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Like water for opportunistic organisms: Protecting patients through utility systems

As a wise individual once noted, “water always wins” (at risk of betraying my nerd status, you can find the entire quote here), and it seems like water in its numerous forms is giving facilities professionals a run for their money this year. From mold in an OR in the Northwest to the constant battle (or so it seems) with Legionella prevention, this is as challenging a time as I can recall for facilities. And that doesn’t even take into account the ongoing impact of minor intrusions—leaks, condensation, overflowing toilets—it is an almost endless list of troubles.

My intent was to provide the above as information, with my usual encouragement to leverage point-of-care/point-of-service staff in the early identification of trouble spots, but I’m also thinking that perhaps someone out there in the field has been able to develop an effective plan for the proactive management of water woes. Certainly, I know of folks with fairly predictable “rainy seasons” and then there are those locations in which rain is a constant threat, not to mention the intrusion of humidity by various (and sometimes nefarious) means. So, what do you do that works (recognizing that this is not a one size fits all proposition)? Do you have any useful/effective strategies you can share with the blogosphere? I generally only hear about stuff that doesn’t work, so it would be a treat indeed to tout someone’s intuitive brilliance.

As a final note for this week, those of your laboring under the yoke of TJC accreditation might do well to give the August issue of Perspectives a look (it’s become less of a regularly useful read for me, but every once in a while). In the Consistent Interpretation column/article, there’s a lot of discussion (under the guise of the Infection Control standards) of PPE use/availability/education, etc. Again, the findings are falling under the IC standards from a past survey result standpoint, but I don’t think it’s a stretch for some (or almost any) of these to be applied as Hazardous Materials & Wastes Management findings. Again, not everything applies, but I think if we’ve learned nothing else over the years, it’s the funky application of survey concepts from one are of scrutiny to another. Stranger things have happened…

Try to keep things cool over the second half of the summer!

Hanging on in quiet desperation is the safety way: Thought of something more to say!

Recognizing that authorities having jurisdiction (AHJ) always reserve the right to disagree with any decision you’ve ever made or, indeed, anything they (or any other AHJ) have told you in the past, how long are existing waivers, guidance and/or equivalencies good for? Answer: It depends (with more permutations that you can shake a stick at…).

Last week, we chatted a little bit about the whole water management thing, including mention of what CMS is telling surveyors to look for, but I thought it might be useful to extract some of the specifics from that missive (if you missed it last week, it’s here). So, here we have:

Expectations for Healthcare Facilities

CMS expects Medicare and Medicare/Medicaid certified healthcare facilities to have water management policies and procedures to reduce the risk of growth and spread of Legionella and other opportunistic pathogens in building water systems.

Facilities must have water management plans and documentation that, at a minimum, ensure each facility:

  • Conducts a facility risk assessment to identify where Legionella and other opportunistic waterborne pathogens (e.g., Pseudomonas, Acinetobacter, Burkholderia, Stenotrophomonas, nontuberculous mycobacteria, and fungi) could grow and spread in the facility water system.
  • Develops and implements a water management program that considers the American Society of Heating, Refrigerating, and Air-Conditioning Engineers (ASHRAE) industry standard and the CDC toolkit.
  • Specifies testing protocols and acceptable ranges for control measures, and document the results of testing and corrective actions taken when control limits are not maintained.
  • Maintains compliance with other applicable federal, state, and local requirements.

Note: CMS does not require water cultures for Legionella or other opportunistic waterborne pathogens. Testing protocols are at the discretion of the provider.

Healthcare facilities are expected to comply with CMS requirements and Conditions of Participation to protect the health and safety of its patients. Those facilities unable to demonstrate measures to minimize the risk of LD are at risk of citation for noncompliance.

Expectations for Surveyors and Accrediting Organizations

Long-term care (LTC) surveyors will expect that a water management plan (which includes a facility risk assessment and testing protocols) is available for review but will not cite the facility based on the specific risk assessment or testing protocols in use. Further LTC surveyor guidance and process will be communicated in an upcoming survey process computer software update. Until that occurs, please use this paragraph as guiding instructions.

Just so you know, I chose to use some of the text in bold font because I think that’s probably the most important piece of this for folks moving forward (kind of makes me think that, just perhaps, there have been citations for folks not actively pursuing water cultures). But it does establish the expectation that a piece of the required risk assessment is going to include something that relates to whether you choose to culture, how often, and how you came to make that determination. I think this helps folks manage some of the ins and outs of this process, but I still feel like this could end up being a source of consternation as surveyors “kick the tires” in the field.

 

Wagging the dog: Can Accreditation Organizations influence each other?

In last week’s issue of HCPro’s Accreditation Insider, there was an item regarding the decision of the folks at the Healthcare Facilities Accreditation Program (HFAP) to update their Infection Control standards for acute care hospitals, with the intent of alignment with CMS expectations (you can find the article here) We’ve certainly covered the concerns relative to Legionella and the management of risks associated with aerosolizing water systems and this may only be a move to catch up on ground already covered by other accreditation organizations (our friends in Chicago already require the minimization of pathogenic biological agents in cooling towers, domestic hot- and cold-water systems, and other aerosolizing water systems), but I’m thinking it might also be something of a “tell” as to where survey focus might be drifting as we embark upon the second half of 2018. Certainly, waterborne pathogens are of critical importance to manage as a function of patient vulnerability (ideally, we want folks to get better during their hospital stays), so it makes perfect sense for this to be on the radar to some degree. At this point, the memorandum from CMS outlining their concerns has been with us for about a year, with an immediate effective date, so hopefully you are well-entrenched in managing those water systems. If this one is still on your to-do list, I think it’s probably advisable to making it a priority to get it to your “to-done” list. But you should definitely check out the latest “clarification” from CMS. While the memo indicates that this does not impose any new expectations or requirements, it does make it a little clearer as to what surveyors are supposed to be checking.

As I think Mr. Gershwin once opined about summer and the easiness of living, it would be nice to be able to set a spell and take one’s shoes off, but vigilance is always the order of the day.

On a somewhat lighter note, I just finished reading Our Towns – A 100,000 Mile Journey Into The Heart of America, which outlines the efforts of a number of (mostly smallish) municipalities across the United States in positioning themselves for a positive future (positive positioning—I kind of like that). The focus is mostly on the socioeconomics of different parts of the country, with a focus on how diversity can be employed in bettering a community (that’s probably a little ham-handed as a descriptor, but you can find an excerpt here if you like). As my work allows me to travel to a lot of places, while I haven’t been to a lot of the same destinations as the Fallows, I do recognize a lot of the stories and a lot of the challenges facing folks lately (and I think you might, too). I would describe the tone of the book as hopeful, so if you’re looking for something to read at beach/pond/summer cottage, etc., you might consider giving Our Towns a shot.

 

We hold these truths…

In the wake of the high-rise fire in London a few weeks ago, those of you with high-rise facilities are probably going to experience some intensified attentions from your local fire folks (it’s already started in Houston). Any time there is a catastrophic fire with loss of life, it tends to result in an escalation in the interests of the various AHJ’s overseeing fire safety. While I suspect that your facilities are not at risk to the extent the conditions at the Grenfell Tower appear to have been, it is very likely that your locals are going to want to come out and kick the tires a little more swiftly/demonstrably than they have in the past. And, since we are responsible for a fair number of folks who are not (or at least less than) capable of getting themselves out in a fire, I think there is a very strong possibility that scrutiny will extend to non-high-rise facilities as well. I think we can say for pretty much certain that the regulatory folks probably didn’t miss this as a news story, and it’s not a very big leap to want to apply any lessons learned to how their areas of responsibility would fare under intensified scrutiny.

As a related aside, one of the challenges that I periodically face in my consulting engagements is the pushback of “it’s always been like this and we’ve never been cited” or something similar. My experience has been that a lot of times, the difference between a good survey and a not-so-good survey can be the surveyor taking a left turn instead of a right, etc. We have certainly covered the subject of imperfect buildings and how to find them (they are, after all, everywhere you look), so I won’t belabor the point, but this probably means that the focus on the physical environment is going to continue apace, if not (and I shudder at the thought) more so. We’ve got a lot of work ahead of us, folks—let’s get those sleeves rolled up!

Finally, as a head’s up, there’s going to be a webinar in August hosted by HC Info on strategies for meeting the CMS guidance (almost makes it sound helpful, doesn’t it) relative to the management of legionella risk that we covered a few weeks back. (Apparently space is limited, so you might want to get right on this: http://hcinfo.com/legionella-compliance.)

Something (nothing official, just an intense feeling) tells me that this is likely going to be a significant survey focus over the next little while, so I’m in favor of gathering as much expert information, etc. as possible. Again, while I have no reason to think that most folks are not appropriately managing these types of risks, I also know that the survey expectation bar appears to have been raised to an almost impossible-to-attain level. To echo the motto of the Boy Scouts—Be Prepared!

Is this the survey we really want?

Moving on to the type of pain that can only be inflicted at the federal level, a couple of things that might require an increase in your intake of acid-reducing supplements…

As it appears that CMS doesn’t love that dirty water (and yes, my friends, that is a shameless local plug, but it is also a pretty awesome tune), now their attentions are turning to the management of aerosolizing and other such water systems as a function of Legionella prevention. Now, this is certainly not a new issue with which to wrestle, which likely means that the aim of this whole thing, as indicated in the above notification—“Facilities must develop and adhere to policies and procedures that inhibit microbial growth in building water systems that reduce the risk of growth and spread of Legionella and other opportunistic pathogens in water”—is something with which we are abundantly familiar. But I will admit to having been curious about the implied prevalence in healthcare facilities as that’s the type of stuff that typically is pretty newsworthy, so I did a quick web search of “Legionella outbreaks in US hospital.” I was able to piece together some information indicating that hospitals are not doing a perfect job on this front, but the numbers are really kind of small in terms of cases that can be verifiably traced back to hospitals. When you think about it, the waters could be a bit muddy as Legionella patients that are very sick are probably going to show up at your front door and there may be a delay in diagnosis as it may not be definitively evident that that’s what you’re dealing with. At any rate, sounds like a zero-tolerance stance is going to be, but the Survey & Certification letter does spell out the instructions for surveyors:

Surveyors will review policies, procedures, and reports documenting water management implementation results to verify that facilities:

 

  • Conduct a facility risk assessment to identify where Legionella and other opportunistic waterborne pathogens (e.g., Pseudomonas, Acinetobacter, Burkholderia, Stenotrophomonas, nontuberculous mycobacteria, and fungi) could grow and spread in the facility water system.
  • Implement a water management program that considers the ASHRAE industry standard and the CDC toolkit, and includes control measures such as physical controls, temperature management, disinfectant level control, visual inspections, and environmental testing for pathogens.
  • Specify testing protocols and acceptable ranges for control measures, and document the results of testing and corrective actions taken when control limits are not maintained.

I have little doubt that you folks already have most, if not all, of this stuff in place, but it might not be a bad idea to go back and review what you do have to make sure that everything is in order. And if you are interested in some of the additional information (including some numbers) available, the following links should be useful:

Moving on to the world of emergency management, during the recent webinar hosted by CMS to cover the Emergency Preparedness final rule, one of the critical (at that time, more or less unanswered) questions revolved around whether we could expect some Interpretive Guidelines (basically, instructions for surveyors in how to make their assessments) for the EP Final Rule. And to what to my wondering eyes should appear, but those very same Interpretive Guidelines.  I will feely admit that the setup of the document is rather confusing as there are a lot of different types of providers for which the Final Rule applies and not all the requirements apply to all of the providers, etc., so it is a bit of a jumble, to say the least. That said, while I don’t think that I am sufficiently well-versed with the specific EM requirements of the various and sundry accreditation organizations (HFAP, DNV, CIHQ, etc.), I can say that those of you using TJC for deemed status purposes should be in pretty good shape as it does appear that one of the early iterations of the TJC EM standards was used in devising the Final Rule, so the concepts are pretty familiar.  A couple of things to keep in mind in terms of how the CMS “take” might skew a little differently are these:

 

  • You want to make sure you have a fairly detailed Continuity of Operations Plan (CoOP); this was a hot button topic back in the immediately post-9/11 days, but it’s kind of languished a bit in the hierarchy of emergency response. While the various and sundry performance elements in the TJC EM chapter pretty much add up to the CoOP, as a federal agency, it is likely that CMS will be looking for something closer to the FEMA model (information about which you can find here), so if you have a CoOP and haven’t dusted it off in a while, it would probably be useful to give it the once over before things start heating up in November…
  • As a function of the CoOP, you also want to pay close attention to the delegation of authority during an emergency, primarily, but not exclusively the plan of succession during an emergency (I found the following information useful and a little irreverent—a mix of which I am quite fond). It does no good at all for an organization to be leaderless in an emergency—a succession plan will help keep the party going.
  • Finally, another (formerly) hot button is the alternate care site (ACS), which also appears to be a focus of the final rule; the efficacy of this as a strategy has been subject to some debate over the years, but I think this one’s going to be a source of interest as they start to roll out the Interpretive Guidelines. At least at the moment, I think the key component of this whole thing is to have a really clear understanding (might be worth setting up a checklist, if you have not already) of what you need to have in place to make appropriate use if whatever space you might be choosing. I suspect that making sure that you have a solid evaluation of any possible ACS in the mix: remember, you’re going to be taking care of “their” (CMS’) patients, so you’d better make sure that you are doing so in an appropriate environment.

Breathe deep the gathering gloom…

As part of our (seemingly) never-ending quest to find topics of interest for you folks, we turn to the fascinating world of utility systems management, in particular, the management of aerosolizing water systems. As a safety generalist, I am always on the lookout for resources that will help increase my understanding of certain subjects and I try to pass on to you those that I find most useful (particularly over time). That said, I feel I have been somewhat remiss in not alerting you to a resource that I have been following for a fairly long time (it might even extend back to my days as a hospital safety manager—so we’re talking well into the safety Mesozoic era—love those birdsongs!). While the focus is Legionella prevention and education, there’s a lot of information regarding the management of risks associated with the aforementioned aerosolizing water systems—possibly the most risky (in terms of potential impact on patients, staff, and visitors) of the various high-risk utility systems.

The resource of which I am speaking is HCInfo; one of the highlights (at least for me) is that you can sign up for periodic e-mail updates; I find the updates, at the very least, to be thought provoking. The most recent blog posting on the site covers the potential impact on litigation relative to cases of Legionnaire’s disease in the wake of CDC’s release of its guidance for developing a water management program to reduce Legionella in buildings (you can find that august offering here). As noted in the blog entry, the CDC has come up with some very specific recommendations that could very well be the next bludgeon used by our regulatory friends. While the focus of the blog is on the litigious nature of things, there are a couple of take-home messages:

 

  1. “You should develop a water management program to reduce Legionella growth and spread that is specific to your building” (page ii of the CDC toolkit);
  2. “Legionella water management programs are now an industry standard for large buildings in the United States (ASHRAE 188: Legionellosis: Risk Management for Building Water Systems June 26, 2015. ASHRAE: Atlanta).”
  3. “This toolkit will help you develop and implement a water management program to reduce your building’s risk for growing and spreading Legionella.” (page ii of the CDC toolkit)
  4. “Environmental testing for Legionella is useful to validate the effectiveness of control measures.” (page 21 of the CDC toolkit)

 

So, while not quite “marching orders,” there is enough certainty lurking within the pages of the toolkit to push for having some sort of plan in place for the management of your aerosolizing water systems (TJC has had a long-standing requirement to minimize pathogenic biological agents in aerosolizing water systems, the CDC toolkit may increase specific focus on this area). The one area that would seem to represent something of a sea change is the “useful”-ness of environmental testing for Legionella. Back in 2003, when CDC published its Guidelines for Environmental Infection Control in Health Care Facilities, there was just enough wiggle room to more or less dismiss the need to do environmental testing for Legionella (to test or not to test, that is the question—and it appears to hinge on what one might consider due diligence). I think partially due to the amount of bureaucratic language in the recommendations section, the sense was that the regular testing was not only just optional, but not really recommended (again, lots of room for interpretation). The current toolkit language definitely makes the case for testing as a means of validating the effectiveness of your control measures. But (as always appears to be the case), it is up to the individual facility to determine frequency, etc. But there is a way to get to that:

 

One of the key components of the CDC toolkit is (wait for it…) a risk assessment of your facility to help determine the applicable risks in your facility. The question then becomes: how long before our regulatory fiends (oops, friends!) start asking pointed questions about what we’ve been doing in this regard. As always, I provide this as information, but as the survey process continues to evolve (mutate?) in how infection prevention concerns are covered, this one really feels like something we need to button down as soon as possible. No doubt there are those of you who have already embarked upon this journey, so if you have any useful war stories that you could share, I’m sure everyone would benefit from your insight. I think this stands a good shot at being next in the line of hot button survey topics—and it’s an important one. My prediction is that everyone will be in reasonably good stead relative to the recommendations in the toolkit (this could be a very timely—and useful—performance improvement initiative for the EOC Committee), but I would encourage you to take whatever steps are required to be certain that you are in good shape.