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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…

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!

No one told you when to run: Closing out one year, embarking on another…

Every once in a while, I like to poke back through recent missives from our friends in Chicago and elsewhere to see if there was anything that I missed on first review or something that didn’t really “pop” out at me at the time. And, somewhat typically, the really pressing hard news stories are in rather shorter supply as we get closer to year’s end. Truth be told, the whole ligature picture has really held sway in recent weeks, almost to the exclusion of everything else.

At any rate, in looking at the most recent (I think) slate of pre-publication standards, I noticed a couple of “new” requirements that gave me a little bit of pause. Due to some editorial constraints, I won’t identify the standards and EP numbers, but I will try to give you a sense of where there “live”: they are identified as “new” on the webpage, so that may be enough for you to find them (you’re a pretty smaht bunch and I have every confidence in your detective-ing abilities). This week we’ll cover the Environment of Care changes and hit the Life Safety changes next week (where did the year go!?!):

 

  • The hospital has a library of information regarding inspection, testing, and maintenance of its equipment and systems. Note: This library includes manuals, procedures provided by manufacturers, technical bulletins, and other information. (Safety Management)
  • Management of smoking materials for patients receiving respiratory therapy. (Smoking Policy)
  • Periodic evaluations of fire hazards during surgical procedures (don’t forget to define that period!) (Fire Safety Management)
  • Process for reducing risks when flammable germicides or antiseptics are using during “hot” surgical procedures (electrosurgery, cautery, lasers) (Fire Safety Management)
  • The hospital meets all other Health Care Facilities Code fire protection requirements, as related to NFPA 99-2012: Chapter 15. (Fire Safety Management)
  • Elevators with firefighters’ emergency operations are tested monthly. The test completion dates and results are documented. (Inspection, Testing & Maintenance of Life Safety Systems equipment)
  • Hyperbaric facility safety, including labeling of equipment used in oxygen-enriched atmospheres (we covered this a couple of weeks ago, with a couple of folks weighing in with questions on how far to go with Chapter 14 of NFPA 99; if the past is any indicator of the future, I would be moving towards adoption of the whole thing and probably start to extend the labeling of equipment out to all oxygen equipment—this is where they start digging into this—we know the targets will move over the next survey years, so better to be ahead of the game than behind). (Medical Equipment Inspection, Testing & Maintenance)
  • Inspection, testing, and maintenance of anesthesia apparatus, including gas flow and oxygen concentration verification; no oil, grease or flammables for oxygen equipment. (Medical Equipment Inspection, Testing & Maintenance)
  • ORs are wet locations unless you have a risk assessment that says otherwise and has been approved by the governing body (it appears that risk assessments done in “isolation” will no longer meet the mark—organizational leadership has to be involved in the process. Written record of the risk assessment is available for survey review. We covered this before.  (Utility Systems Management)
  • Risk level identification of electrical distribution; we did this one before as well.  (Utility Systems Management)
  • Hospital-grade receptacles at patient bed locations and where deep sedation or general anesthesia is administered are tested after initial installation, replacement, or servicing. In pediatric locations, receptacles in patient rooms (other than nurseries), bathrooms, play rooms, and activity rooms are listed tamper-resistant or have a listed cover. Electrical receptacles or cover plates supplied from the life safety and critical branches have a distinctive color or marking.  Keep an eye on those pediatric locations, particularly areas that can “swing” – tamper-resistant receptacles could well become a moderate risk of harm during survey. (Utility Systems Management)
  • Power strips must be appropriately listed for use in patient care vicinity, patient care rooms, etc. Focus on this has already started, so you better start working with your IT folks to make sure everything is going in the right direction. (Utility Systems Management)
  • Extension cords are not used as a substitute for fixed wiring in a building. Extension cords used temporarily are removed immediately upon completion of the purpose for which it was intended. I predict that this is going to keep this standard at the top of the most frequently cited standards list. (Utility Systems Management)
  • Areas designated for administration of general anesthesia using medical gases or vacuum are in accordance with NFPA 101-2012 and NFPA 99-2012 (Utility Systems Management)
  • Electrical system critical branch supplies power for specific needs (task illumination, fixed equipment, select receptacles, and select power circuits) in areas designated for administration of general anesthesia (specifically, inhaled anesthetics) using medical gases or vacuum. The EES equipment system supplies power to the ventilation system. (Utility Systems Management)
  • New buildings equipped with or requiring the use of life support systems (electro-mechanical or inhalation anesthetics) have illumination of means of egress, emergency lighting equipment, exit, and directional signs supplied by the life safety branch of the electrical system described in NFPA 99. (Utility Systems – Emergency Electrical Power Source)
  • Equipment designated to be powered by emergency power supply are energized by the hospital’s design. Staging of equipment startup is permissible. (Utility Systems – Emergency Electrical Power Source)
  • For deemed status hospitals, battery lamps and flashlights are available in areas not serviced by the emergency supply source. (Utility Systems – Emergency Electrical Power Source)
  • Line isolation monitors are tested in accordance with NFPA 99-2012. (Utility Systems Inspection, Testing & Maintenance)
  • Risk level identification of medical gas, medical air, surgical vacuum, waste anesthetic gas disposal (WAGD), and air supply systems. (Inspection, testing & maintenance of medical gas system components)
  • All master, area, and local alarm systems used for medical gas and vacuum systems comply with the category 1–3 warning system requirements. (Inspection, testing & maintenance of medical gas system components)
  • Containers, cylinders, and tanks are designed, fabricated, tested, and marked in accordance with NFPA 99-2012. (Inspection, testing & maintenance of medical gas system components)
  • Locations containing only oxygen or medical air have doors labeled “Medical Gases: NO Smoking or Open Flame.” Locations containing other gases have doors labeled “Positive Pressure Gases: NO Smoking or Open Flame. Room May Have Insufficient Oxygen. Open Door and Allow Room to Ventilate Before Opening.” (Inspection, testing & maintenance of medical gas system components)
  • A precautionary sign readable from 5 feet away is on each door or gate of a cylinder storage room, where the sign, at a minimum, includes the wording “CAUTION: OXIDIZING GAS(ES) STORED WITHIN NO SMOKING.” Storage is planned so cylinders are used in order of which they are received from the supplier. Only gas cylinders and reusable shipping containers and their accessories are permitted to be stored in rooms containing central supply systems or gas cylinders. (Inspection, testing & maintenance of medical gas system components)
  • More cylinder storage stuff (I suspect you know the drill)—NFPA 99-2012 has a great deal of detailed requirements—and I have no reason to think that they won’t be kicking the tires pretty diligently. (Inspection, testing & maintenance of medical gas system components)
  • Also, transfilling of liquid oxygen is a process with very, very specific requirements; if you’re not transfilling liquid oxygen in your facility, you could count yourself fortunate, but be on the lookout for any evidence of liquid oxygen being transferred inside your “house”; NFPA 99-2012 is your guide. (Inspection, testing & maintenance of medical gas system components)
  • Staff responsible for the maintenance, inspection, testing, and use of medical equipment, utility systems and equipment, fire safety systems and equipment, and safe handling of hazardous materials and waste are competent and receive continuing education and training. (Staff Competency & Education)

I know this is a lot of stuff to consider, but I wanted to put it out in front of you folks on the off chance that your bedtime reading hasn’t strayed into the realm of the 2018 standards changes. I have every reason to think that some of this stuff will show up again in this space (and what a space!), but if someone wants to start a particular conversation before we kick off (kick at?) 2018, please feel free.

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…

Do you miss the safety professional you once had time to be?

I think we can agree that things in the safety world are moving along at a pretty good clip, particularly when it comes down to ensuring ongoing compliance with the various and sundry nuances that are flowing forth from the regulatory firehose. Now I’m sure are those of you that would like nothing better than to pore over the various and sundry code handbooks to figure out best to apply the latest changes to your practices/organizations. But I can tell you this: That’s getting to be very close to a full-time job all on its own—and too many of the current generation of survey findings have as much to do with managing the behaviors of staff at point of care and point of service as they do in figuring out what interpretation is going to win the day going forward. So, as I hear of some findings that I would tend to characterize as “frequently cited,” I want to make sure that I share them with you. This week, here’s a couple of items relating to emergency power:

Under the standard dealing with the setup of your emergency power system, there is a “new” performance element that requires a remote manual stoop station (with identifying label) “to prevent inadvertent or unintentional operation.” The performance element also points toward having a remote annunciator (powered by a storage battery) outside the EPS location. Anecdotally, I understand this is coming up with a fair frequency out in California, so probably worth a look-see for your gen sets.

Under the standard dealing with the inspection, testing, and maintenance of emergency power systems, the weekly inspection (and associated documentation) finally shows up as a specific performance expectation, as does the annual fuel quality test (to ASTM standards, so please make sure that your documentation of those activities is up to date).

As a final note for this week; some updates to the behavioral healthcare Life Safety chapter considerations, mostly shifting the Life Safety Code® chapter references from Chapter 26 (Lodging or Rooming Houses) in the 2000 edition to Chapter 32/33 (new and Existing Residential Board and Care occupancies). The changes impact “small” facilities that provide sleeping arrangements for four to 16 individuals. I don’t see anything particularly substantive, or indeed troubling, in the new stuff, but if you feel otherwise after checking it out, then please sing out loud and clear.

ADA vs. LSC: Projecting into the Future—Are You Ready to Rumble?

One of the nagging things (at least for me) that’s been looming in the background is CMS’ statement (and restatement, with a side of reiteration) emphasizing that the Life Safety Code® (LSC) is not an accessibility code and, thus, does not ensure compliance with the Americans With Disabilities Act (ADA). You can find that statement and some other funky stuff here.

The web page also includes some specific considerations that I suspect that you will find of considerable interest (well, it did for me) in that it appears to represent some sense of how the ADA vs. LSC joust is going to manifest itself in the field. The following are the relevant sections, with a link to the individual paragraphs from the Federal Register:

SECTIONS 18.2.3.4(2) AND 19.2.3.4(2)—CORRIDOR PROJECTIONS

This provision requires noncontinuous projections to be no more than 6 inches from the corridor wall. In addition to following the requirements of the LSC, healthcare facilities must comply with the requirements of the ADA, including the requirements for protruding objects. The 2010 Standards for Accessible Design (2010 Standards) generally limit the protrusion of wall-mounted objects into corridors to no more than 4 inches from the wall when the object’s leading edge is located more than 27 inches, but not more than 80 inches, above the floor. See Sections 204.1 and 307 of the 2010 Standards, available at http://www.ada.gov/​regs2010/​2010ADAStandards/​Guidance2010ADAstandards.htm [2] (“2010 Standards”). This requirement protects persons who are blind or have low vision from being injured by bumping into a protruding object that they cannot detect with a cane. (https://www.federalregister.gov/d/2016-10043/p-78)

Although the LSC allows 6-inch projections, under the ADA, objects mounted above 27 inches and no more than 80 inches high can only protrude a maximum of 4 inches into the corridor beyond a detectable surface mounted less than 27 inches above the floor (except for certain handrails which may protrude up to 41/2″). See section 307 of the 2010 standards for requirements for handrails and post-mounted objects. CMS intends to provide technical assistance regarding strategies for how to avoid noncompliance with the ADA’s protruding objects requirement, as well as how to modify non-compliant protruding objects.) (https://www.federalregister.gov/d/2016-10043/p-80)

SECTIONS 18.2.3.4 AND 19.2.3.4—CORRIDORS

This provision allows for wheeled equipment that is in use, medical emergency equipment not in use, and patient lift and transportation equipment be permitted to be kept in the corridors for more timely patient care. This provision also allows facilities to place fixed furniture in the corridors, although the placement of furniture or equipment must not obstruct accessible routes required by the ADA. See section 403.5 of the 2010 Standards. (https://www.federalregister.gov/d/2016-10043/p-88)

So, it appears that we may be looking at some changes of fixtures, etc. (including fire extinguishers—lots of those wall-mounted lovelies floating around, not to mention hand sanitizer dispensers) and a re-think of how we’re positioning furniture in corridors—should be an interesting ride. A hearty thanks to Kevin Kozlowski, president of Oval Brand Fire Products for planting the seed that germinated into this week’s missive. Among other things, Kevin and his folks manufacture a fire extinguisher that meets ADA requirements for wall projections.

If you’d like me to discuss a particular topic, please feel free to kick something my way. I figure any question one person has, the likelihood of others having the same or similar question it pretty strong, so don’t be afraid.

I said you’ll pay for this mischief…

In this world, or the next! Stand by for news…

In this most momentous of years / survey cycles, it appears that there may be at least one more shift in the firmament, that being a transition for a most notable AHJ. The grapevine has been singing this week. (You can reference either the Marvin Gaye or Gladys Knight version; at the moment, I’m leaning toward an invocation of Marvin as it pushes a follow of “What’s Going On”—Brother, Brother, indeed!) There seems to be a changing of the guard afoot in Mordor (or Oak Park, Illinois—take your pick) as it appears that the estimable Director of Engineering for The Joint Commission, George Mills, is transitioning out of the crucible that provides so much in the way of heartburn in the industry.

Word is that one of the engineers in the Standards Interpretation Group (SIG), John Maurer, will be taking the director’s position on an interim basis. Not by any means a comparison (my personal dealings with the departing incumbent have always been reasonable and assistive), but my past interactions with Mr. Maurer have always been thoughtful, helpful and equitable, including indication of how one might plot a course toward satisfactory compliance. In that regard, I don’t anticipate that this will engender a significant change in how business will be conducted, including the practical administration of the Life Safety portion of the accreditation survey process. While details have not yet been officially confirmed, I have no reason to think that the information in general is incorrect, so all I can say is best of luck to everyone as they (and we) embark on their new journeys and pray for a resurgence of benevolence across the board.

To round things out for this week, I would bring your attention to last week’s Joint Commission Quick Safety Issue (QSI #35 in an ongoing series—collect ‘em like baseball cards!) and the topic du jour: minimizing noise and distractions in OR and procedural units.

Now, you’ll get no argument from me that there are certain environments and situations for which noise minimization is desirable, and perhaps, essential. And, empirically, I can’t disagree with any of the characterizations indicated in QSI #35—there are quite a number of footnotes, none of which I have had the time to track down, but, again, I have no reason to think that the scholarship of the article is anything less than spot on. I guess the thought/question/concern I have relates to the practical application of this as an improvement activity (keeping in full mind that sometimes surgeons like to operate to music that ain’t exactly in the realm of quiet—think AC/DC’s “Back in Black” and you’ll be on the right track).

QSI #35 has a whole list of “safety actions to consider,” and the indication is that these are actions that “should” be considered. (But how often have you seen a “should” become very musty during survey…) I wonder if you’ll have the leeway to make the determination of whether you are appropriately managing noise in the procedural environment. I suppose it’s good that this hasn’t shown up in Perspectives

Reefing a sail at the edge of the world…

What to do, what to do, what to do…

A couple of CMS-related items for your consideration this week, both of which appear to be rather user-friendly toward accredited organizations. (Why do I have this nagging feeling that this is going to result in some sort of ugly backlash for hospitals?)

Back in May, we discussed the plans CMS had for requiring accreditation organizations (AOs) to make survey results public, and it appears that, upon what I can only imagine was intense review and consideration, the CMS-ers have elected to pull back from that strategy. The decision, according to news sources, is based on the sum and substance of a portion of Section 1865 of the Social Security Act, which states:

(b) The Secretary may not disclose any accreditation survey (other than a survey with respect to a home health agency) made and released to the Secretary by the American Osteopathic Association or any other national accreditation body, of an entity accredited by such body, except that the Secretary may disclose such a survey and information related to such a survey to the extent such survey and information relate to an enforcement action taken by the Secretary.

So, that pretty much brings that whole thing to a screeching halt—nice work of whoever tracked that one down. Every once in a while, law and statute work in favor of the little folk. So, we Lilliputians salute whomever tracked that one down—woohoo!

In other CMS news, the Feds issued a clarification relative to the annual inspection of smoke barrier doors (turns out the LSC does not specifically require this for smoke doors in healthcare occupancies) as well as delaying the drop-dead date for initial compliance with the requirements relating to the annual inspection of fire doors. January 1, 2018 is the new date. If you haven’t gotten around to completing the fire door inspection, I would heartily recommend you do so as soon as you can—more on that in a moment. So, good news on two fed fronts—it’s almost like Christmas in August! But I do have a couple of caveats…

I am aware of 2017 surveys since July in which findings were issued because the inspection process had not been completed, and, based on past knowledge, etc., it is unlikely that those findings would be “removable” based on the extended initial compliance date. (CMS strongly indicates that once a survey finding is issued in a report, the finding should stay, even if there was compliance at the time of survey.) So hopefully this will not cause too much heartburn for folks.

The other piece of this is performance element #2 under the first standard in the Life Safety chapter. (This performance element is not based on anything specifically required by the LSC or the Conditions of Participation—yet another instance of our Chicagoan friends increasing the degree of difficulty for ensuring compliance without having a whole mess of statutory support, but I digress.) The requirement therein is for organizations to perform a building assessment to determine compliance with the Life Safety chapter—and this is very, very important—in time frames defined by the hospital. I will freely admit that this one didn’t really jump out at me until recently, and my best advice is to get going with defining the time frame for doing those building assessments; it kind of “smells” like a combination of a Building Maintenance Program (BMP) and Focused Standards Assessment (FSA), so this might not be that big a deal, though I think I would encourage you to make very sure that you clearly indicate the completion of this process, even if you are using the FSA process as the framework for doing so. In fact, that might be one way to go about it—the building assessment to determine compliance with the Life Safety chapter will be completed as a function of the annual FSA process. I can’t imagine that TJC would “buy” anything less than a triennial frequency, but the performance element does not specify, so maybe, just maybe…

Civilization and its discontents

A bit of a hodge-podge this week, with the thematic element of security being the tie that binds, so to speak. There continues to be a lot of news (or it certainly seems that way to me) lately about various security concerns, from violence in the workplace to incursions by unauthorized persons into restricted and/or sensitive areas. We have spent a fair amount of time on these subjects this year (and I somehow suspect that this won’t be the last time for discussion in this realm), but I did want to share some resources with you in case you missed them in the deluge of this, that, and the other thing. (I sometimes marvel that I manage to capture anything, given the fire hose of information constantly spewing into the ether, but I digress.) So, in (relative) brief:

Hospitals & Health Networks (H&HN) published a very interesting story last week about efforts by Milwaukee-based Aurora Health Care to use a clinical approach to reducing assaults in their workplace, including establishment of a Behavioral Emergency Response Team (BERT)—I think you’re going to become very familiar with this term. At any rate, a lot of valuable information, so if you’ve not yet checked it out, I would encourage you to do so (“Violence in the Hospital: Preventing Assaults Using a Clinical Approach“).

In the comment section at the end of the H&HN article, an individual left a comment regarding a public health film titled “One Punch Homicide” that might be of benefit as a preventive measure. I have yet to watch the documentary in its entirety—the trailer is pretty intense—then again, there’s nothing not brutal about violence. The film runs about 90 minutes, but, as information, if nothing else, it’s worth a look: www.onepunchhomicide.com.

As our final thought for this week’s adventure, our friends in Chicago are covering the dangers of tailgating. (I guess since the featured videos are Massachusetts-sourced, the concept of tailgating takes on a whole ‘nutha dimension.) As you will recall, a few months earlier, there was an incident involving an interloper at a hospital in Boston. Since then, the security folks have been hard at work coming up with inventive ways to get folks to use those eyes in the back of their head.

Since it is impossible to determine how much influence anything from Chicago might have on the survey front, I would encourage you (I’m very encouraging this week, aren’t I?) to check out the blog by Dave Corbin, director of security and parking at Brigham and Women’s Hospital in Boston, and maybe show these videos to your EOC Committee and maybe others in your organization—this is one of those things that is scary because it’s true (“Leading Hospital Improvement: New Campaign Illustrates Need for Staff Training on Dangers of Tailgating”).

Hope the summer is treating you well—keep it cool and keep it tuned to www.hospitalsafetycenter.com.