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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!

Emergency management in (you guessed it) ambulatory healthcare

I was really, really, really thinking that I’d be able to glom on to some other subject matter this week (which I suppose it partially true), but it would seem that I’m going to be mining this particular vein of compliance (recognizing that “vein” rhymes with “bane”—make of that what you will…) for at least a bit longer.

At any rate, our friends in Chicago recently indicated some changes relative to the requirements for emergency exercises, but it does seem to be that the changes are intended to reflect CMS reducing the number of required exercises, as referenced in the Emergency Preparedness final rule, to one exercise per year and you only have to conduct a “big” (for lack of a better descriptor) exercise every other year. By big, that would be either a community-based, full-scale exercise (if available) or a facility-based functional exercise.

You may, of course, conduct as many “big” exercises as you like, but in the opposite years, you can even run with a tabletop exercise (though there is a fairly specific setup for the tabletop, so make sure each of the elements is accounted for before you try to take credit). Also, if your organization experiences an actual emergency that requires activation of the emergency plan, you can count that as your activation for the year (and it’s beginning to look a lot like COVID-19 is going to populate a lot of folks’ 2020-2021 emergency management program events).

As a somewhat related aside, this reduces the number of performance elements relating to exercises from three to one, so I think we can count this as a victory for the downtrodden, etc.

I know a lot of folks sometimes struggle with how to involve the ambulatory healthcare locations in exercises, so I think this provides a simpler framework to consider when identifying potential compliance gaps/shortfalls.

I think next week we’re probably going to have a little chat regarding fire drills; the July 2020 issue of The Joint Commission Perspectives has some “clarifying” thoughts on the topic that are probably worth kicking around.

Until next time, hope all is well and you’re staying safe!

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!

In the grand scheme of things, this helps—but how much?

A few weeks back we chatted about efforts to engage the 1135 Waiver process as a function of fire and life safety systems inspection, testing & maintenance, particularly as a function of ASHE’s efforts to facilitate a coordinated response. Apparently, this part of the waiver picture was not a priority for the folks at regional CMS, so there were a number of rejection notices sent to folks.

I’m not exactly sure what may have transpired (other than the passing of time, but if there were folks with access to CMS ears that continued to advocate, a debt of gratitude is owed), but some items related to certain inspection, testing & maintenance activities have finally made it to the slate of blanket waivers. You can find the information here, on page 23 of the linked document. Unfortunately, it appears that the blanket waiver announcement is being released in cumulative form, so you have to dig a little bit to find the applicable passage. Because of that, I’ve copied and pasted the information below.

As near as I can tell, the areas of greatest concern for the moment are those activities for which waivers were not granted:

  • Sprinkler system monthly electric motor-driven and weekly diesel engine-driven fire pump testing.
  • Portable fire extinguisher monthly inspection.
  • Elevators with firefighters’ emergency operations monthly testing.
  • Emergency generator 30 continuous minute monthly testing and associated transfer switch monthly testing.
  • Means of egress daily inspection in areas that have undergone construction, repair, alterations, or additions to ensure its ability to be used instantly in case of emergency.

In looking at the list, I think that it is both reasonable and very practical from a safety perspective. Clearly, as busy as it is, there are critical processes/protections that need to be assured, so hopefully you haven’t missed any of those noted activities and, if you have, you probably need to start working on preparing your organizational leaders for some likely survey findings.

As a closing thought, lately while walking I’ve been checking out some new (to me) podcasts, one humor-based (Conan O’Brien Needs A Friend—generally pretty good—a couple of good “laughs out loud” per episode) and one not so much so, which is my shareable moment for you. Lately, the Freakonomics Radio podcast has been covering subjects relating to the pandemic, with the episode I listened to today being “How Do You Reopen A Country?” One of my favorite aspects of this program is their tendency to come at topics in a calm, measured fashion, but generally from a somewhat unusual angle, but I don’t want to spoil it for you be jabbering too much. If you’re interested in something thoughtful, but not crazily scary, you might enjoy the episode.

Hope this finds you safe and well – until next time…

CMS Blanket Waiver Information

Inspection, Testing & Maintenance (ITM) under the Physical Environment Conditions of Participation: CMS is waiving certain physical environment requirements for Hospitals, CAHs, inpatient hospice, ICF/IIDs, and SNFs/NFs to reduce disruption of patient care and potential exposure/transmission of COVID-19. The physical environment regulations require that facilities and equipment be maintained to ensure an acceptable level of safety and quality.

CMS will permit facilities to adjust scheduled inspection, testing and maintenance (ITM) frequencies and activities for facility and medical equipment.

  • Specific Physical Environment Waiver Information:

o 42 CFR §482.41(d) for hospitals, §485.623(b) for CAH, §418.110(c)(2)(iv) for inpatient hospice, §483.470(j) for ICF/IID; and §483.90 for SNFs/NFs all require these facilities and their equipment to be maintained to ensure an acceptable level of safety and quality. CMS is temporarily modifying these requirements to the extent necessary to permit these facilities to adjust scheduled inspection, testing and maintenance (ITM) frequencies and activities for facility and medical equipment.

o 42 CFR §482.41(b)(1)(i) and (c) for hospitals, §485.623(c)(1)(i) and (d) for CAHs, §482.41(d)(1)(i) and (e) for inpatient hospices, §483.470(j)(1)(i) and (5)(v) for ICF/IIDs, and §483.90(a)(1)(i) and (b) for SNFs/NFs require these facilities to be in compliance with the Life Safety Code (LSC) and Health Care Facilities Code (HCFC). CMS is temporarily modifying these provisions to the extent necessary to permit these facilities to adjust scheduled ITM frequencies and activities required by the LSC and HCFC. The following LSC and HCFC ITM are considered critical are not included in this waiver:

  • Sprinkler system monthly electric motor-driven and weekly diesel engine-driven fire pump testing.
  • Portable fire extinguisher monthly inspection.
  • Elevators with firefighters’ emergency operations monthly testing.
  • Emergency generator 30 continuous minute monthly testing and associated transfer switch monthly testing.
  • Means of egress daily inspection in areas that have undergone construction, repair, alterations or additions to ensure its ability to be used instantly in case of emergency.

o 42 CFR §482.41(b)(9) for hospitals, §485.623(c)(7) for CAHs, §418.110(d)(6) for inpatient hospices, §483.470(e)(1)(i) for ICF/IIDs, and §483.90(a)(7) for SNFs/NFs require these facilities to have an outside window or outside door in every sleeping room. CMS will permit a waiver of these outside window and outside door requirements to permit these providers to utilize facility and non-facility space that is not normally used for patient care to be utilized for temporary patient care or quarantine.

Rock on: Where do we go from here?

It would seem that the subtext to all we are experiencing/dealing with now is how long we can anticipate this “siege” to last, and (as is typical of these types of events) we probably won’t have a clear sense of the timing until the clouds break and the “sun” comes out. From a practical standpoint, the current situation is a very robust test of each organization’s continuity of operations plan (COOP), as well as the opportunity to witness the intricacies of the 1135 Waiver process as it unfolds. Of course, the other element that is unfolding is the number of COVID-19 cases worldwide (I’ve found the Johns Hopkins University case map of particular use in watching the spread of cases, both worldwide, but particularly in the United States; if you haven’t “found” it yet, it’s definitely worth a look).

At any rate, from a planning perspective, we’ve gotten to the point where some preparations need to be made to ensure sufficient capacity in the event regions are not successful in their attempts to “flatten the curve.” And those preparations will probably involve real-life/real-time actions to be ready to establish alternate care sites (to see what that looked like 100 years ago, you can scroll down this page to see my old stomping grounds at Brockton Hospital). To aid in that pursuit, just yesterday (March 30), CMS unveiled a number of regulatory changes to encourage thoughtful expansion of capacity, including provisions for what is described as “hospitals without walls.” I would encourage you to review these new materials as they do have some restrictions (mostly checking to make sure your planning dovetails with your state’s planning for alternate care sites).

From a practical standpoint, our friends at the American Society for Health Care Engineering have included with their COVID-19 resources some guidance (including links to other materials) on options for establishing/converting alternate care sites. Again, looking at the COVID-19 map, it is fairly easy to discern where bed capacities are likely to be in greatest demand and hopefully those most dire of conditions will not spread everywhere, but there’s no reason to delay consideration of what can be done in advance to be able to flex up capacity at your facility. I know there’s a lot going on right now and the struggle to attain some level of normalcy is all too real, but it is clear that we are in the process of redefining the magnitude of planning and preparation activities. Anything we can do to stay at least a couple of steps ahead is worth our time and energies.

Stay safe until next time!

Logic doesn’t always prevail…a luxury you can’t afford!

By my observations over time, I’ve found that, all-too-often, logic finishes a distant third behind self-interest (which sometimes manifests itself as crimes of convenience) and panic. Unfortunately, if you currently work in the healthcare industry, you must cling to the bastion of logic as those “other” winds threaten to pull you under.

But sometimes even bureaucracies manage to act judiciously; the good folks at the Centers for Medicare & Medicaid Services (CMS) have elected to curtail some of their “regular” survey activities to afford healthcare organizations the opportunity to focus on COVID-19 preparedness (you might want to bookmark the CMS FAQ page—they’ll be updating frequently). While this doesn’t mean CMS is going to halt all survey activity, it outlined how it would be prioritizing survey activities over the next little while:

Effective immediately, survey activity is limited to the following (in priority order):

  • All immediate jeopardy complaints (cases that represent a situation in which entity noncompliance has placed the health and safety of recipients in its care at risk for serious injury, serious harm, serious impairment, or death or harm) and allegations of abuse and neglect
  • Complaints alleging infection control concerns, including facilities with potential COVID-19 or other respiratory illnesses
  • Statutorily required recertification surveys (Nursing Home, Home Health, Hospice, and ICF/IID facilities)
  • Any revisits necessary to resolve current enforcement actions
  • Initial certifications
  • Surveys of facilities/hospitals that have a history of infection control deficiencies at the immediate jeopardy level in the last three years
  • Surveys of facilities/hospitals/dialysis centers that have a history of infection control deficiencies at lower levels than immediate jeopardy

While that does narrow down the field somewhat, those last two possibilities might be well-served by digging out any survey reports from the past couple of years to see if there are any IC-related issues lurking in the weeds.

According to the information provided to surveyors, the aim is to keep on-site survey time to no more than two days, with a particular focus on (you guessed it!) infection control, particularly as it relates to COVID-19 preparedness. You can see the meat and potatoes of the CMS memos to providers here:

https://www.cms.gov/files/document/qso-20-12-allpdf.pdf-1

https://www.cms.gov/files/document/qso-20-13-hospitalspdf.pdf-2

https://www.cms.gov/files/document/qso-20-14-nhpdf.pdf

As a final note for this week’s entertainment, our friends at ASHE have dedicated a webpage to provide COVID-19 information and resources; some of the materials require membership to access, but this is probably another page you’ll want to visit regularly as the next few weeks unfold.

Identifying issues and finding solutions…

…versus identifying issues and pointing fingers.

I think we can all agree that (at least for the moment) our friends in the regulatory survey services world have misplaced the location of their customers and, as a result, have become significantly more punitive in administering the survey process. Of course, the accreditation survey team always tells organizations that, despite the umpty-ump number of findings, they are a quality organization and really, this was a good survey. I have yet to hear of any instances in which the survey team “supported” anything other than a positive vibe, but it seems that, in growing numbers, that vibe is not really translating past the point of the exit conference.

Now, I know that it is not the role of the accreditation organizations to do anything more than identify deficiencies (I have hopes that a more consultative approach will re-emerge before too long, but I am not holding my breath), but what I keep bumping into are instances in which the folks (internal and external to an organization) charged with preparing organizations for survey are almost as punitive in their administration of the survey prep process. The purpose of environmental rounding/touring, etc., is to help folks become as prepared as possible and to identify strategies for sustaining compliance. It is not about the “gotcha,” with follow-up paperwork. My personal philosophy (as a safety professional in general, but certainly as a consultant) is that my obligation to the process is to help get things going in the right direction, even to the point of cleaning up a spill or picking something up off the floor while touring. Certainly, I can (and do) identify lots of things that need attention, because there are always lots of things to find that need attention (this goes back to my “no perfect buildings” philosophy; probably too much philosophy for so early in the year, but so be it). But I go into this having suffered at the hands of consultants (and others) who are not as interested in helping work through an issue to achieve some sort of sustainable solution.

As an example, I recently heard about an instance in which the environment of care rounding team had identified a resolution to a pesky issue (in this case, ensuring that specimen containers were appropriately labeled) but did not share that resolution with the entire organization. So last time, a “sticky” label was affixed to the container, but the label didn’t stick so well; this “failure mode” was communicated to the folks in infection control, but there was no immediate follow-up. So, next rounding activity, a specimen container to which a “sticky” label had been affixed was, in the local parlance (not really), nekkid in terms of labeling. Well, after the labeling issue had been cited, it was “revealed” that, after some consideration (may have been careful consideration, but less careful in the communication), it was determined that the containers would be stenciled in more permanent fashion. Interesting thing, the “finding” still required response, etc. even though the “finding” was the result in a communications misfire.

At any rate, as I think I’ve noted here before, there’s no regulatory statute that requires us to shoot ourselves in the foot, or, indeed, to engage in friendly fire. To my way of thinking, internally punitive surveying is not helpful and since we know the “real thing” isn’t particularly helpful (to healthcare organizations, at any rate), doesn’t it make more sense to work together towards sustainable compliance?

Quick closing question: While I was having some lab work done today, I noticed that the emergency eyewash station in the sink area was covered with a clear plastic bag. Has anyone out there in blogland encountered this or are practicing it? I’m thinking that this adds a step to activation of the eyewash station, but perhaps there’s a risk assessment that supports it. Just asking for a friend…

On your marks, get set, sweat!

But hopefully not a Billy Idol kind of sweat…

Our friends in Chicago are once again tweaking the survey process, with the result being less time for surveyors to wait for organizations to muster their troops at the outset and pretty much no time at all before they are out and about doing tracers. Basically, what used to be the surveyor planning session in the morning of the first survey day is now being flipped and combined with the special issue resolution session at the end of the day. For organizations to adapt their process to the changes, folks should be prepared to do the following:

  • Prompt alert of/to the leadership team of any on-site survey to facilitate their availability for a prompt opening conference (I can’t think of too many folks who are not already doing this)
  • Prepare all required documentation and deliver those documents to the survey team immediately after the team is escorted to their “base” (the list of required documents is available in the Survey Activity Guide, although it begs the question as to whether this includes the life safety documentation…)
  • Gather the scribes together so they are ready to hit the pavement as soon as the (ever-so-brief) opening conference is completed

Somehow I think this may all tie across with the folks from CMS accompanying the Joint Commission folks as part of the validation process—anyone who has dealt with a state and/or CMS survey will tell you, there’s not a lot of time (or indeed, inclination) for pleasantries. The job of being prickly requires a lot of inflexibility, which does seem to be the hallmark of the current survey process.

These changes to the survey process are effective March 2020.

Don’t get soaked by your water management program!

I don’t know about you, but lately I’ve been finding the most interesting stuff being published in Perspectives are the articles entitled “Consistent Interpretation” because I am fascinated by the data they are collecting that drives taking particular note of the standard or performance element being featured. For example, the January 2020 issue covers the intricacies of managing the risks associated with waterborne pathogens, a topic that I’ve been keeping an eye on if only because of the attentions paid to that topic by our friends at CMS (if you’ve lost track of where they are in the fray, feel free to make the jump—but don’t forget to come back!). I figure there are just enough peculiarities involved for this to wreak some havoc during accreditation surveys, and while there are ways for survey findings to be generated, it would appear (based on the just under 4% citation rate during the first half of 2019) that you folks out there in the field are making pretty good headway.

So, where things can go awry include: Not having a water management plan to deal with waterborne pathogen risks (not sure how someone would have missed that, but perhaps it was a question of a slower than normal implementation track); failing to include a new piece of equipment (for instance, a brand new cooling tower) in the program (I should think the time for risk assessment and inclusion is during the commissioning of new equipment); failing to maintain the water in the system in accordance with the levels called for in the water management plan; failing to document scheduled testing and monitoring; and failing to establish acceptable ranges and/or control measures to be taken when levels are out of range.

It would seem that decorative water features, ice machines, and water dispensers were in the mix as well, including issues with equipment not being maintained in accordance with the manufacturers’ instructions for use, but in looking at all the different ways water management concerns could be cited, I suspect a lot of the cited conditions (you can find more specifics in the January Perspectives) were not widely observed.

That said, since a lot of the nuts and bolts implementation of water management programs may be accomplished by “others,” I think that going forward, the surveyors will be especially attentive to reviewing your water management plan and any deliverables from testing and monitoring activities. There are a lot of moving parts in this endeavor; best to be ahead of the curve and keep a close eye on those reports.