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The roar of the ’20s continues: Optimism abounds!

I trust that you all were able to carve out some downtime over the holidays. While there was (seemingly) much less rushing around than normal, in many ways, the past month or so has been no less exhausting. At any rate, I hope this finds you well and ready for the climb up (out?).

As mentioned the last time we “gathered,” our friends in Chicago are in the process of modifying the survey of the physical environment as it extends to behavioral health organizations. As fate would have it, the changes revolve around ongoing efforts to align Joint Commission standards and performance elements with the requirements of NFPA 101-2012 Life Safety Code® (LSC) and NFPA 99-2012 Health Care Facilities Code, including clarification of fire drill requirements. A couple of items of particular note follow:

  • Behavioral healthcare facilities that use door locking to prohibit individuals from leaving the building or spaces in the building are considered healthcare occupancies. I don’t see this as an issue for inpatient units as this already the “mark,” but it may come into play in your outpatient clinic settings and perhaps any residential care settings. With all the changes in the survey process relating to care locations outside of the main hospital, I think proper identification of occupancy classifications is going to be under greater scrutiny than ever.
  • If you do have residential board and care facilities in your organization, they’ll be looking for at least six fire drills per year for each building and that means evacuation (unless otherwise permitted by the LSC; please check out NFPA 101-2012: 32/33.7.3 for details and exceptions), two of which need to be conducted at night when residents are sleeping. For some strange reason, the pre-publication standard indicates that “at least two annual drills” would be conducted during the night; I think this is probably one more word—that being “annual”—than it needs to be. I don’t know, it just seems less clear than saying, perhaps, at least two drills per year would be conducted at night or something like that. But that may just be me.
  • Depending on the capacity of the branches of your essential electrical system, you may have some flexibility relative to the number of required transfer switches; your system must still be divided into three branches (life safety, critical, equipment), but if your system is 150kVA or less, then you don’t need to have at least one automatic transfer switch for each branch. I suspect that most folks that have facilities that were constructed, had a change in occupancy type, or undergone a major electrical system upgrade since 1983 are probably all set with this, but I think we can anticipate the question being asked—better to know what you have going in, and probably a useful piece of information to include on your Statement of Conditions.

The LS chapter changes appear to be aimed at ensuring that the requirements for new and existing occupancies are appropriately noted; at this point, I don’t see anything particularly problematic, but, as they so often note in the fine print, actual results may vary. You can find the details here.

As I look out the window, it’s snowing, which reminds me that we’ve got to keep turning with the world, so I will let you get back to it. Until next time, hope you are well and staying safe. For those of you who are in the process of receiving the vaccine, thank you for your service!

Just in time for the holidays: Shoes are dropping all over the place, including business occupancies!

Just when you thought that maybe, just maybe, 2020 had run out of surprises, our friends in Chicago have taken one last (hopefully) opportunity to create a little chaos in the future by introducing us to their latest brainchild—the Life Safety chapter standards and performance elements prescribing the management of business occupancies.

I don’t know that there’s anything particularly surprising in the mix, and, ultimately, may help healthcare organizations endure the scrutiny of surveyors that insist on applying healthcare occupancy requirements to business occupancies. In some ways, it also helps to clarify certain general concepts (for example, the protection of hazardous areas—I suspect you’ll be installing some door closers before too long) that were always applicable, but not always meted out during surveys. There are approximately 30 new performance elements (I count 29, but I can never tell when my math skills will legitimately start to deteriorate…) to chew on, but the “good” news is that these are not coming online until July 1, 2021, so perhaps you will have had enough time to really kick the tires in your clinics, etc.

These changes will be in play for behavioral health and critical access hospitals as well, you can find the links for each of those here.

There are also some EC and LS changes coming to behavioral health, but I think we’ll dig into those next time.

In the face of all of this, I hope that each of you has a safe and joyous holiday season and that we all get a really spiffy New Year. I think we’re earned it!

We’re only immortal for a limited time…

Just taking a quick cruise the FAQ pages and came across one or two items of interest; commentary as applicable…

Our friends in Chicago have given the thumbs up to using the current pandemic response to meet the emergency management exercise(s) requirements. Make sure you document the evaluation in accordance with the six critical areas of response:

  • Communications—what worked well and what did not
  • Resources and assets—what resources were abundant, adequate or lacking
  • Safety and security—what issues arose and how were they resolved
  • Staff responsibilities—what issues arose and how were they resolved
  • Utilities—what issues arose and how were they resolved
  • Patient clinical and support activities—what was abundant, adequate or lacking.

There is an indication that they may be “leaning” on EM when the survey process returns in earnest (and we all know how important that is…).

Moving on to the world of equipment management, specifically diagnostic imaging equipment, there is some relief relative to the completion of performance evaluations for certain systems (CT, MRI, NM, PET, but not mammography) for the duration of the declared state of emergency. I’d be curious as to how folks have been managing this in general; I suspect that some folks had these on the schedule before things came to a screeching halt, but we’re rounding the corner on a year’s worth of pandemic delight so probably want to keep an eye on where things stand. As with many things, the clock will be ticking once the state of emergency is discontinued, at which point you’ll have 60 days to get things scheduled. I bet there will be a lot of competition for external resources at that point…

We’ll close out this week’s edition with some fodder for the HVAC-heads in the crowd. I have to admit that the question being asked and the response don’t seem to match up particularly well and I do think there probably ought to be some mention of the manufacturers’ instructions for use (nothing like a little IFU to make one’s day). The question seems more along the line of “what should we be doing now,” but the response seems to focus a little more on “here’s what you do when this is all over,” when it comes to maintaining HVAC equipment being used to support COVID units. Again, I suspect the IFUs have a big part of where we should be at the moment. Hopefully, you’ve had enough ebb and flow of patients to be able to attend to something close to a normal preventive maintenance schedule and it probably couldn’t hurt to reach out to equipment manufacturers’ if we have significantly modified the use of existing systems and equipment. That said, I would certainly recommend including the bulleted items noted in the FAQ once we’re in a position to start returning things to “normal.”

Won’t you be glad when normal doesn’t have to be in quotation marks?

Hope you all remain safe and well!

Someone’s in the kitchen, but there are no banjos involved…

In the never-ending quest for generating new and challenging survey findings, our friends in Chicago have thrown down the gauntlet (or perhaps more aptly, the oven mitt) for a new focus area: the kitchen! Certainly, the kitchen has always been part of the fabric of most regulatory survey visits. If you think about it, kitchens are among the most risk-laden environments in healthcare. You’ve got all the classic physical environment risks—slips, trips, falls, fire, sharps, heat, humidity, chemical hazards, sanitation/cleaning, a lot of entry-level positions—the list goes on and on. You could make the case that the kitchen environment is among the least risk-free environments in any healthcare organization. I will stop short of calling it dangerous, but it sure is hazardous.

To that end, this week’s Joint Commission blog posting outlines some of the major focus areas for the survey process as it relates to the kitchen; the blog also includes a link to a checklist for reducing fire and other risks in the kitchen. If you don’t have a formal process for doing rounds in your kitchen(s), might be work kicking the tires on this one.

Hope you all are well and staying safe. While I think we’re starting to make the adjustments to the “new normal,” the post-Thanksgiving spike (if there is one, and there’s no reason to think there won’t be) should be arriving shortly, so keep up the good work and we’ll get through this!

We know it will never be easy, but will it ever get easier?

It’s always interesting (and perhaps a bit thrilling) when an announcement comes flying over the transom from our friends in Chicago unveiling “modifications” to the Environment of Care (EC) survey process for healthcare occupancies (e.g., ASCs, hospitals, critical access hospitals), but this ended up being a little less breaking news and a little more of a good news/less-good news situation.

For quite some time now, I have mulled over the general thought that the EC interview session portion of the accreditation survey process really doesn’t yield a lot of findings. My sense of the session is that it’s more of an evaluation of group participation than anything else and it appears that others in a position to do something about it are in agreement, at least as a function of identifying survey vulnerabilities.

At any rate, The Joint Commission recently announced that the EC interview session is going away (good news) to provide more time for surveying in the field, including even more focus on EC stuff for the clinical surveyors during tracers (less-good news). I am certainly not worried about folks getting into “big” trouble during this extra hour of time, but it is another hour of wandering around that is likely to generate at least a few more “dings” in the physical environment.

As the Chicagoans continue to battle the forces of CMS in their pursuit of deemed status and reported shortfalls in the surveying of the physical environment, there is a certain inevitability at play here, so I guess we’ll have to wait and see. My immediate prediction is that there will be an increase in EC/Life Safety findings over the next little while (and perhaps a little while after that…).

Now, if they would only remove the requirements to maintain the safety, security, HazMat, fire, medical equipment, and utility systems management plans—I don’t think they generate very many findings and they really don’t serve any real operational purpose for healthcare organizations. Fire response plans and emergency response plans make sense to me, but the rest of it should be captured through the annual evaluation process. Is it really that big a “step” to go from evaluating effectiveness of the EC plans to evaluating the effectiveness of the EC programs in whole? Somehow I don’t think so…

Hope you are all well and staying safe!

I feel like we’ve crossed this bridge before…fire drills are all the RACE!

While the numbers are fairly small (though at almost 30% for a noncompliance rate during 2019 surveys, you could certainly make the case that almost any deficiencies in this area is too much), there remain a couple of common stumbling points when it comes to conducting fire drills. According to the August 2020 issue of Perspectives (get it at your newsstand now!), there continue to be issues with:

  • Not completing/documenting quarterly drills on every shift. I don’t know that there’s a whole lot of mystery here—sometimes you miss a drill. You don’t want to miss a drill; nobody wants to miss a drill! But sometimes the quarter expires so quickly that you don’t realize that a drill was missed until it’s too late. The links below will take you to The Joint Commission’s guidance on the topic, but my best advice is to set a reminder for March 10, June 10, September 10, and December 10 to check fire drill status. That way, you’ve got a couple of weeks if you need to get one in.

https://www.jointcommission.org/resources/news-and-multimedia/podcasts/take-5-the-environment-of-care-fire-drill-matrix-tool/

https://www.jointcommission.org/resources/patient-safety-topics/the-physical-environment/

  • The fire alarm signal was not transmitted on the third shift drills. I absolutely understand why this is still in the mix (as TJC has noted, the allowance for a coded signal for drills between 9P and 5A, does not preclude the transmission of the fire alarm signal). My best advice is to have a line item on your fire drill critique form that goes a little something like: Fire alarm signal transmitted – Yes   No. That way you are providing a surveyor documentation of the signal transmission where you know they’ll be looking.

https://www.jointcommission.org/standards/standard-faqs/hospital-and-hospital-clinics/environment-of-care-ec/000001235/

  • Not enough variation of times when fire drills are conducted; not too much more to say that hasn’t already been said—you have to mix it up—and make sure that the folks conducting the drills understand that once you’ve set up a fire drill schedule, it is to remain unchanged without approval. I know that sounds kind of draconian (and I suppose it is), but our surveyor friends have been rather inflexible on this count and you don’t want to get dinged for a measly 15 or 30 minutes of overlap in your drill times. In the words of the inimitable Moe Howard, when it comes to fire drills—SPREAD OUT! Or, if you’d rather use George Mills’ take on it, you can find that here (with some other Life Safety bon mots).

Now, at the moment, the survey process is not focusing on fire drills as a function of the 1135 Waivers in effect due to the COVID-19 maelstrom. So it would seem that we have a little bit of time to work on the finer points of fire drill compliance. I think the overarching focus is going to end up being (and I think this is likely to be the case with emergency management exercises) is how well you are doing relative to ensuring that “all staff” are participating. For the purposes of the education and training component, I would like to think that if we can demonstrate that everyone in the organization (including the folks in administration) participated, to some degree, over a two-year period, that will result in a finding of compliance during survey. Is it even possible for most places of size to get to everyone, every year? I’m thinking not, but feel free to disagree. I think it may end up going the route of hazard surveillance round frequency—you have to do as many as you have to do to cover the territory you need to cover. So, if in order to be effective, you have to do more than one fire drill per shift per quarter, then that becomes part of the algorithm used for your annual evaluation (or to use the annual evaluation as a place to ensure your clear assessment of the effectiveness of the program). There is always the potential for a surveyor to disagree with your fire drill schedule, as it relates to effective education of staff. Use the annual evaluation to document your assessment of the effectiveness—it may be the only way to keep the survey wolves away from the flock.

So, let’s get the flock out of here…

As always, hope you are well and staying safe. I’ve been traveling some over the past few weeks and, humans being humans, I think we’ve got a ways to go before we wrestle this thing to the ground, so keep those shields up!

Just when you thought it couldn’t possibly get any stranger…

But first (as promised), a word about fire drills (there will be more, maybe next week, depends on what comes flying over the transom…): About a month ago, I mentioned the possibility of a shift in fire drill frequencies for business occupancies from annual to quarterly. This was based on actual experiences during a state/CMS survey in the Southeast. At the time, it seemed a bit incongruous, but the lead Life Safety surveyor was very pointed in indicating that this was the “real deal.” Well, as it should turn out, it appears that somewhere between that pointed closing, and the receipt of the survey report and follow-up, there may have been a little excess stretching of the interpretive dance that we’ve all come to know (and not love). As of the moment, business occupancy fire drills will continue to be on the annual calendar and not the quarterly one. So, three cheers for that!

But the oddest headline of the past couple of weeks revolves around CMS and their “sense” that our friends in Chicago are being, for lack of a better term, overly transparent during the survey process, particularly during exit conferences at the end of each survey day. The thought given voice is The Joint Commission (TJC) is “(p)roviding too much detail or having extensive discussions before or during a facility inspection survey can potentially compromise the integrity of the survey process. Based on the level of detail shared, a facility could correct potential deficiencies mid-course, which would skew the findings and final outcome of the investigation,” (you can read the source article here). Exactly how this determination was made is not crystal clear to me, but it did occur during the process through which TJC’s deemed status was renewed—but only for two years.

For those of you who have participated in surveys over the year, I think we are in agreement that excessive clarity was not one of the hallmarks of the survey process, though it shivers my timbers to think of how they could become even less so. I have noticed a marked decrease in useful information, per issue, in Perspectives over the past few years, so maybe that’s one of the forums that will be less instructive as we enter the post-COVID era of accreditation surveys. We know that much of what goes down during a survey is the result of interpretation of regulations that are as broadly-scoped as they could possibly be (or are they?), so it would seem that we are looking at an even more opaque survey process—holy moley!

Until next time, be well and stay safe. We need each other—and perhaps never more than now!

Yes, I know I said fire drills, but…

Please feel free to accuse me of “dogging it,” but since I am on vacation this week and you all probably need something of a vacation from me, here’s just a quick blast relating to our latest conversation thread.

Hopefully, you noted the recent headlines indicating The Joint Commission’s (TJC) continued status as an accreditation organization with deemed status; you probably also noted that CMS continues to tighten the leash (if you will), approving their accreditation status for only two years. The CMS indicated, among other things that they “…are concerned about TJC’s review of medical records and surveying off-site locations, in particular for the Physical Environment Condition of Participation (CoP).” Talk about waving a red flag in front of a bovine nose or two!

I think we can intuit that the folks from CMS (not unlike, say, The Man from Glad, or UNCLE) were reasonably pointed in their discussions with TJC prior to making the announcement and, in the face of what might reasonably be interpreted as an existential threat, we can expect lots of attention paid to the outpatient setting(s) in general, and a keen focus on all things relating to the care environment. Certainly, the level of angst generated by this “omen” will hinge closely on how widespread your organization is and (potentially) how well your corporate structure compartmentalizes offsite locations. If you’re not sure, one thing you might consider doing is hopping over to TJC’s website for searching accredited organizations and see how your place “shakes out.” Nominally, each of the care locations they think you have should be represented, and it’s always fun to see if what’s there matches up with what you think you have. I can tell you with absolute certainty that there have been some surprises in the past and I have no reason to think the future holds anything different.

So, that’s our missive for this week  and we’ll cover fire drills next time—I wicked promise! Unless something else happens…

Take care and stay safe!

Stuck on the same refrain: Outpatient! Outpatient! Outpatient!

I’m hoping to break the spell in kind of a reverse Beetlejuice invocation…

As we try to obtain some level of clarity relative to the Joint Commission survey process moving forward, there is some indication (and a fair amount of it as far as I’m concerned) that they will be focusing even more closely (thoroughly, exhaustively, etc.) on documentation, which means the survey devil will be, as it always has been, in the details. And one of the truisms of spending more time with the documents is the element of interpretation that surveyors will be bringing to the table and what they will consider evidence of compliance. At the moment, it’s not clear who will be engaging in the document review for the outpatient settings if they are not defined as a healthcare or ambulatory healthcare occupancy, but there is most definitely a movement afoot to include LS/EOC documentation for all care locations. Now, the applicability of the document review is going to be based on what systems, protections, etc., are present at each of the care locations, but the clear expectation is that any system that is present will be maintained in accordance with the applicable code and/or regulation. For example, if you have an outpatient care location that has a fire department connection, then you need to make sure that you have the appropriate documentation of that inspection activity. Likewise, if you have sprinklers, then you better make sure that the sprinkler list is up to date and all pertinent information is available for inspection.

It seems that every week I’m thinking that I can set this aside and each week something else pops up that I feel is worth sharing (have you done an eyewash assessment yet for your outpatient care locations?) and I suspect that we’ve not reached the end of this conversation. That said, I think there is going to be increased focus on generating more findings and you could say that outpatient locations represent a whole mess of opportunities for doing just that. We know they’re coming, we just need to get ahead of the curve. Hope these are helping you strategize.

Be well and stay safe until next time…

Probably not the final word on outpatient clinic settings

Sometimes I have a difficult time finding a unifying “thread” for the weekly chronicle and other times the way forward is fairly clear. This week may be more towards the former, but I think I can tie things together with a little bit of judicious “bridging.”

First we’ll start with what can only be described as “old news,” though the topic (CMS continues to make frowny faces towards the various accrediting organizations, coupled with the odd glare or two) is as old as the hills. At any rate, if one were an accreditation organization (AO), one might look at the ongoing skirmishes ’twixt the Federales and their deemed status minions as an existential threat (the exact degree of the threat is tough to figure out: Can CMS “fire” all the AOs and still be able to ride herd on healthcare? I’m not so sure). It can’t be pleasant to be berated on a regular basis, reminded of one’s failings, etc., so the natural tendency would be to try to get out from underneath. And the one sure way of making that happen is to work towards generating lots and lots (and lots!) of findings, and if you can tie those findings to various levels of criticality, then you can demonstrate your value to the process. Certainly, the various AOs have generated a lot of findings within the hospital settings over the last few years and (at least for our friends at TJC) there’s been some branching out into the “field.”

One of the trends I’ve noticed as this “shift” has been occurring is a fair number of findings relating to eyewash stations  in all sorts of areas and I think a recently updated (June 26, 2020) TJC FAQ for hospital and hospital clinic settings may be instructive as a function of setting the stage (or the table—you pick) for increased focus on those instances in which surveyors feel you need an eyewash station and perhaps you do not have a risk assessment prepared that would indicate otherwise. As we have discussed in the past (you can find pretty much all of those mentions here), eyewash stations (or the lack thereof, of the care and feeding of) tend to generate findings, but (as long as you do the math) you only have to have them under certain very specific circumstances—circumstances with which surveyors are sometimes only passingly familiar.

That said, one other trendy thing I’ve noticed is that glutaraldehyde is starting to creep back into the healthcare safety landscape, which poses its own fair share of complexities when it comes to managing risks (some useful thoughts on that subject on Tim Richards’ blog). And sometimes, just sometimes, when one is discussing the far reaches of an organization, the creeping of something like glutaraldehyde can be much less noticeable than if it were under the white hot lights of the main campus (or the mothership, if you prefer). Sooooo, particularly for those of you with lots of offsite locations (or even only a few), keep an eye out for those funky things that “show up” at generally less than useful times. You might find out it’s the difference between survey success and having to write plans of correction for weeks on end…

Hope you are all staying safe and staying positive. It’s looking like the first wave of COVID-19 is not quite done with us (and I don’t think we can have a second wave until the first one is done), but I know you folks are keeping a lid on things: Keep up the good work!