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!
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.
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.
One of the time-honored pursuits, mostly as a function of what you can and cannot manage through the plan for improvement (PFI) process, is what exactly constitutes a Life Safety Code® (LSC) deficiency. Just so you know, I used the “exactly” descriptor for a reason—because the definition, while pretty clear (at least to my mind—feel free to disagree) is a fair distance from exact, but read on and maybe it will become a little more clear.
The “secret” to all of this can be found on pp. 24-25 of the 2000 edition of the LSC. Contained on these two pages are the “documents or portions thereof” that “are referenced within this (Life Safety) Code as mandatory requirements and shall be considered part of the requirements of this (Life Safety) Code.” Thus, these requirements include some of the items you’d probably expect to be there: NFPA 10 Standard for Portable Fire Extinguishers, NFPA 13 Standard for the Installation of Sprinkler Systems, NFPA 70 National Electrical Code, NFPA 99 Standard for Health Care Facilities; and maybe some that you wouldn’t necessarily include in the mix, but make sense when you think about it: NFPA 30 Flammable and Combustible Liquids Code, NFPA 241 Standard for Safeguarding Construction, Alteration, and Demolition Operations. Not that I usually get into product endorsements, but I think even a casual glance at the list of required elements would point you towards having a subscription to all the NFPA codes—and that’s not getting into the other publications cited as required (ANSI, ASME, UL) because they all have a share in the mandated references. Oh yes, and the final “other” publication mentioned is Webster’s Third New International Dictionary of the English Language, Unabridged; you could probably get into a lot of trouble with that…
Therefore, an LSC deficiency is really any condition or practice that is not compliant with any of the referenced codes (is your head spinning yet?), so you can probably craft a PFI for just about any safety-related hazard. In this world of ever-shrinking operational budgets, the PFI process may become an everyday tool as opposed to the once in a blue moon process it has sometimes been in the past. Remember, if the deficiency can be resolved within 45 days, then you can use your work order system. But if you can’t resolve the deficiency within 45 days (and budget constraints are no doubt going to have a greater impact on that in the future), then the PFI could become your new BFF.
Digging into the files of my Hospital Safety Director’s Handbook, here are some thoughts about the Statement of Conditions (SOC).
The SOC process, from a survey perspective, does a couple of things [more]
We’re happy to announce two brand new professional development seminars that will focus on the hot topics of Life Safety Code compliance and emergency managment: [more]
Hi everyone, it’s Scott Wallask checking in today. I’m happy to announce that we’ve posted a free online recording of our January 29 audio conference, “Hospital Safety in 2009: A Sneak Preview of HCPro’s 3rd Annual Hospital Safety Center Symposium.”
You can listen [more]
I just happened to notice a new Joint Commission FAQ (posted January 6) giving folks 45 days to correct a Life Safety Code deficiency before bumping it up to PFI status. That’s good news for the folks in the field.
- The first thing I’d look at is the severity of the repairs. For example, is the PFI a barrier wall in a patient care area?
- Then look at what resources need to be brought to bear to manage the long-term items (e.g., time, materials, staffing, access, and whatever else comes into play in figuring out how the conditions will be resolved).