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As we relive our lives in what we tell you…

While it is always my intent to be amazingly timely in posting things, sometimes items that I’ve earmarked for sharing end up languishing in my draft emails folder. And, as I was poking around trying to decide what to run with this week, I came upon an item that, while a little long in the tooth in terms of when it was published, should still provide some food for thought (and action) as we navigate the waters of preparedness. There are always things to do and events to plan for, but you’ll probably want to review the document to look over the updates.

As usual, there’s nothing that I see that makes me crazy, but I also know that, in the hands of some surveyors, what looks like flexibility to folks with practical experience can become “the only way.” So you might want to check out the review tool being used in a certain Midwest state very close (so close they are the same) to our friends from Chicago. At some point, I suspect that the conversations during survey are going to turn to “What about the next one?” (as we venture further into the realm of emerging infectious diseases, or EID), so it’s probably a good idea to start planning along those lines. Hopefully the next one doesn’t get here for a very, very long time, but…

A couple of general thoughts regarding some of the changes:

Play nicely with others: collaboration versus isolation. In one of those ever-shifting dualities brought on by the pandemic, there’s been a lot of “distancing” (social or otherwise) that has only (at least to my mind—feel free to disagree) increased the degree of difficulty when it comes to meaningful collaboration. At least now we can get folks to “visit” from time to time, but a lot of the most difficult situations, conditions, etc., over the last year or so were very much accomplished “on the fly.” I think we all try to live by the “stronger together” ethic, but I guess it just proves the point that the whole 96-hour thang is very dependent on the event(s). That said, if you are accredited by our friends in Chicago, be very certain that you have met the requirements for evaluating emergency response activities, have a documented review of your emergency inventory, reviewed your HVA, evaluated your emergency response plan/emergency management plan/emergency operations plan. It doesn’t have to be complicated, but there is some indication that shortfalls will be cited. Please take an hour this week and make sure all those little duckies are in neat rows.

The umbrella can provide protection for a lot of different events: we did touch on this earlier in the year, but I’m glad to see that guidance is being provided to surveyors that it is not necessary to have response plans/protocols for every possible event. That said, you want to make sure that you have a good cross-section of folks participating in the planning process, particularly with the whole EID issue. Infection control and prevention folks are amazingly important when it comes to planning for emergencies (but after the last 12 months or so, you really didn’t need me to tell you that), but there are other folks in your organization that have a part to play in the planning. I think one of the critical performance metrics going forward will be the general concept of continuity as it impacts operations across the continuum of care. Your planning must key on how the place stays in business over the long haul (recognizing we’re still “hauling” to a fair degree…) and you really want to include consideration of continuity as a specific evaluation element. We now know that we can appropriately to a really long event, but the hows and whys are going to be key as we move out of response into recovery mode.

I think you folks “got this,” but it never hurts to look preparedness in the eye from time to time.

Don’t let weighing in weigh you down…

In what I would term an interesting move (I don’t know that I would go so far as to call it unprecedented, but it might well could be), our friends in Chicago are rearranging the deck chairs in the Emergency Management chapter. It does seem like it’s more of  a consolidation than a wholesale rewrite, but the strategy of setting up new standard and performance element numbers makes this potentially a big deal (as we know, surveyors tend to focus on the stuff that has changed since the last survey visit, so if you’re using the existing numerical indicators, you’ll likely need to change—or get rid of them entirely). I suspect this may have more to do with trying to align the existing EM standards et al. with the CMS requirements (It will be interesting to see if they end up developing a crosswalk—probably when it’s adopted).

While I can’t say that I’ve digested the whole thing, it does seem like they removed a lot of the specifics relating to the management of LIP volunteers (including an allowance for organizations to forego the use of volunteers, a strategy they had never really “approved”; I know a couple of instances in which organizations were cited for declining to use volunteers), but it makes me wonder what degree of specificity is going to come into play when they start surveying to this.

That said, I don’t see anything that’s giving me heartburn; since CMS based Appendix Z on much of the TJC standards from 2007-ish, what was once old (and abandoned) is now fresh and new and cutting edge. I have the same hopes for myself over time…

At any rate, the critical processes are still represented. I think it will show over time that some of the specificity of the current standards pushed folks to do things that didn’t necessarily make sense from an organizational standpoint, but I guess we’ll have to wait until the final version is out and about and able to take care of itself. I’m guessing substantive changes are not likely to be made at this point, but they are asking for comments, so if you’ve got a mind to say something, I would encourage you to do so.

Next week we’ll chat a little bit about some recent interpretive dances from the perspective of Perspectives. Stay tuned!

Time has come today: There’s late and there’s LATE

Depending on where you are, you may be bumping up against process elements that are causing certain activities to be “late,” even beyond the grace periods you’ve woven into your management plans, etc. And with the Delta variant becoming more and more of a factor, there is a fair likelihood that the challenges of scheduling activities, particularly those provided by resources external to your organization. I wish that I had a “magic bullet” for this, beyond invocation of the ongoing Public Health Emergency and making use of the 1135 Waiver process (remember when it was really unclear as to what that all meant?). But I think those items should be enough, with a little judicious planning and discussion, to get you over the compliance hump. If you need a primer on that process, be sure to visit the CMS website dealing with such things.

As a somewhat related aside, it does appear more than likely that our friends from Chicago (and, likely, others of the regulatory persuasion) will be moving towards a full embrace of the remote review of documentation. And while that may end up reducing a surveyor day or two from future surveys (they do have a lot of documents to review, so that time would shift from the onsite schedule), it also increased the importance of making sure that your committee minutes, annual evaluations, and other foundation documents provide as much compliance information as possible. Clearly document what waivers have been adopted and for how long; clearly document any risk assessments/mitigation strategies for compliance gaps or shortfalls. While I won’t ask you to “air out your dirty laundry,” you absolutely want to be forthcoming on the impact COVID response has had on normal operations. And if something is late, document the issue resulting in the tardiness of the activity and, again, use the risk assessment process to clearly document that you’re not putting folks at risk while things are sorting themselves out.

As a final note, the Chicagoans are working very diligently to try and get things back on track from a survey perspective, so if you’re expecting them any time soon (or they haven’t shown up yet), I think you need to plan on seeing them before the end of the first quarter of next year. That’s not to say there might not be outliers, but they’re definitely going to be knocking on your door before you know it.

Thanks for all you’ve done and continue to do. It’s made all the difference!

If there weren’t challenges…

…it really wouldn’t be an event that requires emergency response.

Somehow over the last little while, the fundamental nature of what constitutes an emergency and, even more importantly, what an appropriate response looks like, appears to have morphed over time. Now we seem to embrace the expectation that whatever happens, hospitals are going to be right on top of things (in a way that, frankly, doesn’t seem to apply to them that would sit in judgment, but that might be something of an editorial comment). But really, can you imagine what would have happened a year ago when pretty much everybody else was working from home, suspending normal operations, etc. (in full recognition that healthcare facilities don’t have the option of opting out of such things)? Now a lot of folks (and no, I’m not going to name names—if you don’t know, then it’s probably just as well) are playing catch-up and generating a wee bit of chaos as they get back to it. Happy happy, joy joy!

At any rate, I do hope that all the surveyors out there kicking the EM tires are paying close attention to some of the information contained in the CMS updates to the emergency preparedness requirements, including:

  • It’s OK for your response process to be the same for multiple risks/hazards
  • Your HVA/program must address each type of hazard, but your policies and procedures can indeed be consolidated (can you imagine how many binders you would need?!?)
  • It is not the job of the surveyor to analyze the appropriateness of the identified risks; their job is to make sure that your program (including policies and procedures) align with your risk assessments (speaking of your risk assessments, they must be demonstrably facility-based/community-based and they must include staffing considerations; emerging infectious disease planning must be in the mix—no surprise there)
  • It is OK (and certainly much more effective) to have each organization’s EM person “show” the requested elements as opposed to surveyor “browsing” of the plan, etc. (the CMS guidance encourages the use of crosswalks to more quickly/readily identify where the component pieces “live”)
  • It is also OK to have your documentation in whatever format makes sense: hard copy, electronic, etc.

I think these are fairly representative of a common-sense approach to surveying compliance with the EM standards; I guess we’ll see how things unfold in the field…

Just a few odds and ends to wrap things up:

  • They encourage the use of the ASPR-TRACIE checklists; lots of good stuff there and well worth poking around and discovering.
  • Emergency power—you have to have what is required by the Life Safety Code® (LSC)/COP for your facility; but please remember that any additional emergency power considerations must be maintained in accordance with the LSC (and, by extension, NFPA 110 et al). I think some folks have this sense that anything not required by the LSC/110 combo can be maintained in whatever fashion they like. This seems to be drawing a line in the sand that they’re not buying it (again, I guess we’ll see what happens in the field—maybe anything that is not LSC-related isn’t offered up for scrutiny); also, they do not allow extension cords to directly connected to generators; generator must interface with facility through transfer system.
  • Functional exercises, mock disaster drills and workshops can be used to count towards the activation requirements (by the way, long-term care facilities are on the hook for annual education; everyone else can go with biannual).
  • Inpatient facilities need to have two years of documentation present; outpatient facilities have to have four years available.
  • Emergency plans are expected to evolve (mutate?) over the course of a long-term event (and I think we know a little something about that…), your plan should include provisions for monitoring guidance from public health.
  • Your plan must include provisions for tracking staff when electronic payroll systems, etc., not available—for example, power outages, etc. consider check-in procedures for on-duty and off-duty staff.
  • Your plan must include a process for communicating with the various AHJS (and, boy howdy, aren’t there an awful lot of those kicking around); as well as provisions for surge planning. As for staffing, while the use of volunteers is optional, there is an expectation that you will have a process for managing them. Over the years, I’ve run into any number of folks that were not at all inclined to deal with volunteer practitioners, but I think the days when that was a reasonable decision point are rapidly fading into the distance.
  • Your plan must also include a process for evacuating patients that refuse to do so; I figure there must be some empirical information that drove the inclusion of this in the guidance. I’m presuming that you have a process already for dealing with recalcitrant individuals, including patients, so I don’t know that this breaks any ground.

Now that I’ve finished typing this, I really don’t see a lot that I would considering troubling or, indeed, troublesome. I would imagine that a lot of this stuff has become rather more hard-wired than not over the past 15 months or so, if it were not already. I think there were a lot of common lessons learned, though the “equation” for “solving” the challenges is probably unique to every organization (unless you’re part of a system in which the facilities are virtually identical). From a compliance standpoint, I think you folks should be OK, but please reach out if you feel otherwise.

So, with June bearing down on us, I trust that you all continue to be well and are staying safe. See you next week!

You better? You bet!

It would seem that while the rest of the world has been busy responding to a pandemic, the folks behind the scenes have been working on identifying the lessons learned and memorializing them in an update to Appendix Z. At first glance, it seemed that this was more a codification of past updates, but as a I looked through the thing in its entirety, it does seem like the changes are more significant/substantive than I thought. That said, I do think that much of the updated material is aimed at helping surveyors to understand what is (and what is not) actually required and that, as with everything in our world, customization of approaches, etc., is not only desirable, but is really the only way to “roll” when it comes to appropriately preparing to respond to an(y) emergency. I suppose one could make the case that, after all of this hoo-hah of the past year-plus, if we’ve not managed to improve our preparedness, then what exactly have we been doing?

Part of the dynamic I keep coming back to with all this is if it were “business as usual,” then it wouldn’t be an emergency. And one of the defining aspects of an emergency is that it tends to push the normal limits of an organization. I remember the hue and cry that went out immediately following Superstorm Sandy’s trek up the East Coast regarding the level of hospital preparedness—because people struggled at the outset. But when the final report from CMS was issued, it turned out that hospitals generally did what they had to do to keep patients and staff safe.

As we look back at the past 18 months or so, I suspect that each organization within the sound of my voice is better prepared than previously for managing the impact of a long-term pandemic event. I also suspect that there have been any number of improvement opportunities identified and I am hopeful that, among other things, your organizational leadership has gained a greater appreciation for emergency preparedness as a proactive undertaking (recognizing that response is typically characterized by reactivity). The truth of the matter is this: while emergency preparedness does not, in and of itself, generate revenue. Effective emergency preparedness allows an organization to continue generating revenue while the feces is striking the rapidly rotating blades—and that makes all the difference in the world.

I suspect that this is going to take a couple of sessions to work through some of the subtleties of the updates, so I would encourage you to start chipping away at this as wander through the very merry month of May. There is a lot of material to digest and while I don’t see anything that’s making me crazy from a survey prep standpoint, I’ll let you be the judge of how that shakes out—at least for the moment.

Before I close out this week’s chat, I did want to tip you to one resource that I think will be really helpful. One of the more painful aspects of the Emergency Preparedness Final Rule has been that the official document that is Appendix Z is designed to include the requirements for all provider types, which makes an already complex set of rules that much more confusing. But someone (bless them, whoever they are) worked to peel out the requirements for each provider type, so if you’re not a “regular” hospital or you have operational responsibilities for more than one provider type, you can find the specifics for each here. There are other resources as well, but just having the requirements by provider type is (at least to me) crazy wonderful—and I hope you think so too.

Next week, we’ll chat about some of the ways in which organizational leaders are going to be looped into this on an ongoing basis—if that doesn’t sound like fun…

The trouble with normal?

It always gets worse!

While I can’t say with absolute certainty, it seems likely that I’ll be employing relatively brief missives over the next couple of weeks as we do seem to be shifting gears a bit as far as the “return to normal.” As I write this, it’s been a couple of weeks since my last air travel and (based solely on my own observations) I have every reason to think that the COVID surge being reported is going to be a disruptive factor—I am hoping that this is the last wave before we reach safe harbor, but I’m not just seeing noses in enclosed public spaces, I’m seeing lots of full faces. I received my second dose of the vaccine about 10 days ago, but I’m going to keep masking up for the foreseeable future when I’m traveling. I will be happy to be proven that it was more than I needed to do, but I’m still waiting on the data…

So, just a couple of resource items for moving into the next phase of normalcy. First up, I was always (OK, since last June) surprised by the variability of screening practices and that surprise continues today. But if you want to get a sense of what I’m seeing in the field, this would be a good starting point. I don’t know that there’s a whole lot of data regarding how effectively screening helped stem the tide of COVID or even how often cases were identified through that process, but maybe someday there will be some sense.

Another element for consideration is visiting folks in nursing homes and other care facilities. I don’t think there’s anyone who would argue that there has been a significant emotional toll since the onset of COVID, which, I suppose has given the powers that be a fair amount of time to come up with how to transition safely on the visitation front. In September 2020, CMS issued some guidance in that regard and, a few weeks ago, updated that guidance in light of vaccinations, etc. Again, if we get another spike, this might be the best we get for a while, but at least it’s something…

And that, as they say, is that—at least for this week. Who knows what might come flying out of nowhere to create havoc, so stay tuned.

Be well and stay safe. Every day brings us a little closer to the end of this thing!

Doing the waive: Categorical waivers are still in the mix…

In preparation for last week’s missive on the transmission of fire alarm signals during fire drills (more on that in a moment), I ran across a CMS categorical waiver that was posted early last fall (September 25, to be exact) that provided some relief for folks wishing to use corrugated medical tubing in certain circumstances, rather than the rigid copper tubing required under NFPA 99-2012, due what CMS might consider an unreasonable hardship as corrugated medical tubing can be installed more efficiently and economically than rigid copper. The basis of the waiver is due to a more recent version of NFPA 99 (the 2018 edition) in which there are provisions that provide for installation of the corrugated. At this point, we all know the drill: You have to read the whole thing very carefully to ensure you don’t step on any regulatory toes, but if you’ve got some tricky installations coming up, this might be something of a relief. You can find all the details here.

Now, the reason I bring up the transmission of fire alarm signals deal is that the most recent edition of NFPA 101 (2021) includes some clarification in this regard (a shout out to Grant Finch out in Oregon for his detective skills on this). As noted last week, the current language indicates transmission of a fire alarm signal (with no additional information to be found as defining what that means, leaving things in the hands of the interpretive dance masters). The 2021 edition, in section 19.7.1.4, requires fire drills to include the simulation of emergency for fire conditions (much as it does now), but it goes on to say “include activation of the fire alarm system notification appliances.” Section 19.7.1.7 still provides for the coded announcement between 2100 and 0600 hours, so that piece of it remains the same.

At any rate, I am hopeful that, with this current version clarification, even if there is no categorical waiver forthcoming, the accreditation organizations will stop fussing about the fire alarm signal transmission and move on to other things. After all, the truly applicable code for testing fire alarm signals is NFPA 72, so why would need to include signals in our fire drills—which reminds me, you still need to document the elapsed time of the fire alarm signals generation to its receipt at the central monitoring service, etc. I’ve been running into a spate of vendors that are not including that in their documentation, so you probably want to give your latest testing documentation a look. And while we’re on the subject, I personally think it’s bogus for your testing vendor to just give you a printout of the month’s alarm activity in which the test occurred; they should either highlight it on the sheet or pull the dates/times/results off the printout. I suspect that they are being more than adequately compensated for their services, which (to my mind) includes a summary of the results, particularly any deficiencies. I don’t think you should have to hunt for the deficiencies and now with the rollout of the virtual survey process (something on that next week), surveyors will have more time than ever to comb through your reports for those funky little missed devices, etc. Your fire alarm (and sprinkler system) ITM vendor should be highlighting the “to do” list so you can get it “to done.”

Hope you’re having a safe and productive week. See you on the flip side!

From the sky we look so organized and brave

Once again (I’m thinking there’s no surprise to this), the public health emergency wrought by the impact of COVID-19 on just about anything you’d care to name has been extended. You can find the somewhat reiterative announcement here (apparently, there’s no one at the federal level that proofreads this stuff—go figure). If the past sequence of review and extension continues to hold true, we can expect the next extension to “drop” sometime in April. It would be delightful to think that distribution of the vaccine would somehow interrupt a further extension, but I suspect we probably have at least one more after that, as we move ever closer to whatever is going to constitute the “new normal” (based on the latest numbers from CMS, things do seem to be retreating/receding from red, so to speak).

As we continue our slog through the pandemic, our good friends in the CMS workshop have been busy establishing a portal for all things waiver-related. It may be that there’s too much information (there are a whole bunch of links to various sites, etc.), but on the off chance that you folks might find something useful contained therein, you can check it out here.

There are a couple of YouTube videos in the mix to help complete the online waiver request forms (if you would feel so inclined, you can go directly to the waiver request site by using this link).

Ultimately, it’s all about being able to continuously provide appropriate care to our patients; sometimes that means going from one moment to the next—which, as we’ve learned over the last little while, breeds its own special brand of exhaustion…

I encourage you to make the most of what little “down” time you have to recharge your batteries as much as you can. The vaccination process seems to be gathering some momentum, but we’re still a ways away from the finish line. I guess this is one race we’ll all be finishing at the same time…

Until next time, please stay well and be safe!

Remote control: Don’t forget to close the loop

It would seem that the likelihood of ongoing remote surveys is growing in relation to the number of organizations awaiting survey. To be honest, I’ve not seen an official accounting of where the various accreditation organizations (AO) are falling relative to survey delays. That said, I can’t imagine that there must be a fairly significant backlog of surveys to be conducted, so I suppose we’d best be prepared for at least some of that process to occur remotely—particularly document review. To that end, if you missed this news item, I think it will help provide an understanding of how the process is evolving (mutating?!?); the focus of the piece is how DNV is administering the process, but there are certainly some clues as to how the process in general is likely to “exist” over the next little while.

One thing I hadn’t encountered before (or if I had, it was lost in the slipstream of last year) is the COVID data being provided by CMS. It appears that the information is updated on a regular basis (at this writing, the most recent information was for the period ending December 23, 2020) and while it is labeled as Nursing Home Data, CMS feels that the data is applicable to survey planning for hospitals. It appears that unless you are in a “green” county (you’ll see what I mean when you download the spreadsheet), then you probably won’t be seeing a “live” survey team (will we have to face zombie survey teams?). In traveling the past few months and living in a state that requires a negative test before returning or self-quarantining, I can tell you that those green windows sometimes don’t stay open for very long. Fortunately, I have not yet been in a position where I have tested positive away from home—probably my second worst fear; the worst fear being to bring this stuff back home to share with my family.

That said, my own practice has been very much “out in the field,” with a mix of some remote document review. I really do miss the interaction of document review with the folks who are actually responsible for the critical processes. It’s very difficult to have an appreciation for the process when you can’t discuss the operational challenges, the process for making corrections, etc. One of the “common” themes I’ve noted is that the documentation provided remotely tends not to include evidence of corrective actions; certainly this is something I’m accustomed to asking for when I’m doing onsite document review, but I don’t know of too many surveyors that wouldn’t be looking to “close the loop” on any identified deficiencies as soon as they find them in the documentation and it’s tough to really hold someone’s feet to the fire relative to producing corrective action documentation when you are not “in the building” with a specific ending point for the survey. There are certainly any number of surveyors who will cite an organization for failing to provide evidence of corrective actions and I think remote document review only increases the potential for missing pieces of the puzzle.

So my consultative recommendation is this: Make sure that you attach evidence of corrective actions to any documentation you might provide remotely to a survey team. You know you’re going to be asked for it anyways, so you might as well get ahead of the “ask.”

That’s it for this week. I hope you continue to be well and stay safe—we will get through this!

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!

Madman Across the Water Management Program

This week brings us something of an unexpected development in the management of the physical environment as our friends in Chicago are seeking comments on a proposed standards revision that more clearly indicates the required elements for water management programs. I don’t know that I was expecting this change, though I suppose it falls under the “one outbreak is one too many” category, nor was I expecting the solicitation of commentary from the field (I look forward to seeing the results of the comment period). It would seem that the proposed performance element is based very closely on the CDC recommendations, which clearly take into consideration the guidance from ASHRAE 188 Legionellosis: Risk Management for Building Water Systems and ASHRAE 12 Managing the Risk of Legionellosis Associated with Building Water Systems, so it doesn’t appear that we’re breaking new ground here.

Additionally, we know from past discussions that CMS has been pretty focused on the risks associated with building water systems (most recently, here, but there are others), so this may be a case of ensuring that everyone is paying attention to the areas of (presumably) greatest risk. And, as near as I can tell, none of the existing COVID-related blanket waivers exempts folks from managing the risks associated with building water systems, so hopefully you’ve been staying with your identified frequencies for testing, etc. And if you haven’t, you probably should be identifying a game plan for ensuring that those risks are being appropriately managed.

Clearly, there’s a little time before these “changes” go into effect (the comment period ends November 16, 2020), but since this is pretty much what CMS has been looking for since 2017 or so, you want to have a solid foundation of compliance moving forward. I recognize with everything else going on at the moment, this might not be a priority, but this is one of those concerns in which proactivity will keep you out of compliance jail.

Until next time, hope you are all well and staying safe!