you have a standardized approach to providing education to your incident command folks? Is it the basic FEMA and associated stuff? Or have you found something else? I’d be really keen to hear what you’re doing to ensure reasonable competence, etc., in your response activities.

Another way in which succession planning can have an impact on general compliance are those instances in which critical processes are “owned” by one individual in an organization. And when that individual takes time off, or even leaves the organization, sometimes the stuff they were doing falls through the cracks. I can’t tell you how many times I’ve run into instances when eyewash checks, fire pump tests, preventive maintenance for equipment, etc., went undone because the person responsible didn’t (or wasn’t able to) make a handoff. As you can probably figure out, surveyors are not going to look too kindly upon these kinds of gaps and with the threshold for findings being at such a low point, you really only need a couple of “drops” before you’re looking at survey troubles. I would imagine that those of you with work order systems can engineer a failsafe into the process so if someone is off, it’s easy to discern that the activity needs to be reassigned. But what if you pay to send someone to school to learn how to maintain a certain piece (or pieces) of equipment and that individual leaves the organization and you (potentially) without a service contract for the equipment in question because you brought it “in house”? These are all real life examples of how the best laid plans of facilities/safety professionals can go astray. Specialized knowledge and skill is rather a premium at the moment and you want to be sure you have processes in place that will withstand attrition (in all its glories).

Next week, I want to talk a little bit about how folks are managing construction projects. You know me: I never miss an opportunity for some ponderings…

The exodus is here: Are you prepared?

Some say not so much.

First off, many thanks to the standards sleuths out there that assisted on solving last week’s missing EP caper; it’s nice to know that I am not merely orating into the void (oration being a somewhat hyperbolic description of this blog—lend me your eyes!).

Now, on to our continuing coverage of emergency management stuff.

The ECRI report outlining the Top 10 Patient Safety Risks for 2018 (if you missed it last week, you can download it here), does make mention of all-hazards emergency preparedness as #7 on the Top 10 list, though I have to say that their description of the challenges, etc., facing hospitals was whatever word is the opposite of hyperbolic (I did a quick search for antonyms of hyperbolic, but nothing really jumped out at me as being apropos for this discussion), pretty much boiling down to the statement that “facilities that were prepared for…disasters fared better than those that were not.” And while there is a certain inescapable logic to that characterization, I somehow expected something a bit weightier.

That said, the ECRI report does at least indicate that there may have been hospitals that were prepared, which is a little more generous than hospital preparedness was described in the report from our friends at the Johns Hopkins Bloomberg School of Public Health Center for Health Security (you can find the report here). The opening of the Hopkins report goes a little something like this: “Although the healthcare system is undoubtedly better prepared for disasters than it was before the events of 9/11, it is not well prepared for a large-scale or catastrophic disaster.” Now that is a rather damning pronouncement, and it may be justified, but I’m having a bit of a struggle (based on reading the report) with what data was used in making that particular pronouncement. I’m not even arguing with their recommendations—it all makes abundant sense to me from a practical improvement standpoint—and I think it will to you as well. But (I’m using a lot of “buts” today), I’m having a hard time with the whole “is not well prepared” piece (in full recognition that it is healthcare as a single monolithic entity that is not well prepared). Could hospitals be better prepared? Of course! Will hospitals be better prepared? You betcha! Could hospitals have more and better access to a variety of resources (including, and perhaps most importantly, cooperation with local and regional authorities)? Have the draconian machinations of the federal budgeting process limited the extent to which hospitals can become prepared? Pretty sure that’s a yes…

Could the nation (or parts therein) experience catastrophic events that significantly challenge hospitals’ ability to continue to provide care to patients? Yup. Will the nation (or parts therein) experience catastrophic events that significantly challenge hospitals’ ability to continue to provide care to patients? Probably, and perhaps (given only the weather patterns of the last 12 months or so) sooner rather than later. There have always been (and there always will be) opportunities for hospitals to improve their level(s) of preparedness (preparedness is a journey, it is not a destination), including building in resiliency to infrastructure, resources, command leadership, etc. And while I appreciate the thought and preparation that went into the report, I can’t help but think that somehow this is going to be used to bludgeon hospitals on the regulatory front. In preparation for that possibility, you might find it useful to turn your emergency management folks loose on a gap analysis relative to the recommendations in the report (again, I can’t/won’t argue with the recommendations—I like ’em), just in case your next accreditation surveyor tries to push a little in this realm.

’Tis the season…for more emergency management goodness!

Recognizing the somewhat hyperbolic nature of this week’s headline (you need only listen to current news/weather feeds to be able to determine that emergencies are not quite as seasonal as perhaps they once were…), I did want to share one more emergency management-related nugget with you (I do try to mix things up, but until I start seeing some “hard” survey results—or some regulatory panjandrum makes some sort of announcement, I’m going to keep seeding this space with various and sundry bits of stuff), this coming to us from the left coast, aka California.

While I have little doubt that you Californians in the audience are familiar with the California Department of Public Health (CDPH—four scary letters, though perhaps not as scary as OSHPD for the facilities folks in Cali) requirements for workplace emergency plans (which is highlighted in this month’s CDPH Occupational Health Watch), I think that there might well be some useful information for folks in other parts of the country (I have found, over some few years of experience, that regulatory tsunamis can start in California and find their way to all manner of locales). To be honest (and why else would we be here?), the plan elements required (or at least the ones the surveyors want to see) by the usual regulatorily-inclined suspects, are frequently not quite as useful from an operational preparedness/mitigation/response/recovery standpoint (they provide a useful structure for the aforementioned quartet, but when it comes down to doing the do, again, sometimes not so much).

At any rate, the Cal/OSHA Emergency Action Plan requirements, provide (at least in my mind—feel free to disagree) a good basic sense of the pieces to have in place that are not necessarily as patient-focused. When the fecal matters starts impacting the rapidly rotation turbine blades, it’s important to have a structure in place that addresses the employee aspect, particularly for those of you with offsite non-clinical operations (billing, finance, HR, etc.: a lot of folks don’t have enough space at the main campus for all the moving pieces that constitute a healthcare organization). So, here’s the California stuff (and please feel free to share any good stuff your state might have on the books—this is all about getting prepared and staying prepared—every little bit helps):

(b) Elements. The following elements, at a minimum, shall be included in the plan:

(1) Procedures for emergency evacuation, including type of evacuation and exit route assignments;

(2) Procedures to be followed by employees who remain to operate critical plant operations before they evacuate;

(3) Procedures to account for all employees after emergency evacuation has been completed;

(4) Procedures to be followed by employees performing rescue or medical duties;

(5) The preferred means of reporting fires and other emergencies; and

(6) Names or regular job titles of persons or departments who can be contacted for further information or explanation of duties under the plan.

(c) Alarm System.

(1) The employer shall establish an employee alarm system which complies with Article 165 (link to that info here).

(2) If the employee alarm system is used for alerting fire brigade members, or for other purposes, a distinctive signal for each purpose shall be used.

(d) Evacuation. The employer shall establish in the emergency action plan the types of evacuation to be used in emergency circumstances.

(e) Training.

(1) Before implementing the emergency action plan, the employer shall designate and train a sufficient number of persons to assist in the safe and orderly emergency evacuation of employees.

(2) The employer shall advise each employee of his/her responsibility under the plan at the following times:

(A) Initially when the plan is developed,

(B) Whenever the employee’s responsibilities or designated actions under the plan change, and

(C) Whenever the plan is changed.

(3) The employer shall review with each employee upon initial assignment those parts of the plan which the employee must know to protect the employee in the event of an emergency. The written plan shall be kept at the workplace and made available for employee review. For those employers with 10 or fewer employees the plan may be communicated orally to employees and the employer need not maintain a written plan.

 

I hope this provides you with some useful (and perhaps even thoughtful) information as we roll through emergency year 2018. I am hoping for a time of minimal impact for communities this year (I think we had just about enough last year), but the oddness of the weather patterns over the past couple of months gives me pause. (I live in the Boston area and Houston and its environs had snow before we did!)

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!

When the tough get going: Emergency Management and other considerations

First off (and apologies for the short lead time on this), but next week (February 13), CDC is hosting a webinar on the importance of assessing for environmental exposures during emergencies (and in general). While this is likely to be some useful information as a going concern, you can also earn CEUs for tuning in. A summary of the program as well as registration information, etc., can be found here. Overall, I think hospitals had a pretty good track record of emergency response in 2017, but somehow these things never seem to get easier over time…

Another issue that I see starting to gain a little traction in the survey world is dealing with concerns relating to medical gas and vacuum systems; for the most part (I’m sure there are some exceptions, but I can’t say that I’ve run into them), folks in hospitals tend to rely on contracted vendors to do the formal inspection, testing, and maintenance of medical gas and vacuum systems, which tends to keep an in-depth knowledge of the dirty details at (more or less) arm’s length. A couple of weeks ago, I received some information from Jason Di Marco of Compliant Healthcare Technologies (many thanks to Jason!) that I thought would be worth sharing with you folks. Of primary interest is a downloadable guide to medical gas systems (available here in exchange for your email address) that really gives a good overview of the nuts and bolts (as it were) of your med gas system. Jason also publishes a blog on the critical aspects of medical gas and vacuum system inspection, testing, maintenance, compliance, etc., where I found a fair amount of useful information. Again, I can see the regulatory compliance laser focus starting to turn in the direction of all the systems covered under NFPA 99 and I can also see some of those prickly surveyor types trying to pick at the knowledge base of the folks managing these processes. So, in the interest of never having too much information, I would suggest getting a little more intimate with your medical gas and vacuum systems.

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.

Try to run, try to hide: Some random thoughts to open the 2018 Physical Environment campaign

I suspect that I may return to the coming changes to the Life Safety standards and EPs dealing with outpatient occupancy, but I wanted to toss a couple of other thoughts your way to start things off with a lesser potential for headaches derived from over-stimulation of the regulatory madness response.

Some of the funkiest findings that arise during survey are those relating to the euphemistic “non-intact surfaces.” The overarching concerns relate to how effectively non-intact surfaces can be cleaned/disinfected, with the prevailing logic being “not particularly well.” One of the surfaces that will encounter scrutiny during survey is the omnipresent patient mattress and I suspect a recent study by ECRI is only going to increase attentions in this regard because, to be honest, what they found is kind of disturbing. As we’ve discussed in the past, ECRI publishes an annual list of technology challenges, and #3 on the hit list this year involves the risks associated with “mattress ingress,” which roughly translates into blood and body fluids seeping into mattresses with non-intact surfaces. I think part of the dynamic at work is that mattresses are somewhat (and in some instances, very much) more expensive than in the “old days,” which decreases the ability for organizations to have a ready supply of backup mattresses for replacement activities. Of course, you have to have a robust process for identifying mattresses to be replaced and that process generally hinges on the active participation of the folks in Environmental Services. As one might imagine, this can become a costly undertaking if you’ve got a lot of cracked or otherwise damaged mattresses, but if you need some additional information with which to encourage the importance of the process, Health Facilities Management magazine has something that I think you’ll find useful.

Another one of those funky findings that I see bubbling up from time to time are those related to the use (including availability) of appropriate Personal Protective Equipment (PPE). From a practical standpoint, I know it can be a wicked pain in the butt to get folks to do what they’re supposed to when it comes to PPE use (especially when they are engaged in the inappropriate mixing of chemicals—yow!). While it is too early to tell whether this is going to be helpful or another bludgeon with which regulatory surveyors can bring to bear on safety professionals, the tag team of CDC and NIOSH have come up with a “National Framework for Personal Protective Equipment Conformity Assessment – Infrastructure” to help achieve some level of standardization relative to PPE use. It does (of course!) include the use of processes that very much resemble those of a risk assessment, including identification of risks and hazards and identification of PPE types needed to address those risks and hazards. Part of me is fearful that this is going to be just one more opportunity for field surveyors to muddy the waters even more than they are now (is that even possible? I hope not…). At any rate, this is probably something with which you should be at least passingly familiar; you can find the details, as well as the downloadable document, here.

As you’ve probably noticed over the last little while, these pages tend to focus more on TJC and CMS than most of the accreditation organizations, but I was happy (Pleased? Intrigued? Something else?) to see that the Health Facilities Accreditation Program (HFAP) had published a summary of its most frequently cited standards/conditions during 2017 in its annual Quality Report. I’ll let you look over the document in its entirety, but some of the EC/EM/LS findings were kind of interesting. In no particular orders, some topics and thoughts:

  • Business continuity: Effective recovery from an emergency/disaster is the result of thoughtful planning. The road to recovery should be clearly charted.
  • Emergency supplies: Apparently there is a move towards maintaining emergency supplies as a separate “entity”; also an inventory is important.
  • Security of supplies: Make sure there are provisions for securing supplies; I suspect this is most applicable during an emergency, particularly an extended-time event.
  • Personal Protective Equipment: Don’t forget PPE in your emergency planning activities.
  • Decontamination/Triage/Utilities/Volunteers: Make sure you have a handle on these in your emergency plan.
  • Environment of Care: Eyewash stations, ligature risks, dirty and/or non-intact surfaces, clustering of fire drills, past due inspections of medical equipment, air pressure relationships, open junction boxes, obstructed access to electrical panels, etc., risk assessment stuff, making sure that all care environments are demonstrably included in the program.
  • Life Safety: Improper installation of smoke detectors, exit/no exit signage concerns, fire alarm testing issues (not complete, no device inventory, etc.), egress locking arrangements, unsealed penetrations, rated door/frame issues.

Again, the link above will take you to the report, but there’s really nothing that couldn’t be found anywhere if there are “lapses of concentration” in the process. Right now, healthcare organization physical environments are being surveyed with the “bar” residing at the perfect level. I have encountered any number of very effectively managed facilities in the 16 years I’ve been doing this, but I can count the number of perfect buildings on the finger of no fingers. Perhaps you have one, but if you’ve got people scurrying around the place, I suspect perfection is the goal, but always a distance away…

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.

Survey Preparation—When do you start kicking the tires?

In the “old” days, the survey preparation cycle was a fairly well-defined undertaking—you knew (pretty much) when they were coming and about six months before their estimated arrival, prep activities began in earnest. Now, you might say, that it’s pretty freaking obvious that that particular strategy is not so great for ensuring results in the current climate (even though, at least at the moment, surveys are happening on that same 36-month recurrence—there have been a few wild card survey arrivals, but not like we’ve been led to expect), but I still find a lot of folks (particularly when it comes to bringing in an extra pair of eyes to look things over) are waiting until the “survey year” to really give the place a thorough review. Now, I am two minds on that topic—while I understand that the closer you can get to survey, the (purportedly) more accurate a picture you have of what things will look like during the actual survey, I also know (from experience) that if you find vulnerabilities (particularly when it comes to documentation), you really need to have something of a track record of compliance (12 months of pristine is a good place to be, though surveyors can certainly walk you back as far as they want—a greater risk for facilities that are smaller in terms of square footage) if you are going to “survive” with minimal findings—recognizing that it is really, really tough to pull off no physical environment findings.

In other news this week, emergency management stuff continues to take center stage as Jose takes aim at the Northeast (it’s beginning to appear that any place that could experience a hurricane is going to endure just that). On the Joint Commission website (www.jointcommission.org) there’s an announcement that TJC is temporarily suspending survey activities in Florida, Puerto Rico, and the Virgin Islands, as well as the Houston area for organizations that have been severely affected by recent weather events. The posting does indicate that if there are questions, organizations should reach out to their Joint Commission Account Executives, which I suspect will involve ascertaining a working definition of “severely affected.” I’m sure that TJC-accredited organizations went through the appropriate notification sequence if they had to curtail or otherwise modify their services, in accordance with the requirement to notify TJC within 30 days of any substantive changes in operations (I think we’re still within the 30-day window from the onset of Harvey, but if your organization has altered services, etc., and not yet made the call to TJC, I would put that on the to-do list for this week). I guess it would be good not to have to go through a survey during the recovery phase, but I don’t know that it wouldn’t be worth seeing how well you could do in the midst of everything else.

Let’s see what else do we have? Ah yes—the Centers for Disease Control and Prevention have updated the hurricane preparedness page on their website; definitely a cornucopia of information for health care providers, response and recovery workers, as well as affected communities in general. Nothing jumps out at me as being super special, but I think all of the available information is worthy of review. I won’t say that I’ve pored over every bit of information, but with all that’s happened (and all that might yet be on the horizon), it’s nice to have some learned source material. Speaking of which, the Association for Linen Management has also published some disaster recovery guidelines; for those of you with operational responsibilities for linen, there’s some good stuff here (and not just the warm feeling I get whenever I think about my halcyon days managing the linen department) and definitely worth checking out.