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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.)

Do you know the way to TIA?

Last week we touched upon the official adoption of a handful of the Tentative Interim Agreements (TIA) issued through NFPA as a function of the ongoing evolution of the 2012 edition of the Life Safety Code® (LSC). At this point, it is really difficult to figure out what is going to be important relative to compliance survey activities and what is not, so I think a brief description of each makes (almost too much) sense. So, in no particular order (other than numerical…):

  • TIA #1 basically updates the table that provides the specifications for the Minimum Fire Protection Ratings for Opening Protectives in Fire Resistance-Rated Assemblies and Fire-Rated Glazing Markings (you can find the TIA here). I think it’s worth studying up on the specific elements—and perhaps worth sharing with the folks “managing” your life safety drawings if you’ve contracted with somebody external to the organization. I can tell you from personal experience that architects are sometimes not as familiar with the intricacies of the LSC—particularly the stuff that can cause heartburn during surveys. I think we can reasonably anticipate a little more attention being paid to the opening protectives and the like (what, you thought it couldn’t get any worse?), and I suspect that this is going to be valuable information to have in your pocket.
  • TIA #2 mostly covers cooking facilities that are open to the corridor; there are a lot of interesting elements and I think a lot of you will have every reason to be thankful that this doesn’t apply to staff break rooms and lounges, though it could potentially be a source of angst around the holidays, depending on where folks are preparing food. If you get a literalist surveyor, those pesky slow cookers, portable grills, and other buffet equipment could become a point of contention unless they are in a space off the corridor. You can find the whole chapter and verse here.
  • Finally, TIA #4 (there are other TIAs for the 2012 LSC, but these are the three specific to healthcare) appears to provide a little bit of flexibility relative to special locking arrangements based on protective safety measures for patients as a function of protection throughout the building by an approved, supervised automatic sprinkler system in accordance with Originally, this section of the LSC referenced which doesn’t provide much in the way of consideration for those instances (in Type I and Type II construction) where an AHJ has prohibited sprinklers. In that case, approved alternative protection measures shall be permitted to be substituted for sprinkler protection in specified areas without causing a building to be classified as non-sprinklered. You can find the details of the TIA here.


I suppose before I move on, I should note that you’re probably going to want to dig out your copy of the 2012 LSC when looking these over.

As a quick wrap-up, last week The Joint Commission issued Sentinel Event Alert #57 regarding the essential role of leadership in developing a safety culture (some initial info can be found here). While I would be the last person to accuse anyone of belaboring the obvious (being a virtual Rhodes Scholar in that type of endeavor myself), I cannot help but think that this might not be quite as earth-shattering an issuance as might be supposed by the folks in Chicago. At the very least, I guess this represents at least one more opportunity to drag organizational leadership into the safety fray. So, my question for you today (and I suspect I will have more to say on this subject over the next little while—especially as we start to see this issue monitored/validated during survey) is what steps has your organization taken to reduce intimidation and punitive aspects of the culture. I’m reasonably certain that everyone is working on this to one degree or another, but I am curious as to what type of stuff is being experienced in the field. Again, more to come, I’m sure…

In season, out of season: What’s the difference?

…when you don’t know the reason…

Some Joint Commission goodness for your regulatory pleasure!

For those of you in the audience that make use of the online version of the Accreditation Manual, I would implore you to make sure that when you are reviewing standards and performance elements that you are using the most current versions of the requirements. I think we can anticipate that things are going to be coming fast and furious over the next few months as the engineering folks at TJC start to turn the great ship around so it is in accordance with the requirements of the 2012 edition of just about everything, as well as reflecting the CMS Conditions of Participation. To highlight that change, one example is the requirement for the testing of the fire alarm equipment for notifying off-site fire responders (decorum prevents me from identifying the specific standard and performance element, but I can think of at least things that might serve as placeholders, but I digress); the January 1, 2017 version of the standards indicates that this is to occur at a quarterly frequency (which is what we’ve been living with for quite some time), but the January 9, 2017 version indicates that this is to occur on an annual basis, based on the 2010 edition of NFPA 72. In looking at the 2010 edition of NFPA 72, it would appear that annual testing is the target, but I think this speaks to the amount of shifting that’s going to be occurring and the potential (I don’t know that I would go so far as to call it a likelihood, but it’s getting there) for some miscommunications along the way. At any rate, if you use the online tool (I do—it is very useful), make sure that you use the most current version. Of course, it might be helpful to move the older versions to some sort of archived format, but that’s probably not going to happen any time soon.

Speaking of updates, last week also revealed additional standards changes that will be taking effect July 1, 2017 (get the detailed skinny here). Among the anticipated changes are the official invocation of NFPA 99 as guidance for the management of risk; some tweaking of the language regarding Alternative Equipment Management (AEM) program elements, including the abolition (?!?) of the 90% target for PM completion and replacing it with the very much stricter 100% completion rate (make sure you clearly define those completion parameters!); expansion of the ILSM policy requirements to include the management of Life Safety Code® deficiencies that are not immediately corrected during survey (you really have to look at the survey process as a FIFI—Find It, Fix It!—exercise); the (more or less) official adoption of Tentative Interim Agreements (TIA) 1, 2, and 4 (more on those over the next couple of weeks) as a function of managing fire barriers, smoke barriers, and egress for healthcare occupancies; and, the next (and perhaps final) nail in the coffin of being able to sedate patients in business occupancies (also to be covered as we move into the spring accreditation season). I trust that some of this will be illuminated in the upcoming issues of Perspectives, but I think we can safely say that the winds of change will not be subsiding any time soon.

Also on the TJC front, as we move into the 2017 survey year, those of you that will likely be facing survey, I encourage you to tune in to a webinar being presented on the SAFER (Survey Analysis For Evaluating Risk) matrix, which (aside from being transformative—a rather tall order and somewhat scary to consider) will be the cornerstone of your survey reports. We’ve covered some of the salient points here in the past (this is quickly becoming almost very nearly as popular a topic for me as eyewashes and general ranting), but I really cannot encourage you enough to give this topic a great deal of attention over the coming months. As with all new things TJC, there will be a shakedown cruise, with much variability of result (or this is my suspicion based on past experiences)—it is unlikely that this much change at one time is going to enhance consistency or it’s hard to imagine how it would/could (should is another matter entirely). At any rate, the next webinar is scheduled for Tuesday, March 7, 2017; details here.

Please remember to keep those cards and letters coming. It’s always nice to hear from folks. (It almost makes me think that there’s somebody out there at the other end of all those electrons…) Have a safe and productive week as we await the arrival of Spring!


Ring out, solstice bells!

And so we turn again to our perusal of the bounty that is the December issue of Perspectives and that most splendid of pursuits, the Clarifications and Expectations column. With the pending changes to the Life Safety (LS) chapter, it appears that we are in for a sequential review of said chapter, starting at the beginning (the process/program for managing LS compliance within your organization) and (at least for now) moving to a deep dive into the ILSM process in January—so stay tuned!

So let’s talk a little bit about the requirements relative to how the physical environment is designed and managed in such a manner as to comply with the Life Safety Code® (LSC). Previously, there were but four performance elements here: assigning someone to manage the process (assessing compliance, completing the eSOC, managing the resolution of deficiencies); maintaining a current eSOC; meeting the completion time frames for PFIs (did you ever think we would get to a point where we could miss those three letters?); and, for deemed status hospitals, maintaining documentation of AHJ inspections. For good or ill (time, as always, will be the final judge), the number of performance elements has grown to six with a slight modification to some of the elements due to the shift away from the eSOC as one of the key LS compliance documents and the evolution (mutation?) of our friend the Plan for Improvement into the Survey-Related PFI. With greater numbers of performance elements, I guess there will be a subsequent increase in confusion, etc. regarding interpretations (yours, mine, theirs) as to what it all means, which leaves us with requirements to:


  • Designate resources for assessing life safety compliance (evidence could be letters of assignment, position descriptions, documentation in meeting minutes); the survey process will include an evaluation of the effectiveness of the chosen method(s) for assessing LS compliance


  • Performance of a formal LS compliance assessment of your facility—based on time frames determined by your organization (big freaking hint: “best practice” would be at least annually); you can modify/adjust time frames based on the stability of your physical environment (if there’s not a lot going on, you might be able to reduce frequencies, though I haven’t been to too many places that didn’t have some activities that would impact LS compliance (Can you say “network cabling”? Sure you can!). Also, there is mention of the use of certain performance elements sprinkled throughout the LS chapter that will be used for any findings that are not specifically covered by the established performance elements. Clearly, there is a desire to leave no stone unturned and no deficiency unrecorded. Yippee!


  • Maintaining current and accurate life safety drawings; we’ve covered this in the past (going back to 2012), but there are still some folks getting tagged for having incomplete, inaccurate or otherwise less-than, life safety drawings. Strictly speaking, the LS drawings are the cornerstone of your entire LS compliance efforts; if they need updating and you have a survey any time in the next 12-18 months, you better start the leveraging process for getting them reviewed/revised. They don’t tell you how to do it, but if they’re not on auto-cad at this point, you better have a wizard for whatever program you are using. All they need to do is find one inconsistency and they can cite it…ugh! Check out the list in Perspectives and make sure that you can account for all of it.


  • Process for resolving deficiencies identified during the survey; we know we have 60 days to fix stuff found during the survey (and hopefully they don’t find anything that will take longer than that to resolve—I have this feeling that that process is going to be exceptionally unwieldy—and probably unyielding to boot). The performance element covers the process for requesting a time-limited waiver—that’s got to happen within 30 days of the end of the survey. Also, the process for requesting equivalencies lives here (if folks need a refresher on equivalencies, let me know and I will put that on the list for 2017 topics). Finally, this is also where the official invocation of the ILSM process as a function of the post-survey process is articulated (I think we covered that pretty thoroughly last week, but if you have questions—go for it!).


  • Maintaining documentation of any inspections and approvals (read: equivalencies) made by state or local AHJs; you’ve got to have this stuff organized and in a place you can lay your hands on it. Make sure you know how often your AHJs visit and make sure that you have some evidence of their “presence.” I think it also makes sense to keep any inspections from your property insurers handy—they are almost as powerful an AHJ as any in the process and you don’t want to run afoul of them—they can have a significant financial impact if something goes sideways with your building.


  • The last one is a little curious to me; I understand why they’re saying it from a global perspective, but it really makes me wonder what prompted specific mention. You can read the details of the language in Perspectives, but my interpretation of this is “don’t try any funny stuff when you’re renovating interior spaces and leave 4-foot corridor widths, etc., when you have clearly done more to the space than ‘updated finishes.’” I think this is the call-to-arms relative to having a good working knowledge of Chapter 43 of the 2012 You need to know what constitutes: repair; renovation; modification; reconstruction; change of use or occupancy classification; addition (as opposed to subtraction). Each of these activities can reach a degree/scope that “tips” the scales relative to the requirements of new versus existing and if you haven’t made that determination (sounds very much like another risk assessment, don’t it?) then you can leave it in the hands of a surveyor to apply the most draconian logic imaginable (I think draconian logic might be oxymoronic—and you can put the accent on either syllable), which will not bode well for survey success.


That’s the word from unity for this week; next week, we’ll check up on some Emergency Management doings in the wake of recent flooding, including some updates to the Joint Commission’s Emergency Management Portal (EMP?). Hope your solstice salutations are merry and bright until next time!

History shows again and again how standards (and EPs) point out the folly of men…

It’s beginning to look like the proofreaders in Chicago must be enduring some late nights watching the Cubs! I don’t know about you folks, but I rely rather heavily on the regular missives from The Joint Commission, collectively known as Joint Commission E-Alerts. The E-Alerts deliver regular packages of yummy goodness to my email box (okay, that may be a little hyperbolic) and yesterday’s missive was no exception. Well, actually, there was an exception—more on that in a moment.

While it did not get top billing in the Alert (which seems kind of odd given what’s been going on this year), the pre-publication changes to the Life Safety chapter of the accreditation manual have been revealed, including comparison tables between what we had in January 2016 and what we can expect in January 2017. Interestingly enough, the comparison tables include the Environment of Care (EC) chapter stuff as well (though the EC chapter did not merit a mention in the E-Alert), so there’s lots of information to consider (which we will be doing over the course of the next little while) and some subtle alterations to the standards/EP language. For example (and this is the first “change” that I noted in reviewing the 112 pages of standards/EPs), the note for EC.02.02.01, EP 9 (the management of risks associated with hazardous gases and vapors) expands the “reach” to specifically include waste anesthetic gas disposal and laboratory rooftop exhaust (yes, I know…very sexy stuff!). It does appear that at least some of the changes (tough to figure out the split between what is truly “new” and what is merely a clarification of existing stuff—check out the note under EC.02.03.05, EP 1 regarding supervisory signal devices because it provides a better sense of what could be included in the mix). Another interesting change occurs under EC.02.03.05 (and this applies to all the testing EPs) is that where previously the requirement was for the completion dates of the testing to be documented, now the requirement actually states that the results of the testing are to be documented in addition to the completion dates. Again, a subtle change in the language and certainly nothing that they haven’t been surveying to. Oh, and one addition to the canon is the annual inspection and testing of door assemblies “by individuals who can demonstrate knowledge and understanding of the operating components of the door being tested. Testing begins with a pre-test visual inspection; testing includes both sides of the opening.” At any rate, I will keep plowing through the comparison table. (Remember in the old days, it would be called a crosswalk. Has the 21st century moved so far ahead that folks don’t know what a crosswalk is anymore?)

The top billing in yesterday’s All Hallows Eve E-Alert (making it an Eve-Alert, I suppose) went to the latest installment in that peppiest of undertakings, the Physical Environment Portal. Where the proofreaders comment comes into play is that the Alert mentions the posting of the information relative to LS.02.01.30, (which happened back in August) but when you click on the link, it takes you to the update page, where the new material is identified as covering LS.02.01.35, so there is updated material, though you couldn’t really tell by the Alert. So, we have general compliance information for the physical environment folks, some kicky advice and information for organizational leadership, and (Bonus! Bonus! Bonus!) information regarding the clinical impact of appropriately maintaining fire suppression systems (there is mention of sprinkler systems, but also portable fire extinguishers). I’d be interested to see if anyone finds the clinical impact information to be of particular use/effectiveness. I don’t know that compliance out in the field (or, more appropriately, noncompliance) is based on how knowledgeable folks are about what to do and what not to do, though perhaps it is the importance of the fire suppression systems and the reasons for having such systems (Can you imagine having to evacuate every time the fire alarm activates? That would be very stinky.) that is getting lost in the translation. I have no reason to think that the number of findings is going to be decreasing in this area (if you’re particularly interested, the comparison table section on LS.02.01.35 begins on p. 80 of that document—any changes that I can see do appear likely to make compliance easier), so I guess we’ll have to keep an eye on the final pages of survey year 2016 and the opening of the 2017 survey season. Be still my beating heart!

I wanna know: Have you ever seen the rain?

In our intermittently continuing series on the (final!) adoption of the 2012 Life Safety Code®, we turn to the one area about which I have still the most concerns—the magic land of NFPA 99. My primary concern is that while NFPA 99 contains lots and lots of references to risk assessments and the processes therein, I’m still not entirely convinced that the CMS oversight of the regulatory compliance process is going to embrace risk assessments to the extent that would allow us to plot our own compliance courses. I guess I will have to warily keep my fingers crossed and keep an eye on what actually occurs during CMS surveys of the physical environment. So, on to this week’s discussion…

When considering the various and sundry requirements relating to the installation and ongoing inspection, testing and maintenance of electrical system components, one of the key elements is the management of risk associated with electrical shock in wet procedure locations. NFPA 99 defines a wet procedure location as “(t)he area in a patient care room where a procedure is performed that is normally subject to wet conditions while patients are present, including standing fluids on the floor or drenching of the work area, either of which condition is intimate to the patient or staff.”

Typically, based on that description, the number of areas that would “rule in” for consideration as wet procedure locations is pretty limited (and depending on the nature, etc., of the procedures being performed maybe even less limited than that). But in the modern age, the starting point for this discussion (and this is specifically provided for under section of the 2012 edition of NFPA 99) is that operating rooms are to be considered wet procedure locations—unless a risk assessment conducted by the healthcare governing body (yow!) determines otherwise (all my yammering over the years about risk assessments is finally paying off—woo hoo!). By the way, there is a specific definition of “governing body”: the person or persons who have overall legal responsibility for the operations of a healthcare facility. This means you’re going to have to get your boss (and your boss’ boss and maybe your boss’ boss’ boss) to play in the sandbox on this particular bit of assessmentry.

Fortunately, our good friends at ASHE have developed a lovely risk assessment tool (this is a beta version) to assist in this regard and they will share the tool with you in exchange for just a few morsels of information (and, I guess, a pledge to provide them with some useful feedback as you try out the tool—they do ask nicely, so I hope you would honor their request if you check this out—and I really think you should). Since I’m pretty certain that we can attribute a fair amount of expertise to any work product emanating from ASHE (even free stuff!), I think we can reasonably work with this tool in the knowledge that we would be able to present it to a surveyor and be able to discuss how we made the necessary determinations relative to wet procedure locations. And speaking of surveys and surveyors, I also don’t think it would be unreasonable to think that this might very well be an imminent topic of conversation once November 5 rolls around and we begin our new compliance journey in earnest. Remember, there is what I will call an institutional tendency to focus on what has changed in the regulations as opposed to what remains the same. And I think that NFPA 99 is going to provide a lot of fodder for the survey process over the next little while. I mean think about it, we’re still getting “dinged” for requirements that are almost two decades old—I think it will be a little while before we get our arms (and staff) around the ins and outs of the new stuff. Batten down the hatches: Looks like some rough weather heading our way!

At any rate, here’s the link to the wet procedure location assessment tool.

Hope everyone has a safe and festively spooky (or spookily festive) All Hallows Eve!

If accredited you wish to be, you must answer these questions three!

And other tales: If you thought the dervishes were whirling last week…you ain’t seen nothing!

Hortal hears a chortle from the portal: The much-anticipated (you tell me how hyperbolic that characterization might be…) return of updated content for the Joint Commission (oops, THE Joint Commission)’s Physical Environment Portal (PEP) has finally reached these shores. O frabjous day! Callooh! Callay! He chortled in his joy (from Jabberwocky by Lewis Carroll; see, chortling has been around for a while…).

The new content breaks down into three sections: one for facilities and safety folks, one for leadership, and one for clinical folks, lending further emphasis to the ongoing melding  of the management of the physical environment into a tripod-like structure (tripods having more stability and strength than a one- or two-legged structure—think about that one for a moment). At any rate, interestingly enough, the suggested solutions for both the clinical and leadership “legs” of the tripod are aimed at “supporting” the facilities “leg” through endorsement of the key process(es) as well as keeping smoke doors closed, not compromising closing devices (how may doors can a doorstop stop if a doorstop could stop doors?), and participation during construction activities. So, if you visit the noted URLs, you will find a whole bunch of stuff, some of it downloadable, to share with the other “legs” in your organization. It seems pretty evident to me, that at least part of the intent of the information shared, particularly the stuff earmarked for leadership and clinical folks, is to ratchet up the “investment” of those two groups in the management of the physical environment. On the face of it, nobody in healthcare has “time” to shoulder this burden on their own, hence the practical application of the tripod (sort of: that may be a bit of a reach on my part, but there’s some truth lurking around somewhere—and we will ferret it out).

Also breaking recently was the information (funneled from our fine friends at ASHE) that TJC is going to be including a set of three questions in the pre-building tour portion of the survey process (I think this is in addition to other questions that might be asked, including whether you have any identified Life Safety Code® (LSC) deficiencies). The intent, as described by Jim Kendig, TJC’s field director for surveyor management and development (I worked with Jim, like, a million years ago. Hi, Jim!), is to gather some pertinent/useful information before setting out to tour your facility.

Question 1: What type of firestopping is used in the facility?

Question 2: What is your organization’s policy regarding accessing interstitial spaces and ceiling panel removal?

Question 3: Which materials are used for high-level disinfection or sterilization?

On the face of it, I’m thinking the response to Question 1 might very well be the most challenging as I can’t recall too many facilities that have just one manufacturer’s product protecting their rated barriers. My consultative advice is you would be well-served to have some sort of document that identifies the various products in use, where they “live” in your organization, perhaps even color pictures of the products in situ so the surveyors will know what they are looking for (and please don’t try to pass off that yellow expanding foam stuff as an appropriate product—no point in getting into a urination competition with a surveyor over that). As to the other questions, as near as I can tell they’re pretty straightforward; the surveyor is going to have plan for extra time if a containment has to be erected/constructed for every ceiling tile removal or perhaps they will identify specific locations for inspections and just run through those one after the other. As to high-level disinfection and sterilization, lots of environmental and infection control opportunities for bungles there (BTW, it’s probably a very good idea to have a very good idea where those processes are occurring; it can be more widespread than you would prefer).

As a final thought for this week, I would encourage you to participate in ASHE’s survey of the potential impact of CMS’s requirement for all hospital outpatient surgery departments to be classified as Ambulatory Surgical occupancies under chapters 20 and 21 of the 2012 LSC. There is a fair amount of potential that this requirement is going to have an impact on facilities in which dental or oral surgery is being performed, plastic surgery, endoscopy, laser surgeries, etc. To help with the assessment of the impact of this change, ASHE is asking folks to complete a survey for each of the facilities you oversee that will be affected; you can find the survey here.

I think it’s probably well worth your time to at least see what they’re asking about; I’m beginning to think that we are going to look back on 2016 as a really ugly year (compliance, popular culture, you name it!). Where’s that fast-forward button…or do we talk to Mr. Peabody and Sherman about that Wayback Machine…

Devilish details and the whirling dervishes of compliance

In the absence of any new content on The Joint Commission’s Physical Environment Portal (the PEP ain’t none too peppy of late), I guess we’re going to have to return to our old standby for the latest and greatest coming out of Chicago: Perspectives! The August Perspectives has a fair amount of content pertinent to our little circle, so it probably makes too much sense to cover those key items and announcements.

The front page headline (as it should be) relates the ongoing tale of the dearly departing PFI process (which, I suppose, kind of makes this something of an obituary). Effective August 1, 2016, open PFI items will no longer be reviewed by the survey team nor will they be included in the Final Report generated by the survey. All Life Safety chapter deficiencies will become Requirements for Improvement (RFI) with a 60-day submittal window for your Evidence of Standards Compliance (and remember, one of the other TJC practices that departed this year was the “C” performance elements, so all of those pesky Opportunities for Improvement (OFI) at the end of your past survey reports will now become RFIs). Also, only equivalency requests related to survey events will be reviewed. More on that part of the big picture in a moment.

Also in the August Perspectives comes the official print announcement that the requirements of the 2012 Life Safety Code® will not be surveyed until November 1, 2016 (which should make for a very interesting few months in survey land for those of you moving towards the “closing” of your survey window), giving everyone on the regulatory compliance team a chance to complete the online education program, and give CMS time to update the survey forms and K-Tags. Apparently, the self-directed education program takes about 20 hours to complete (you can see the entire CMS memorandum here). The education program includes a pre- and post-test, and requires a passing score of 85%. I’m kind of curious about the format (I’m thinking perhaps the classic multiple choice format) and even more curious about whether they would ever make such a thing available to safety and facilities professionals. Presumably this means that whoever comes to your door on Tuesday, November 1 to survey your building will have passed the test. Would it be rude to ask them how they fared?

Next we turn to the “Clarifications and Expectations” column which, for all intents and purposes, is something of a recap of the PFI stuff, with the additional indication that TJC will no longer offer extensions and the automatic six-month grace period is no longer available. Ostensibly, this means that those of you with open PFIs had probably better start cleaning things up. I’m still waiting to see something (anything?) on the subject of the inaccessible fire and smoke dampers; I think I’ve mentioned previously of instances in which CMS has forced the issue of correcting the dampers, but I can’t help but think that that could be a very big pain in the posterior for some folks. I’d like to think that if these were simple to fix, they would already have been corrected (we wouldn’t take advantage of the process, would we?) so this could create a fairly burdensome situation for folks.

For those archivists among you, there is some interesting background on the 60-day time limit. Section §488.28(d) of the Code of Federal Regulations states: “Ordinarily a provider or supplier is expected to take the steps needed to achieve compliance within 60 days of being notified of the deficiencies, but the State survey agency may recommend that additional time be granted by the Secretary in individual situations, if in its judgment, it is not reasonable to expect compliance within 60 days, for example, a facility must obtain the approval of its governing body, or engage in competitive bidding.” Now that does provide a little sense of what will “fly” if one is forced to ask for a time-limited waiver (TLW—another acronym for the alphabet soup of compliance), but it’s tough to say whether any flexibility extends beyond those elements (who would ever have thought that competitive bidding might be helpful!).

Anyway, one thing relating to the SOC/PFI maelstrom (at least tangentially—and not mentioned in the August Perspectives) is the question of whether or not the presentation of the categorical waivers at the beginning of the survey process is still required. Certainly, the effective adoption date of the 2012 LSC (July 5, 2016) might potentially be the tipping point for informing the survey team of any categorical waivers your organization might have adopted, but I think the most appropriate cutoff date (if you will) for this practice would be on November 1, 2016 when CMS (and its minions) are charged with surveying to the requirements of the 2012 LSC. My overarching thought in this regard is that presenting the waivers to the survey team at the start of the survey certainly doesn’t hurt you and since the 2000 edition of the LSC is still the primary survey reference, it seems most appropriate to continue highlighting the waivers for the time being.

Back to Perspectives: One final EC-related item, for those of you with memory care units, there is specific coverage of the expectations under EC.02.06.01 relative to patient stimulation (or overstimulation), outdoor spaces for patients and residents with dementia, and other environmental elements. While these requirements apply to the Memory Care Certification chapter of the Nursing Care Center manual, again, if you happen to have a memory care unit within your span of control, you might find these expectations/performance elements useful in managing the environment. Even when not required, sometimes there are elements worth considering. After all, improving the patient experience as a function of the physical environment is one of our most important charges.

Blame it on Cain…

We’ll see how long this particular screed goes on when we get to the end…

In my mind (okay, what’s left of it), the “marketing” of safety and the management of the physical environment is an important component of your program. I have also learned over time that it is very rare indeed when one can “force” compliance onto an organization. Rather, I think you have to coax them into seeing things your way. At this point, I think we can all agree that compliance comes in many shapes, colors, sizes, etc., with the ideal “state” of compliance representing what it is easiest (or most convenient) for staff to do. If we make compliance too difficult (both from a practical standpoint, as well as the conceptual), we tend to lose folks right out of the gate—and believe you me—we need everybody on board for the duration of the compliance ride.

For instance, I believe one of the cornerstone processes/undertakings on the compliance ride is the effectiveness of the reporting of imperfections in the physical environment (ideally, that report is generated in the same moment—or just after—the imperfection “occurs”). There are few things that frustrate me more than a wall that was absolutely pristine the day before, and is suddenly in possession of a 2- to 3-inch hole! There’s no evidence that something bored out of the wall (no debris on the floor under the hole), so the source of the hole must have been something external to the hole (imagine that!). So you go to check and see if some sort of notification had occurred and you find out, not so much. Somebody had to be there when it happened and who knows how many folks had walked by since its “creation,” but it’s almost like the hole is invisible to the naked eye or perhaps there’s some sort of temporal/spatial disruption going on—but I’m thinking probably not.

I’m reasonably certain that one can (and does) develop an eye/sense for some of the more esoteric elements of compliance (e.g., the surveyor who opens a cabinet drawer, reaches in, and pulls out the one expired item in the drawer), but do we need to educate folks to recognize holes in the wall as something that might need a wee bit of fixing? It would seem so…

At any rate, in trying to come up with some sort of catch phrase/mantra, etc., to promote safety, I came up with something that I wanted to share with the studio audience. I’d appreciate any feedback you’d be inclined to share:






I’m a great believer in the power of the silly/hokey concept when you’re trying to inspire folks; when you think of the most memorable TV ads, the ones that are funny tend to be the most memorable in terms of concept and product (the truly weird ads are definitely memorable, but more often than not I couldn’t tell you what product was being advertised). I think that as a four-part vision, the above might be pretty workable. What do you think?

This week in hell: What about the damn dampers?

We are certainly in the (very) early stages of the departure of The Joint Commission’s Plans for Improvement (PFI) process from our midst (Is it possible for a process to have abandonment issues? I suspect we’re going to be feeling something like it for quite some time to come.) and there continues to be much to chew on. This week, I’m going to break it down into a couple of chunks that will hopefully allow us to more easily digest this big mouthful of unpleasantness, but first, a rant (ooooh, big surprise):


  • I honestly don’t have a dog in this particular fight beyond my position as an observer of accreditation and regulatory compliance activities in healthcare, but I continue to “bump” up against the practice of TJC revealing substantive (and substantial) changes in forums that are not completely accessible to everyone with a dog in the fight. I don’t know about you, but my boss is generally inclined for me to be busy doing productive work, so I don’t oft (okay, never) get to the annual ASHE conference (and yes, I recognize the educational value, etc., of such gatherings, but, as you all probably know pretty well, that can be a very tough sell). Consequently, I (and perhaps a whole bunch of “yous” out there in the audience) was not present when the discontinuation of the PFI process was announced. I don’t know if there was a Q&A that followed the announcement, so I have no idea if questions were asked and answered, asked and deferred, asked and not answered, etc. I suspect if we all had known what was coming down the pike this year, between adoption of the 2012 Life Safety Code® (LSC) and PFI getting kicked to the curb, we might all have made a little bit of an extra effort to get to ASHE (well, perhaps you would have—I was having way too much fun tripping around Texas). At any rate, at the very least, I would love to see a transcript of the presentation as well as any Q’s and A’s that might have occurred. As an alternative thought, I also believe that something this monumentally important is deserving of a free webinar from TJC that includes a live Q&A (or if not a live Q&A, answers to pre-submitted questions would be okay)—this has the potential to be enormously painful for facilities and safety folks over the next little while (the optimist in me says “little while,” my fear is fairly long while) and, as customers, I think those same facilities and safety folks deserve a little time with the powers that be.
  • So what do we do with the damn dampers? As near as I can tell (with absolutely no empirical data beyond the number of questions I’ve received on the topic), there are a fair number of folks who have taken advantage of the PFI process for managing inaccessible dampers. When the PFI process goes away, does this mean all those dampers have to be brought in to compliance within the 60-day window? I am truly hoping that something specific to this issue is forthcoming before folks start tying up all the mechanical contractors in the US. Perhaps there’s a categorical waiver in the future for this piece of business—I think that would be a nice surprise. One thing I can tell you is that I know of at least one hospital that CMS required to clean up the damper issues identified on the PFI, so I have no reason to think that leniency will be the order of the day.
  • For those of you that reflect the PFI process in either your management plans or your ILSM plans/policies, you should probably pull those out and update the process as a function of no PFI process (I’m still not quite over the initial shock of that). Certainly for many, many years, a fundamental part of the standards-based requirements relative to ILSM was the management of LSC deficiencies that could not be immediately corrected (or corrected immediately, depending on your perspective), which brings us squarely into the realm of the PFI process. At any rate, make sure you make a quick of any policies/processes (hey, maybe even in your work order system) to make sure that you expunge all evidence of the PFI process.
  • As to the discontinuation of the Basic Building Information component of the Statement of Conditions, one of the things that’s “driven” by the information contained therein is the number of survey days, based on the square footage of healthcare occupancies in your facility. I don’t believe that the square footage question is asked during the organizational application process (might be worth checking with the individual in your organization charged with filing the application to verify what may or may not be in the mix), which makes me wonder how they will make the determination if folks don’t update the eBBI information. I suppose they have a basic starting point now, so it probably won’t change that much, but I also think of the SOC as a great means of communicating certain information to the surveyors—existing waivers/equivalencies (which makes me wonder: are we looking at a day when all the existing waivers/equivalencies granted by TJC go away or at least have to be resubmitted to CMS?), locations and square footage of suites, level of sprinkler coverage, and other unique aspects of the building can all be memorialized in the comment section of the SOC. But if the surveyors aren’t going to look at the SOC any more, do we print out the information and provide it to them directly or does this become one more potential sticking point during a survey? I guess a lot of the same information can be included on the life safety drawings, but I know a lot of folks don’t have the wherewithal to manage the drawings themselves so they use an architect or fire protection engineer for updates, etc.


All that said, I guess we’ll just have to keep our fingers crossed that some level of sanity is restored to the process, but given the state of the world, I don’t think I’m going to be holding my breath while I wait.