RSSAll Entries Tagged With: "Perspectives"

Inadvertent inundations: Oh, what fun! 2017 most frequently stubbed toes during survey!

As luck would have it, the latest (April 2018) edition of Perspectives landed on the door step the other day (it’s really tough to pull off the home delivery option now that it is an all-electronic publication) and included therein is not a ton of EC/LS/EM content unless you count (which, of course, we do) the listings of the most frequently cited standards during the 2017 survey season. And, to the continued surprise of absolutely no one that is paying attention, conditions and practices related to the physical environment occupy all 10 of the top spots (I remain firm in my “counting” IC.02.02.01 as a physical environment standard—it’s the intersection of IC and the environment and always will be IMHO).

While there are certainly no surprises as to how this list sorts itself out (though I am a little curious/concerned about the rise of fire alarm and suppression system inspection, testing & maintenance documentation rising to the top spot—makes me wonder what little code-geeky infraction brought on by the adoption of the updated Life Safety Code® and other applicable NFPA standards has been the culprit—maybe some of it is related to annual door inspection activities cited before CMS extended the initial compliance due date), it clearly signals that the surveying of the physical environment is going to be a significant focus for the survey process until such time as it starts to decline in “fruit-bearing.” I do wish that there was a way to figure out for sure which of the findings are coming via the LS survey or during those pesky patient tracer activities (documentation is almost certainly the LS surveyor and I’d wager that a lot of the safe, functional environment findings are coming from tracers), but I guess that’s a data set just beyond our grasp. For those of you interested in how things “fell,” let’s do the numbers (cue: Stormy Weather):

  • #1 with an 86% finding rate – documentation of fire alarm and suppression systems
  • #2 with a 73% finding rate – managing utility systems risks
  • #3 with a 72% finding rate – maintenance of smoke and other lesser barrier elements
  • #4 with a 72% finding rate – risk of infections associated with equipment and supplies
  • #5 with a 70% finding rate – safe, functional environment
  • #6 with a 66% finding rate – maintenance of fire and other greater barrier elements
  • #7 with a 63% finding rate – hazardous materials risk stuff
  • #8 with a 62% finding rate – integrity of egress
  • #9 with a 62% finding rate – inspection, testing & maintenance of utility systems equipment
  • #10 with a 59% finding rate – inspection, testing & maintenance of medical gas & vacuum systems equipment

Again, I can’t imagine that you folks are at all surprised by this, so I guess my question for you all would be this: Does this make you think about changing your organization’s preparation activities or are you comfortable with giving up a few “small” findings and avoiding anything that would get you into big trouble? I don’t know that I’ve heard of any recent surveys in which there were zero findings in the environment (if so, congratulations! And perhaps most importantly: What’s your secret?), so it does look like this is going to be the list for the next little while.

Fall On Me: Keeping Emergency Management Changes in Perspective

As I was ruminating on a topic for this week’s conversation, the October issue of Perspectives came zipping over the electronic transom, and I think there is just enough stuff here to cobble together a relatively cogent offering to you all out there in the blogosphere (that’s right—after 10+ years, I’m working on cogency—who’d a thunk…)

First up is the announcement of proposed changes to the Emergency Management chapter (I say proposed, because the indication is that these changes still require approval by CMS) with an intended survey implementation date of November 15, 2017 (when the Emergency Management final rule takes full effect). From my experiences with folks, I still don’t think they’re barking up a tree for which we cannot (collectively) provide a reasonable response, but if you’re interested in what they think they need to change in the standards, the list of additions includes consideration of:

  • Continuity of operations and succession plans
  • Documentation of collaboration with local, tribal, regional, state, and federal EM officials
  • Contact information on volunteers and tribal groups
  • Documented annual training of all new/existing staff, contractors, and volunteers
  • Integrated health care systems
  • Transplant hospitals

Again, I don’t see anything that strikes me as being particularly daunting, though there’s still a fair amount of angst relative to these changes (as is the case with anything that changes). I know there’s been some consternation relative to managing Memorandums of Understanding (or Memoranda, if that be your preference) and Alternate Care Sites, but I think the important thing to keep in mind is that the journey to the Final Rule started back when the 2008 TJC standards were in full bloom. And I suspect that those of you who have been doing this for a while recall those heady days of focus on MOU’s, ASC’S, COOP’s and the like, concepts that have really kind of faded into the operational ether as the efficacy of those approaches has yielded wildly inconsistent levels of preparation. For some folks, MOU’s, ASC’s and COOP’s are essential, but I’ve also seen evidence that when the feces is striking the rapidly rotating blades, it is often the group that shows up first with the closest thing to cash that has access to resources. When you think about it, things like MOU’s are only an agreement to do the best one can under the circumstances—that’s why the interface with local and regional EM authorities is so very important. At any rate, next we’ll chat a bit about what the CMS survey instructions involve and why I think you folks are going to be in pretty good shape. I am curious as to whether or not there is an intent to modify the emergency response exercise requirements to more closely mirror the Final Rule—I guess all in the fullness of time.

Moving on to other Perspectives topics, it would seem that last month’s Clarifications and Expectations column was indeed the last official communication under George Mills’ direction. The column is on hiatus for the moment—I guess we’ll have to wait and see whether November brings it back (though oy could certainly make the case that EC-EM-LS topics are taking up a fair amount of space in the monthly Perspectives, Clarifications and Expectations columns notwithstanding).

There is a new Sentinel Event Alert (#58!) regarding issues relating to inadequate hand-off communications; the reason I mention it here is that, while the focus in Perspectives is very much on the clinical side of things, I think there is more than a little crossover into the safety / physical environment realm. I’m just planting the seed here, but I suspect that I will have more thoughts on this in the coming little while.

Finally (for this week), there is a piece on Workplace Violence as a function of screening for early detection of risk to harm self or others. I suspect that this may be a harbinger of next steps as it relates to how organizations are managing at-risk patients, particularly as a function of the current focus on ligature risks. In recognition that all the risks that are not medically/clinically necessary have removed, if you don’t have a pretty robust screening process in place, it makes it very challenging to manage the risks that remain. At any rate, I’d keep an eye on this one—much as they’ve been peeling the Infection Control “onion” over the past couple of years, I think this is how they’re going to expand focus in the behavioral health realm.

But, as a subset of that, I did want to muse a bit on those instances when entities that were thought of as “friendly” turn out (under certain circumstances) to be not so much. I suspect that most of you saw the news item back in July regarding the nurse working in the ED of a hospital in Salt Lake City, UT, who was forcibly arrested by local police for not acquiescing to a request that was not allowed by organization policy (if you missed it, you can see some of the story here or here.) I mention this only to point out that the management of this stuff is not always simple (OK, it pretty much never is simple), but this does offer up yet another facet to how facilities safety and security professionals have to proactively advocate for staff (and patient) safety. Some of the images of the arrest are most harrowing and definitely beg the question of how this came to pass in this day and age (or maybe it’s not as questionable an outcome as perhaps it might once have been). At any rate, it’s always important to periodically review what I refer to as the “rules of engagement,” particularly when it comes to interacting with law enforcement folks. If our folks can’t be protected from our “friends,” then what shot do we have against an unknown/unknowable “foe.”

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!

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.

Don’t be a Haz-been (or perhaps Haz-not would be more appropriate…)

I would like to take this opportunity to draw your attention to the two most recent issues of Perspectives, for a couple of reasons. First, as the articles (part 1 and part 2) deal with EC.02.02.01, which is on the top 10 list for most-cited standards during 2015, and Joint Commission interpretation relative to the wonderful world of hazardous materials (and it is, indeed, a wonderful world). Second, these articles introduce a new “voice” into the mix, Kathy Tolomeo, CHEM, CHSP, who is one of the engineers at The Joint Commission’s Standards Interpretation Group and is one of the folks in Chicago who reviews clarifications, ESC submittals, perhaps (presumably) PFIs, etc. In that context, I think it’s important to have a sense of how individual reviewers “see” the regulatory compliance landscape, and these articles provide some sense (I will stop short of saying insight) of compliance strategies.

As a starting point, those are good reasons to check out the articles. But I also found these articles particularly helpful in that compliance strategies are discussed in some detail (I mean the articles are only a couple of pages long, so there are limits to how much detail), including an example (in the December Perspectives) of a hazardous materials inventory form, which I think paints a very nice (and perhaps most importantly, clear) picture of what you need to have in place (I’ve encountered a lot of folks struggling with what is expected for the HazMat inventory). There are discussions of eyewash stations and lead PPE, ventilation, and risk assessments (imagine that!) in the December Perspectives; the January issue covers hazardous gases and vapors, permits, licenses, manifests, and other documentation, labeling, monitoring for radiation exposure, proper routine storage, and prompt disposal of trash.

I guess you could say it’s a bit of hodgepodge in terms of ground covered, but that is the wonderful world of hazardous materials and waste. Check out these articles and maybe, just maybe, you can keep yourself off this year’s (or next year’s, depending on when you’re going to be surveyed) Top 10 list.

How many feet in a mile? How many square feet in a smoke compartment?

I recently came across a survey finding that I thought would be worth sharing with the class. In this particular survey, an organization was cited because it had not identified the square footage of their smoke compartments on its life safety drawings (this was a Direct Impact finding relative to maintaining a current e-SOC). In looking over the information published in the October 2012 issue of Perspectives (See the highlight box on p. 12 entitled “What to Include in Life Safety Code Drawings.” Please check it out if you have not yet done so; anything that shows up in Perspectives is enforceable as a standard!), I clearly see that there is a requirement to include the square footage of any areas designated as suites.

The only mention of smoke compartments indicates that they are required to be identified by location, but there is no mention of the square footage. Now this would seem to be a case of a surveyor interpreting (perhaps even over-interpreting) a requirement based on information that has not appeared in either the standards manual or in Perspectives (square footage for smoke compartments isn’t mentioned in the February 2012 issue of Environment of Care News either). I think this would be a good survey finding with which to practice using the clarification process and I suspect that the organization in question is going to make good use of that process.