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Documentary evidence: Sounds like you’re going to have to push a little more paper next survey!

A few weeks ago, our friends in Chicago upped the ante in releasing the updated documentation list for the Life Safety portion of the survey (you can find it—and I really, really, really suggest that you do so sooner rather than later—by logging into your Joint Commission portal and the clicking through the following internal links: > Survey Process, > Survey Activity Guide, > Additional Resources). And this is definitely a case of the list having shifted towards documentation of activities and conditions for which folks have been struggling to get in line. Now, from anecdotal discussions with folks, there’s not always a ton of time available for document review. So, in a lot of instances, the focus is on inspection, testing and maintenance of fire alarm and suppression systems equipment, emergency and standby power supply systems, medical gas and vacuum systems, with some “drift” into fire drills and other more or less standard areas of concern/coverage, including the management plans (sometimes—and those don’t appear to have earned a mention on the updated list).

However, according to that same updated document list, looks like a lot of focus on inventory lists (operating components of utility systems; high-risk operating components on your inventory, infection control components); “embracing” (you can think of that as reviewing and adopting) manufacturer recommendations for inspection, testing and maintenance of utility systems or outlining the Alternative Equipment Maintenance program being used. And the same types of things for medical equipment—inventory, high risk equipment, consideration of manufacturer recommendations, etc. It also appears that there will be focus on sterilizer inspection, testing, and maintenance; compliance of your hyperbaric facilities (if you have them) with Chapter 14 of NFPA 99-2012; testing manual transfer switches in your emergency power supply system. Let’s see, what else…oh yes, for those of you with recently (I’m guessing that pesky July 6, 2016 date is the key point in time) constructed or renovated procedural areas, you need to make sure that you have (and are testing) task lighting in deep sedation and general anesthesia areas (the annual testing requirement is for a 30-minute test).

I’m sure there’s other stuff that will pop to the surface as we move through this next phase of the survey process; I’m curious about how much in-depth looking they’re going to be able to do and still be able to get to the lion’s share of your building (unless they start using unmanned drones…). I’m also curious that they don’t specifically indicate the risk assessment identified in Chapter 4 of NFPA 99-2012 (it has been asked for during CMS surveys), but that may be for the next iteration. Part of me can’t help but think back to those glory days when we wished for adoption of the 2012 Life Safety Code®; I guess we can take full advantage of the operational flexibilities inherent in suite configuration and a couple more things, but it never really seems to get any easier, does it?

At any rate, please hop on your organization’s TJC portal and give the updated list a look. If you see something that gives you hives, sing out: we’re all here to help!

The mystery of the disappearing EP and other tales

I have no way to be certain of the numbers, but I do know of at least one organization that fell victim in 2017 to an Element of Performance (EP) that has since gone “missing.” Once upon a time, EC.02.05.03 (having a reliable emergency electrical source) had an EP (#10, to be precise) that, among other things, required hospital emergency power systems (EPS) to have a remote manual stop station (with an identifying label, natch!) to prevent inadvertent or unintentional operation. (I’m not really sure how a big ol’ stop button that’s labeled would prevent somebody from inadvertently operating the emergency power system; it would surely help if the inadvertent operation happened, but prevention…)

So, to follow this back to the applicable NFPA citation NFPA 110-2010 5.6.5.6, we find “(a)ll installations shall have a remote manual stop station of a type to prevent inadvertent or unintended operation located outside the room housing the prime mover, where so installed, or elsewhere on the premises where the prime mover is located outside the building.” The Explanatory Material goes on to indicate that “(f)or systems located outdoors, the manual shutdown should be located external to the weatherproof enclosure and appropriately identified.” So, that all seems pretty straightforward, don’t you think.

Well, recently (last week) I was working with a hospital that had not bumped into EC.02.05.03, EP 10 and, since I had not yet committed the standard and EP numbers to memory (every time things get changed, I swear to myself that I will not memorize the numbers, but somehow it always ends up happening…), we went to look at the online portal to the standards. And we looked, and looked, and looked some more, and could not find the EP for the remote manual stop. I just figured that I had sufficiently misremembered where this EP, so my plan was to look at survey reports that I know included RFIs for not having the remote manual stops and go from there. So, I looked it up in the survey report, checked the online portal and, guess what? No more EP 10 (in the interest of the complete picture, this EP also requires emergency lighting within 10 seconds at emergency generator locations and a remote annunciator (powered by storage battery) located outside the emergency power system location). Now, from a strict compliance standpoint, as the 2010 edition of NFPA 110 is the applicable code edition based on adoption of the 2012 Life Safety Code® (and I did check the 2013 and 2016 editions, each of which contain the same requirements), I can only guess that the requirements contained in EP 10 are still actionable if your (or anybody else’s) AHJ sees fit to cite a deficiency in this regard, so it’s probably worth keeping a half an eye out for further developments if you have not yet gotten around to installing the lighting, remote stop, and annunciators for your emergency power system equipment locations.

Also, just to alert you to (yet) another offering from ECRI, this past week saw the unveiling of the Top 10 Patient Safety Concerns (download the white paper here). There are a few items on the list that should be of interest to you folks (in bold):

  1. Diagnostic errors
  2. Opioid safety across the continuum of care
  3. Care coordination within a setting
  4. Workarounds
  5. Incorporating health IT into patient safety programs
  6. Management of behavioral health needs in acute care settings
  7. All-hazards emergency preparedness
  8. Device cleaning, disinfection, and sterilization
  9. Patient engagement and health literacy
  10. Leadership engagement in patient safety

I haven’t delved too much into the latest emergency preparedness stuff (ECRI’s take, as well as the Johns Hopkins report), but I’ve queued that up on my reading list for this week, just as soon as I dig out from our most recent wintry spectacular—currently raging outside my window, so I’m going to send this on its way before the power gets too dodgy…

You don’t have to be a weather(person)man to tell: Kicking off survey year 2018!

Your guess is as good as mine…

Just a couple of brief items (relatively—you know how I do go on, but I will try) of interest. I don’t know that there’s a common theme besides an effort to anticipate in which direction the survey winds might blow in 2018:

  •  Previously in this space, I’ve mentioned the work of Matt Freije and his team at HCInfo as they have done yeoman’s (yeoperson’s?) work in the field of water systems management and the “fight” against In response to last year’s letter of intent by CMS to take a more focused look at how hospitals and nursing homes are providing appropriately safe water systems for their patients, Mr. Freije has developed a checklist to help folks evaluate their current situations and has posted the checklist online for comment, suggestions, etc. I’m having a hard time thinking that this might not become something of a hardship for folks arriving late to the party, so if you’ve not yet embraced poking around this subject (and even if you have), you’d do well to check out the checklist.
  •  A couple of inspection items relative to the ongoing rollout of the various and sundry changes wrought by the adoption of the 2012 Life Safety Code®, some of which have yet to migrate in detail to the accreditation organization publications (at least the ones that I’ve seen), but have popped up during recent CMS surveys:
    • Make sure you fire alarm circuit breakers are clearly marked in red (check out NFPA 72 10.5.5.2 for the skinny on this).
    • Make sure your ILSM/fire watch policy/process reflects the appropriate AHJs—you need to make sure that you know for sure whether your state department of public health, et al, want to be notified. They do in California, and probably elsewhere.
    • In NFPA 25, chapters 5 and 13 indicate some monthly inspections of gauges, valves for condition, appropriate position (open or closed) and normal pressures—again, they’re not specifically listed in the accreditation manuals yet, but I suspect that they’ll be coming to a survey report near you before too long.
    • A final note for the moment in this category, NFPA 70 (2011 edition) 400.10 indicates that “flexible cords and cables shall be connected to devices and to fittings so that tension is not transmitted to joints of terminals.” Keep an eye on power strips, particularly in your IT and communications closets for those dangling power strips (and some of them aren’t so much dangling as they are pulled across open spaces, etc. I suspect you know what I mean.) I know the folks who manage this stuff think that we are just being pains in the butt, but now you may have a little codified leverage.
  •  In my post a couple of weeks ago, I don’t think I played the personal protective equipment (PPE) card with sufficient gravity; part of folks’ understanding of the hazards of using chemicals is recognizing the importance of actually using appropriate PPE as identified on the product SDS. When you think about it, the emergency eyewash station is not intended to be the first line of defense in the management of exposures to chemical hazards, but rather what happens when there is an emergency exposure. If the use of PPE is hardwired into the process, then the only time they’ll need to use the eyewash equipment is when they do their weekly testing. At that, my friends, is as it should be.

 

An invitation to the regulatory dance—and the band keeps playing faster…

About a year ago, we chatted a bit about the likely changes to the regulatory landscape under a new administration, most of which (at least those related to the changing of the guard) never really materialized to any great extent. But one thing held true—and continues as we embark upon the good ship 2018—the focus on management of the physical environment is very much at the forefront of preparatory activities.

We also chatted a bit about The Joint Commission’s previous exhortations to healthcare leaders to focus more attention on the management of the physical environment (I was going to provide a link to TJC’s leadership blog regarding our little world, but it appears that the page is not so easily found, though I’m sure it has nothing to do with revisionist history…). But it does appear that there’s no reason to think that the number (and probably types) of survey findings in the environment are going to be anything but steady, though hopefully not a steady increase. Remember, we still have two years in the survey cycle before everyone gets to have undergone their first survey with the loss of the rate-based performance elements.

Which brings us squarely to 2018 and our continuing storm of regulatory challenges; I had made a list of stuff that I believed would play some role of significance in 2017 and (strangely enough) appear to be poised to do the same in the coming year (or two…or three?!?):

 

  1. Physical environment standards remain among the most frequently cited during TJC surveys (Nine of the 10 most frequently cited standards for the period January through June 2017). Please check out the September 2017 issue of Joint Commission Perspectives for the details! Just so you know (and I do believe that I’ve mentioned this in the past), I “count” IC.02.02.01 as a physical environment standard. Yes, I know it’s under the Infection Control chapter, but disinfection, the management of equipment and supplies? That all happens in the environment!
  2. CMS, in its report card to Congress, identified the physical environment as the largest “gap” of oversight during all accreditation organization surveys
  3. Also in its report card to Congress, CMS singled out TJC as lagging behind its competition when it comes to improving identification of deficiencies relative to the Conditions of Participation. I firmly believe that the report card to Congress was the proverbial “spark” that fanned the flames of regulatory focus in the environment. I don’t know when we can expect an updated edition of the report card (I suspect that it may be a while), but knowing that CMS is “concerned” can only mean continued focus…
  4. CMS adoption of the 2012 Life Safety Code® (effective survey date of November 1, 2016) definitely did create some level of confusion and uncertainty that always accompanies “change.” And 2017 demonstrated very clearly that it’s not just “us” that have to learn the practical application of the new stuff—the surveyors have to catch up as well! I am definitely starting to see the impact of the adoption of the 2012 Health Facilities Code (NFPA 99)—if you don’t have a copy in your library, it might just be time.
  5. TJC is in the process of revising its Environment of Care and Life Safety chapters to more closely reflect CMS requirements. January 2018 continues the rollout of the standards/performance elements updates—and they’re still not done. As we’ve discussed over the last few weeks, there’s still a lot of shifting requirements (some we always knew were in place, others merely rumored).
  6. Recent TJC survey reports indicate an increasing focus (and resulting vulnerabilities) on outpatient locations, particularly those engaging in high-level disinfection and/or surgical procedures. The physical environment in all areas in which patients receive care, treatment, and services are generating up to 60% of the total physical environment findings in recent surveys. That was just as true in 2017 as in 2016—each care location in the organization has to be prepared for multi-day scrutiny.
  7. CMS published its final rule on Emergency Preparedness (including Interpretive Guidelines, effective November 2016, with full implementation of requirements due November 2017). While organizations in compliance with current TJC Emergency Management standards will be in substantial compliance with the new rule, there will be some potential vulnerabilities relative to some of the specific components of the rule. The key sticking points at the moment appear to relate to the Continuity of Operations Plan (COOP) and the processes for delegating authority and leadership succession planning during extended events.
  8. Introduction of TJC’s SAFER matrix, which did indeed result in every deficiency identified during the survey process being included in the final survey report. Formerly, there was a section called Opportunities For Improvement for the single findings that didn’t “roll up” into a Requirement For Improvement. With the SAFER matrix, everything they find goes into the report. And there did seem to be a preponderance of findings “clustered” (make of that descriptor what you will) in the high risk sections of the matrix.
  9. As a final “nail” in the survey process coffin, effective January 2017, TJC will no longer provide for the clarification of findings once the survey has been completed. While this didn’t result in quite the devastation in the process as it might have first appeared (mostly because I think it forced the issue of pushing back during the survey), it also appears that clarification only during survey was not the hard line in the sand it appeared to be when this first “dropped.” That said, there very definitely seems to be a reluctance on the part of the folks at the Standards Interpretation Group (SIG) to “reverse the call on the field” once the survey team has left the building; just as there is a reluctance to vacate physical environment findings once the LS surveyor has hit the bricks. If you feel that a finding is not valid, there is no time like the present when it comes to the pushback.
  10. One unexpected “change” during 2017: The focus on ligature risks in the various environments in which behavioral health patients receive care, treatment, and/or services. We’ve discussed the particulars fairly extensively in this space and while I didn’t see it “coming,” it has certainly leaped to the top of the concern pile. The recent guidance from the regulators has (perhaps) helped to some degree, but this one feels a lot like the focus on the procedural environment over the past couple of years. I don’t think they’re done with this by any stretch…

 

In my mind, still working from the perspective of CMS calling out the physical environment as an area of concern, the stuff noted above indicates the likely result that the next 12-24 survey months will show a continued focus on the physical environment by the entire survey team (not just the Life Safety surveyor) and a likely continued plateau or increase in findings relating to the physical environment. I still believe that eventually the regulatory focus will drift back more toward patient care-related issues, but right now the focus on the physical environment is generating a ton of findings. And since that appears to be their primary function (generating findings), there’s always lots to find in the environment.

As I like to tell folks (probably ad nauseum, truth be told), there are no perfect buildings/environments, so there’s always stuff to be found—mostly fairly small items on the risk scale, but they are all citable. The fact of the matter is that there will be findings in the physical environment during your next survey, so the focus will shift to include ensuring that the corrective action plans for those findings are not only appropriate, but also can demonstrate consideration of sustained compliance over time. Preparing for the survey of the physical environment must reflect an ongoing process for managing “imperfections”—not just every 36 (or so) months, but every day.

But I never wave bye-bye: Closing out 2017 with some LSC goodies…

As noted last week, this week’s foray looks into the changes to the Life Safety chapter that will be onboarding at the turn of the new year (the details can be found here). I think (for the most part), there is nothing particularly earth-shattering in the new requirements: really just a mix of updating the NFPA standards edition numbers, some increased granularity relative to fire alarm systems, and a couple of opportunities for some quick risk assessments/evaluations to ensure that what you had is not going to get you into survey difficulty. Also (and I guess only time will tell us how important this is going to be), it is important to continue to monitor the practical applications of Chapter 43, especially when one is in the throes of changing utilization to the point of a shift in occupancy classifications. My not-insubstantial gut tells me that this has great potential for consternation in the field, including the ongoing impact of inconsistent (bordering on draconian) interpretations. Certainly some of the granularity indicated below will lessen some of the over-interpretation woes (definitive reads on square footage should help), but those hard lines drawn in the sand can also represent some challenges as you are planning and executing renovation, etc., projects. In my experience, there aren’t too many projects that remain the same (in terms of scope) through the design and build phases, so you may find yourself paying more attention to expanding project footprints.

And so:

LS.02.01.10

  • Building undergoing change of use or occupancy must be in compliance with 101-2012:43.7 (certain exceptions, as always, apply); likewise, any additions must comply with the requirements for new.
  • Any of you with non-sprinklered smoke compartments undergoing major rehabilitation are putting sprinklers in (I hope); major rehabilitation involves more than 50% of the area of the smoke compartment or 4500 square feet—whichever comes first.
  • Multiple occupancies in a building must observe the most stringent occupancy requirements—so keep those occupancy separations well-defined and tight; also, outpatient surgical departments must be classified as ambulatory healthcare regardless of the number of patients served. Those of you at organizations considering going to provider-based models need to keep those surgical procedure locations under close watch.

 

LS.02.01.20

  • Make sure your horizontal sliding doors that are not automatic closing are limited to a single leaf and have a latch or other mechanism to prevent the door from rebounding; also, there are some specific requirements for horizontal doors serving an occupant load of 10 or fewer, including operability from either side without special knowledge or effort and a couple other things. 101-2012: 18/19.2.2.2.10.2 will help you with the details.
  • Make sure that every corridor provides access to at least two approved exits; no passing through any intervening rooms or spaces other than corridors or lobbies.
  • Have you included a look at door widths in your ongoing rated door program? Existing exit access doors have to be at least 32 inches in clear width, though you can hold on to your 28-inch doors if you’re not evacuating by bed, gurney, or wheelchair. New exit access doors have to be at least 41½ inches in clear width (psych hospitals have to be at least 32 inches wide). Doors not subject to patient use, exit stairway enclosures or serving newborn nurseries can hold the line at 32 inches. Door pairs with an inactive leaf must have the inactive leaf secured with automatic flush bolts. There are a few other pieces of this, so make sure you transfer/transmit the particulars to the folks inspecting the doors.
  • Existing exit access doors and exit doors are of the swinging type and are at least 32 inches in clear width. Exceptions are provided for existing 34-inch doors and for existing 28-inch doors where the fire plan does not require evacuation by bed, gurney, or wheelchair.
  • Travel distances to exits are measured in accordance with NFPA 101-2012: 7.6.

 

LS.02.01.30

  • Laboratories using quantities of flammable, combustible, or hazardous materials that are considered a severe hazard are in accordance with NFPA 101-2012: 8.7 and NFPA 99 requirements. I’m thinking most of you are probably not in position of severe hazardousness, but if you’re thinking what I’m thinking, a little risk assessment should solidify any of the particulars.

 

LS.02.01.34

  • Make sure your fire alarm system is up to snuff relative to the applicable requirements of NFPA 70 National Electric Code and NFPA 72 National Fire Alarm Code—probably worth a conversation and some verification by your fire alarm inspection, testing, and maintenance folks. This includes a more than passing familiarity with placement and types of devices, ensuring an alternative power supply for alarm systems, etc. Make sure that manual and automatic initiation of the fire alarm system is in accordance with the noted requirements, including pull stations. Also, make sure your alarm zones are not larger than 22,500 square feet (for some reason, I think that this might provide some angst for folks…) and spaces open to corridors are provided with appropriate smoke detection.

 

LS.02.01.50

  • Make sure that any spots containing equipment using gas or gas piping are up to snuff with NFPA 54 National Fuel Gas Code and electrical complies with NFPA 70. You can maintain existing installations that are not fully compliant as long as there are no life-threatening hazards.
  • Make sure those pesky heating devices are in appropriate compliance—with both code and your organizational policy.
  • Equipment using gas or gas piping complies with NFPA 54-2012, National Fuel Gas Code; electrical wiring and equipment complies with NFPA 70-2012, National Electric Code. Existing installations can continue in service provided there are no life-threatening hazards.
  • If you have fireplaces in your facility, there are specific considerations, including carbon monoxide detection; 101-2012: 9.2.2 will give you the lowdown.
  • 101-2012 9.4 will get you the straight dope on escalators, dumbwaiters, and moving walks—and don’t forget to consult ASME/ANSI A17.1 for new and ASME/ANSI A17.3 for existing equipment.

 

LS.02.01.70

  • If you’re hanging draperies, curtains (including cubicle and shower curtains), and loosely hanging fabric in non-sprinklered compartments, then 101-2012: 10.3.1 is the compliance source. Of course, if you have sprinklers, there are exceptions…
  • No sprinkler protection? Upholstered furniture purchased on or after July 5, 2016 must meet Class 1 or char length and heat release criteria—101-2012: 10.3.2.1 and 10.3.3; mattresses purchased on or after 7/6/2016 must meet 101-2012 10.3.2.2 and 10.3.4
  • If you have a new engineered smoke control system, it must be tested in accordance with NFPA 92-2012, Standard for Smoke Control Systems. If you have an existing engineered smoke control system, it must be tested in accordance with established engineering principles.

 

Since I don’t want you to be completely comatose for your New Year’s celebrations, I will cover the ambulatory occupancy changes sometime in January (please feel free to prod me if you’d rather I do it sooner than later). And on that note, I wish each and every one of you safe celebrations and a most prosperously compliant New Year!

On the nth day of Christmas, CMS gave to me: Ligature risks revisited

As you will no doubt recall, back at the beginning of November, The Joint Commission released guidance relative to survey expectations and ligature risks, splitting things into guidance for behavioral health units/hospitals and then some separate items for expectations in non-behavioral health settings (emergency departments, inpatient units). The information release indicated that there were some folks from CMS involved in the (what will apparently be ongoing) discussion on what healthcare organizations can expect over the next little while as the challenges of managing all variations of the behavioral health patient population. What wasn’t clear at the time (at least to me—and it’s still not) was whether CMS’ participation in that process could be interpreted as an at least tacit endorsement of the guidance statements.

And now (well, this past week), CMS issued its own thoughts relative to its expectations, including indication that more will be forthcoming (in approximately six months’ time, so let’s just say sometime next summer). The Survey & Certification memorandum outlines the current slate of expectations (yours and theirs), starting with the pretty much unassailable notion that: “Ligature risks compromise Psychiatric Patients’ right to receive care in a safe setting.” I think we can all agree that that is a reasonable assertion with which to start a conversation.

The memo also goes on to outline the CMS definition of a ligature risk: “(a) ligature risk (point) is defined as anything which could be used to attach a cord, rope, or other material for the purpose of hanging or strangulation. Ligature points include shower rails, coat hooks, pipes, and radiators, bedsteads, window and door frames, ceiling fittings, handles, hinges and closures.” For me, the only surprise was that the example list didn’t say “include, but are not limited to.” I’m used to the regulatory rapscallions leaving themselves an “out” when it comes to this kind of stuff. While the list is pretty comprehensive, I think it stops a little short of all-inclusive, but perhaps as a function of the designated behavioral health environment, it will do. Which leads to the next highlight: this particular guidance is “primarily aimed at Psychiatric units/hospitals.” I guess that means that guidance for non-BH areas like regular emergency departments and acute-care hospital inpatient units that might have to manage behavioral health patients—maybe in the summer, but not really clear on that. It will be interesting to see how future guidance will dovetail (or not) with the TJC stuff.

So, as we wait for the next installment, it appears that it will be left in the hands of the folks on the ground (CMS regional offices, state survey agencies, accreditation organizations) to “the identification of ligature and other safety risk deficiencies, the level of citation for those deficiencies, as well as the approval of the facility’s corrective action and mitigation plans to minimize risk to patient safety and remedy the identified deficiencies.” At least for the moment, we know how TJC is going after this issue, but everything else is somewhat in the land of gray.

A couple of other items covered include time frame for correction of deficiencies (you have to fix things in the time frame identified by the surveying body, unless it is determined that it is not reasonable to expect compliance within the designated time frame, then only CMS can grant additional time for correction); the specific direction that ligature risks do not qualify for Life Safety Code® (LSC) waivers (because ligature risks are not LSC deficiencies); and if you do get to take additional time for corrective actions, monthly electronic progress reports—including substantiating evidence of progress towards compliance—will be the task. It would seem that the monthly check-in, particularly as a function of providing “substantiating evidence of progress” will help to keep the fires of progress burning bright in the hearts and minds of folks charged with making the necessary corrections. As a function of that, I’ve heard of some anecdotal accounts of surveyors indicating that there is a six-month grace period for corrective actions as long as you can substantiate that the corrections will take that long, but the word from Chicago is that is not the case. I have certainly witnessed long lead times for procurement of ligature-resistant door hardware and such, but that’s not enough to delay the reporting of progress process.

The Survey & Certification memorandum includes an attachment that outlines the current guidance to surveying agencies/organizations. I would encourage you all to give that a thorough look-see (and perhaps a dramatic reading instead of the traditional “’Twas the night before Christmas”—bet it puts the kiddies to sleep PDQ). Doubtless, I will weigh on some of the particulars as they leap out at me (much like those leaping lords) in the coming weeks, but I think I’ve gone on long enough for the moment. That said, I will leave you with these two passages from the guidance attachment:

  •  “In order to provide care in a safe setting, hospitals must identify patients at risk for intentional harm to self or others, identify environmental safety risks for such patients, and provide education and training for staff and volunteers.”

 

  • “Although all risks cannot be eliminated, hospitals are expected to demonstrate how they identify patients at risk of self-harm or harm to others and steps they are taking to minimize those risks in accordance with nationally recognized standards and guidelines.”

Certainly nothing we haven’t talked about in the past in regards to an endless supply of subjects, but kind of interesting to see this included in a missive from the palace…

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

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

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

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

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

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

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

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

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

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

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

SECTIONS 18.2.3.4 AND 19.2.3.4—CORRIDORS

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

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

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

If brevity is the soul of wit…

Hope everyone enjoyed a festive and (most importantly) safe Independence Day—with any luck, today (July 5) does not mark the end of summer (as some do say) so much as it marks the beginning of the end of spring (up here in the Northeast, spring was loath to depart, but it does seem that pre-autumn weather has finally made a commitment to spending some time in the northern hemisphere).

I was looking recently at past blog posts for a reference to the CMS stance on law enforcement interactions with patients as a function of restraints and patient rights—always a fun topic—and I noted that the posts used to be a mite briefer than tends to be the case of late. (You can be the judge of whether my decline in brevity has left me soulless or witless.) I absolutely recognize that there’s been a lot of stuff to cover over the past 18 months with the firestorms of compliance that swept the healthcare environment, which has (no doubt) promoted some of the “volume” of bloggery. But it has caused me to wonder whether I am consuming the compliance elephant in sufficiently small bites to be of use to you folks out there in the field. As near as I can tell, the purpose of this whole thing (as much as I enjoy having a place to pontificate) is to provide information and thoughts on what is happening at the moment to you, my faithful audience of safety folk. And (as near as I can tell) it never hurts to ask one’s audience whether this works for you—please feel free to give me an e-dope slap if you think the “Space” has gone intergalactic in a less-than-useful way. At any rate, I am going to experiment with smaller bites of information in the coming weeks so you’ll have more time for other things—perhaps outdoors…

As far as news goes, things are relatively quiet as we observe the anniversary of CMS’s adoption of the 2012 Life Safety Code. Hopefully you all have done your NFPA 99 risk assessments; polished off those door inspections and are speeding towards the completion of activities relating to initial compliance with the Emergency Preparedness Final Rule. Health Facilities Management This Week discussed some prepublication EC/LS standards relating to the testing of emergency lighting systems; inspection and testing of piped medical gas and vacuum systems; and updating pertinent NFPA code numbers. The pre-pub stuff is aimed at behavioral health care, laboratory, nursing care center, and office based surgery accreditation programs. You can find the details here: https://www.jointcommission.org/prepublication_standards_%E2%80%93_standards_revisions_to_environment_of_care_and_life_safety_chapters_related_to_life_safety_code_update_/

(I guess some of those links are about as brief as I am…)

Thanks, as always, for tuning in—I really appreciate having you all out there at the other end of the interweb…see you next week!

Point the finger (doesn’t matter which)

Or extend your hand?

First up, as a general rule of thumb (which could be one of the pointed fingers represented above, unless you don’t think a thumb is a finger), when CMS identifies an implementation date that is in the future, I think that we can safely work towards being in full compliance with whatever the Cs are implementing—on that implementation date. Apparently there’s been enough confusion (not really sure who may or may not have been confused, but sometimes it’s like that) for CMS to issue something of a clarification as to what is expected to be in place by November 15, 2017, which means education and exercises (and any other pesky items in your EM program that didn’t quite synch up with the final rule on emergency preparedness for healthcare organizations). Since this is very much brave new world territory when it comes to how (though perhaps the correct term would be “how painfully”) CMS is going to administer the final rule as a function of the survey process. I think it initially, unless we hear something very specific otherwise, means that we need to be prepared to meet the full intent of the language (making sure that you have trained/educated “all” staff; making sure that you participated in a community-wide exercise of some level of complexity) until these things start to sort out. My gut tells me that if they were going to engage in any more exculpatory/explanatory/clarifying communications, it would have been included in the above-noted transmission. And while I have little doubt that there will be some variability (states do not necessarily coordinate response) as to how this all pans out in the field, the education of “all” staff and participation in the communitywide exercise deal seem to be pretty inviolable. Certainly there have been instances in the past in which healthcare organizations have struggled to coordinate exercises with the local community(s), but my fear is that if you fall short on this, you will need to have a very compelling case of why you weren’t able to pull off a coordinated exercise. Community finances and fiscal years and local emergency response hegemony are all contributing factors, to be sure, but where you could “sell” that as a reason for not dancing with the locals to some of the accreditation organizations, I’m thinking that (as is usually the case) reasonableness and understanding might not be the highlights of any discussion with the feds and those that survey on their behalf. From what I’ve seen in the field, when it comes to CMS and the survey process, you are either in compliance or you are not in compliance and there is very little gray in between. Community drill done—compliant! Community drill not done—not compliant! Wouldn’t it be nice if life were always that simple?

At any rate, just to use this a reminder that the first anniversary of the 2012 Life Safety Code® is coming up—make sure you get all that annual testing and such out of the way—and don’t forget to make sure that all your fire alarm and suppression system documentation includes the correct version of the applicable NFPA code used for testing. I am dearly hoping to retire EC.02.03.05 from the most frequently cited standards ranks and while I fear the worst with this change. (To my mind, getting tagged for having the wrong NFPA year on the documentation would pretty much suck—please excuse my coarse language—but sucking is exactly what that type of finding would do.)