RSSAll Entries in the "Environment of care" Category

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.

 

A quiet week in Lake Forgoneconclusion: Safety Shorts and Sandals!

But hopefully no open-toed sandals—maybe steel toed sandals…

Just a couple of quick items as we head out of the Independence Day holiday and into the heat of the summah (and so far, scorching has been the primary directive up here in the Northeast—hope it’s cooler where you are, but I also hope it didn’t snow where you are either…but I guess if you were in Labrador last week, all bets are off).

When last week’s musings on the ligature risk stuff in the July Perspectives went to press (or when I finished my scribbling), the new materials had not yet made their way to TJC’s Frequently Asked Questions page, though I thought that they might—and that’s exactly what has happened. To the tune of 17 new FAQs for hospitals, so if you haven’t yet laid eyes on the July Perspectives, head on over to the FAQ page and immerse yourself in the bounty (that’s a somewhat weird turn of phrase, but I’m going to stick with it).

While you’re there, you should definitely poke around at some of the other stuff on the FAQ page. There are lots and lots of recommendations for risk assessment types of activities, so if you’re looking for some risk minimization opportunities, you might find some useful thoughts. Of particular note in this regard is the practical application of safety practices in those organizational spaces for which your oversight is somewhat more intermittent; I’m thinking offsite physician practices or medical office buildings and similar care locations. Depending on where you are and where they are, it might not be quite so easy to keep a really close eye on what they’re doing. And while I tend to favor scheduling surveillance rounds with folks in general, I also know that if you don’t stop by from time to time, you might not catch any lurking opportunities (and they do tend to be lurksome when they know you’re coming for a visit). In a lot of the survey results I’ve seen over the last 18 months or so, there’s still a pretty good chunk of survey findings generated during the ambulatory care part of the survey process. Safety “lives” at the point of care/service, wherever that may be—definitely more ground to cover now that in the past. At any rate, I think you could use the FAQ stuff as a jumping off point to increase the safety awareness of folks throughout—and you can do that independently of anyone’s vacation schedule (including your own).

Hope you and yours had a most festive 4th!

Will it go ’round in circles? More managing the physical environment relative to suicide risk!

Hopefully you have already gotten a chance to look through the July 2018 issue of Perspectives for the latest reveals on how (at least one accrediting body) is working through the issues relating to ensuring each organization has a safe environment for the management of behavioral health patients. There is a fair amount of content (this comes to us in the form of FAQs—presumably these will find their way to the official FAQ page, if they have not yet done so) and splits up into three general categories: inpatient psych units, emergency departments (ED), and miscellaneous. (I’m going to guess that the FAQs relative to managing at risk patients in acute care settings is going to merit their own FAQ edition, so I guess we’ll have to stay tuned.)

I don’t know that I would term anything to be particularly surprising (lots of emphasis on the various and sundry risk assessment processes that comprise an integrated approach to such things), though they do make some efforts to describe/define, going so far as to indicate that only patients with “serious” suicidal ideation (those with a plan and intent) need to be placed under “demonstrably reliable monitoring” (aka 1:1 monitoring), with the further caveat that the monitoring be linked to immediate intervention, which means something in terms of competency, education, experience, etc. Clearly (and I completely agree with this) there is an expectation relative to who does the monitoring that probably doesn’t include a rookie security officer or other newbie. I personally have advocated for a very long time the use of folks who are specifically prepared for these types of activities, so maybe that idea is going to approach something of a standard. We shall wait and see.

Another interesting item is the indication that if you (and, yes, I mean you!) designate a room in your ED as a “safe room,” then the expectation (at least for TJC) is that room (or rooms if there are more than one) would be ligature resistant. Makes sense, but I think it does represent something of a caution for those of you looking at designating safe rooms in your EDs (and perhaps extending to the inpatient side of things—probably in the next installment). I guess the other interesting thing (and this probably doesn’t apply to all) relates to freestanding EDs: the recommendations (you can check out the November 2017 issue of Perspectives for the particulars if you’ve not yet done so) for EDs would apply. I understand that this is rather a big deal in general and is very close to endlessly complex in the practical application of the management of risks. I think this is one “ball” we’re going to be keeping an eye on for the next little while.

To end this week in the truth is stranger than almost anything category, I was looking through an email (devoted to all things culinary) and I noted a headline: “We’re All Using Clorox Wipes Wrong, Apparently” and I said to myself, “Dwell times have entered the vernacular of the American household” (I’m not saying it’s anything more than a toehold, but still) and darned if I wasn’t pretty much spot on. The other “revelation” is the absence of bleach in some of the kitchen wipe products identified in the article (I think I knew that, but I can’t really say when I might have acquired said knowledge). There’s also some information on what surfaces should be cleaned with certain kitchen wipes, etc. At any rate, I thought it worth sharing, at least as an example of how our work can span all demographics.

Happy Independence Day to all!

Education < / = / > Achievement: Don’t Let Survey Prep Get in the Way of Good Sense

I’d like to start off this week with an interesting (and hopefully instructive) tale from the field:

I was doing some work recently at an organization that is facing down the final six months of its survey window. This was my first visit to the facility and I was working on getting a sense of the place as well as identifying the usual list of survey vulnerabilities. As we’ve discussed before, one of the things that’s always in the mix, particularly with the gang from Chicago, is the care and feeding of emergency eyewash stations. This particular organization has adopted the strategy of having folks at the department level perform the weekly testing (a sensible approach from my standpoint—I think the most important piece of the weekly testing is helping to ensure that folks who might actually need the eyewash in an emergency actually know how the darn thing works), but the documentation form had two columns: one for the date and one for the signature of the person doing the test. The sheet did not, however, have any instructions on it, which prompted me to inquire as to how folks would know what (and why) they are checking, since the purpose is not just to run the water. The response to my inquiry was rather noncommittal, which is not that unusual, so I continued to collect data relative to the process. So, over the course of the facility tour, we found a couple of eyewashes with missing caps and no clear indication on the testing form that this had been identified as an issue. OK, not crazily unusual, but pointing towards a process that could use some tweaking. A couple of eyewashes with obstructed access provided a little more data.

Then we made our way to the kitchen. No real compliance issues with the eyewash itself, but I noted that they were checking the eyewash station on a daily basis and recording the temperature at that same frequency. Now, the ANSI standard does not require daily verification of eyewash flushing fluid temperature, so I asked about this particular practice (BTW: Nowhere else had we seen this practice—at least not yet …) and was informed another hospital in the region had been cited for not doing the daily temp checks (I have not been able to verify that this was an actual survey finding, but sometimes believing is enough … to cause trouble). And then we headed over to the lab and ran into a similar practice (they were just verifying the temps during the weekly test) and the feedback there was that a College of American Pathologists (CAP) surveyor had told them a story about an individual that had suffered eye damage because the (low temperature) water from the eyewash interacted with a chemical. This was not written up as a finding, but was relayed as an anecdotal recommendation.

The “funny” thing about all this (actually, there are a couple of process gaps) is that each of the eyewash stations in question are equipped with mixing valves, which pretty much mitigates the need for daily or weekly temperature checks (you want to check the temp when you’re doing the annual preventive maintenance activity). But the more telling/unfortunate aspect of this is that (independent of each other) these folks had unilaterally adopted a process modification that was not in keeping with the rest of the organization (it has been said, and this is generally true, that you get more credit for being consistently wrong than inconsistently right). Now, one of the big truisms of the survey process is that is almost impossible to push back when you are not compliant with your own policy/practice. And while I absolutely appreciate (particularly when the survey window is closing) wanting to “do the right thing,” it is of critical importance to discuss any changes (never mind changes in the late innings) with the folks responsible for the EOC program. While I pride myself on not telling folks that they have to do something that is not specifically required by code or regulation, some of the regulatory survey folks don’t share that reticence. The other potential dynamic for these “mythical” requirements is when a surveyor tells an organization something that doesn’t show up in the actual report. I run into this all the time—they may “look” at the finding in the report, but what they sometimes react to is what the surveyor “said.” Compliance has way more than 50 shades of whatever color you care to designate and what works/worked somewhere else doesn’t always work everywhere, so folks make these changes without knowing what is actually required and end up increasing the potential for a survey finding.

And healthcare isn’t the only pursuit in which incomplete communications (or making sure that communications are as complete as they can be) can have an impact. At the moment, I am reading An Astronaut’s Guide to Life on Earth by Col. Chris Hadfield (this, apparently, is going to be the summer for reading astronaut memoirs, be that as it may) and I came across a passage in which Hadfield describes a debriefing following a practice spacewalk in which one of the instructors noted that while Hadfield has a “very clear and authoritative manner,” he encouraged the folks participating in the debrief to not be “lulled into a feeling of complete confidence that he’s right.” As soon as I saw that, I was able to tie it back to the management of surveyors who speak in a “very clear and authoritative manner” and sometimes turn out not to be worthy of complete confidence that the surveyor is correct. If you are doing something that, in good faith and the extent of your knowledge, is the “right thing” and somebody (even me!) comes along and says you’re not doing that right, never be afraid to ask to see where it says that in the code/regulation, etc. (BTW: I’m not giving you permission to be obnoxious about it!) Surveyors (same for consultants) see a lot of stuff and sometimes compliance becomes a fixed idea, or process, in their head, but that doesn’t mean it’s the only way. And if you hear something that makes you think you have a vulnerability (something you’ve heard through that pesky grapevine), talk it out before you make any changes. That gives everyone in your organization a fighting chance at compliance.

As a final note, if you’ve forgotten about Col. Hadfield’s most notable performance (beyond the astronaut thing), check it out:

Not enough rounding in the world: Compliance and readiness in the face of everyday chaos…

As I was engaged in my walk this morning (the sun just starting to cast its light on the Rockies!), I was pondering the complexities of the healthcare environment as a function of compliance. One of the truisms of my practice is that I am good at finding those points where things don’t quite gel. Sometimes (most times, to be honest), it’s relatively minor stuff (which we know is where most of the survey findings “live”) and every once in a while (mostly because my eyes are “fresh” and can pick out the stuff that’s happened over time; as I like to say, squalor happens incrementally), you find some bigger vulnerabilities (maybe it’s a gap in tracking code changes or a process that’s really not doing what you need it to do). So, after tooling around for a couple of days, folks will inevitably ask me “what do you look for?” and I will stumble through something like “I try to find things that are out of place” or something like that.

This morning, I had something of an epiphany in how that question actually informs what I do: it’s not so much what I look for, it’s what I look “at.” And that “at,” my friends, is everything in a space. One of the process element that gets drilled into housekeeping folks (I’m pretty sure this is still the case, it definitely was back in 1978 when I started this journey), is to check your work before you go on to the next thing, and that means going back over everything you were supposed to do. I’ve had conversations with folks about what tools I’ve seen that have been effective (and I do believe in the usefulness of tools for keeping track of certain problematic or high-risk conditions), but only in very rare circumstances have I “relied” on a tool because I have an abject fear of missing something critical because I had a set of queries, if you will. I would submit to you that, from a compliance standpoint, there are few more complex environments in which to provide oversight than healthcare. It is anything but static (almost everything except for the walls can move—and does!) and in that constant motion is the kernel of complication that makes the job of facilities safety professional infinitely frustrating and infinitely rewarding.

So, I guess what I’m advising is not to limit your vision to “for,” but strive for “at everything—and if you can impart that limitless vision to the folks who occupy your organization’s environment, you will have something quite powerful.

 

What the world needs now: Effective management of workplace violence

By now I’m sure you’ve all noted the unveiling of the latest Sentinel Event Alert (#59 for those of you keeping count) from our friends in Chicago; this particular SEA represents the third swing at concerns and considerations relative to workplace safety, inclusive of workplace violence. But, as I look at the information and guidance provided in the May 2018 issue of Perspectives, it makes me wonder what pieces of this remain elusive to folks, beyond the “normal” operational challenges of providing effective safety education to staff on a regular basis.

So, my questions for the group are these:

  • Have you clearly defined workplace violence?
  • Have you put systems into place across your organization that enable staff to report workplace violence events, inclusive of verbal abuse?
  • Have you identified all the potential sources of data relative to workplace violence occurrences?
  • Are you capturing, tracking, and trending all reports of workplace violence, inclusive of verbal abuse and attempted assaults, when no harm occurred?
  • Are you providing appropriate follow-up and support to victims, witnesses, and others impacted by workplace violence, including psychological counseling and trauma-informed care?
  • Are you reviewing each case of workplace violence to determine the contributing factors?
  • Are you analyzing data related to workplace violence, and worksite conditions, to determine priority situations for intervention?
  • Have you developed any quality improvement initiatives to reduce incidents of workplace violence?
  • Have you provided education to all staff in de-escalation, self-defense, and response to emergency codes?
  • Are you evaluating on an ongoing basis the effectiveness of your workplace violence reduction initiatives?

If your response to any of these questions is “no” or “not sure,” it’s probably worth (at the very least) some discussion time at your EOC and/or organizational QAPI committee, but I have a strong suspicion that most of you have already identified the component pieces identified above in your own efforts. That’s not to say that there aren’t improvement opportunities relative to workplace violence (as there likely always will be), but I do think we’ve made some pretty decent strides in this regard over the past few years. There was a time when the incidence rate was sufficiently concentrated to certain healthcare environments (cities, urban areas, etc.), but, and this is probably the toughest risk element to truly manage, it appears that workplace violence can happen at any time, anywhere. In some ways, it reminds me of the early days of the Bloodborne Pathogens standard and Universal Precautions; it was frequently a struggle for safety and infection control folks to sufficiently encourage good behaviors (and lord knows hand washing can still be a struggle), but much of what was initially viewed as foreign, inconvenient, etc. has finally been (something close to) hardwired into behaviors.

Again, I’m not convinced that this revisitation of covered territory helps anything more than increasing the risks of getting hammered during a survey if you can’t specifically identify how your program reflects their expert advice, but maybe it will help to gently remind organizational leaders that this one’s not going to go away.

It was a fine idea at the time: Safety story of the week!

Now it’s a brilliant…

I think we’ve hung out together long enough for you to recognize that I have some geeky tendencies when it comes to safety and related things, sometimes straying beyond the realm of health care. And this is (pretty much definitely) one of those instances.

Over the weekend, while listening to NPR, I happened upon a story regarding safety concerns at the Tesla factory out in California and how operating at the brink (cusp?) of what’s possible can still fall victim to some time-honored realities of the workplace. The story, coordinated by The Center for Investigative Reporting, and aired on their program Reveal (you can find the story, and a link to the podcast of the story here) aims at shedding some light on some folks injured while employed at Tesla. While I can’t say that there’s the figurative “smoking gun” relative to decisions made, but it does seem to fall under the category of “you can make the numbers dance to whatever tune you’d care to play.” I thought it was a very well-done piece and while there may not be specific application to your workplace, I figure you can always learn from what others are (or aren’t) doing. At any rate, I can’t tell the story as well as they have (the podcast lasts about 55 minutes; the SoundCloud link is about halfway down the page), so I would encourage you to give it a listen.

One other quick item for your consideration: We chatted a few weeks ago about the shifting sands of compliance relative to emergency generator equipment and I wanted to note that I think it would be a pretty good idea to pick up a copy of the 2010 edition of NFPA 110 (it’s not that large a tome) or at the very least, go online and use NFPA’s free access to their code library, and familiarize yourself with the contents. Much as I “fear” will be the case with NFPA 99, I think there are probably some subtleties in 110 that might get lost in the shuffle, particularly when it comes to the contractors and vendors with whom we do business. Recently, I was checking out an emergency generator set that was designed and installed in the last couple of years and, lo and behold, found that the remote stop had not been installed in a location outside of the generator enclosure. Now I know that one of the things you’re paying for is a reasonably intimate knowledge of the applicable code and regulation, and emergency power stuff would be no exception (by any stretch of the imagination) and it perturbed me that the folks doing the install (not naming names, but trust me, this was no mom & pop operation that might not have known better) failed to ensure compliance with the code. Fortunately, it was identified before any “official” survey visits, but it’s still going to require some doing to get things up to snuff.

I have no reason to think that there aren’t other “easter eggs” lurking in the pages of the various and sundry codified elements brought on by the adoption of the 2012 Life Safety Code®, so if you happen to find any, feel free to give us all a shout.

And you may find yourself in another part of the survey process (more HazMat fun)

And you may ask yourself, well, how did I get here?

As is sometimes the case, I like to respond to questions from the “studio” audience and last week I received a question from the field that I think is worth a few inches of verbiage here. The question, as luck would have it, relates to the ascendancy of EC.02.02.01 (with 63% of the hospitals being surveyed taking hits), the management of hazardous materials and wastes.

While it may seem a little incongruous, with a side order of daunting, I think that the primary reason for the ascendance of EC.02.02.01 is that there are any number of things that can generate findings, particularly from the clinical surveyors (not that the LS surveyor couldn’t find stuff, but from what I’ve seen in recent survey reports, a lot of the HazMat findings are being generated during “regular” tracers). So, in no particular order:

  • emergency eyewash equipment (availability/accessibility/documentation of testing & maintenance)
  • availability and use of personal protective equipment (PPE) in accordance with product Safety Data Sheets (SDS)
  • management of hazardous energy sources, particularly as it relates to managing lead PPE;
  • labeling of secondary containers
  • management of hazardous gases and vapors (particularly as a function of ventilation, but also monitoring if you happen to have folks still using glutaraldehyde and/or cadmium-based products)
  • ensuring appropriate staff education is in place, particularly Department of Transportation education for staff signing manifests
  • with the odd issue relating to staff being able to competently access SDS

We’ve certainly spent our fair share of time talking about eyewash equipment (surveyors are as prone to over-interpretation as anyone, so you better have a clearly articulated risk assessment in your back pocket), and, interestingly enough, on May 31 (my birthday!), the folks at HCPro are hosting a webinar on the evergreen topic of eyewash stations, so you may want to give that look-see (listen-hear?).

I think the stuff surveyors are kicking folks on is pretty straightforward. I mean, just think about unlabeled or inappropriately labeled secondary containers—what’s the likelihood that you’ve got one out there somewhere in your organization? An unlabeled spray bottle; a biohazard container for which the label was washed off—lots of opportunities for the process to come up short.

At any rate, the list above is representative of what I’ve seen (in consulting practice and in actual survey reports). Anybody have any other potential findings that they’ve seen?

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

Or ear buds…

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

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

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

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

Inadvertent inundations: Oh, what fun! 2017 most frequently stubbed toes during survey!

As luck would have it, the latest (April 2018) edition of Perspectives landed on the door step the other day (it’s really tough to pull off the home delivery option now that it is an all-electronic publication) and included therein is not a ton of EC/LS/EM content unless you count (which, of course, we do) the listings of the most frequently cited standards during the 2017 survey season. And, to the continued surprise of absolutely no one that is paying attention, conditions and practices related to the physical environment occupy all 10 of the top spots (I remain firm in my “counting” IC.02.02.01 as a physical environment standard—it’s the intersection of IC and the environment and always will be IMHO).

While there are certainly no surprises as to how this list sorts itself out (though I am a little curious/concerned about the rise of fire alarm and suppression system inspection, testing & maintenance documentation rising to the top spot—makes me wonder what little code-geeky infraction brought on by the adoption of the updated Life Safety Code® and other applicable NFPA standards has been the culprit—maybe some of it is related to annual door inspection activities cited before CMS extended the initial compliance due date), it clearly signals that the surveying of the physical environment is going to be a significant focus for the survey process until such time as it starts to decline in “fruit-bearing.” I do wish that there was a way to figure out for sure which of the findings are coming via the LS survey or during those pesky patient tracer activities (documentation is almost certainly the LS surveyor and I’d wager that a lot of the safe, functional environment findings are coming from tracers), but I guess that’s a data set just beyond our grasp. For those of you interested in how things “fell,” let’s do the numbers (cue: Stormy Weather):

  • #1 with an 86% finding rate – documentation of fire alarm and suppression systems
  • #2 with a 73% finding rate – managing utility systems risks
  • #3 with a 72% finding rate – maintenance of smoke and other lesser barrier elements
  • #4 with a 72% finding rate – risk of infections associated with equipment and supplies
  • #5 with a 70% finding rate – safe, functional environment
  • #6 with a 66% finding rate – maintenance of fire and other greater barrier elements
  • #7 with a 63% finding rate – hazardous materials risk stuff
  • #8 with a 62% finding rate – integrity of egress
  • #9 with a 62% finding rate – inspection, testing & maintenance of utility systems equipment
  • #10 with a 59% finding rate – inspection, testing & maintenance of medical gas & vacuum systems equipment

Again, I can’t imagine that you folks are at all surprised by this, so I guess my question for you all would be this: Does this make you think about changing your organization’s preparation activities or are you comfortable with giving up a few “small” findings and avoiding anything that would get you into big trouble? I don’t know that I’ve heard of any recent surveys in which there were zero findings in the environment (if so, congratulations! And perhaps most importantly: What’s your secret?), so it does look like this is going to be the list for the next little while.