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Don’t Call It A Comeback: The Statement of Conditions breathes again!

Not a whole lot going on in the July 2019 issue of Perspectives, but it appears that a little more consideration will need to be paid to the Statement of Conditions (SOC) and Basic Building Information (BBI) sections of The Joint Commission’s web portal for hospitals and other healthcare organizations. The article in Perspectives indicates that we can expect some changes to the questions asked in the BBI section, though the only specific indication thus far is that the questions relating to square footage of your buildings will be aimed at obtaining greater specificity of information, ostensibly to aid in the planning of survey visits. The impression I always had when it came to the square footage ranges was that they tended to “look” at the upper end of the range information, sometimes “encouraging” additional survey days when they might not necessarily have been warranted. My consultative recommendation to folks was to use the comment section to indicate the precise (or would “exact” be the more appropriate descriptor?) square footage so there would be minimal potential for extra survey days. Should be interesting to see how this all shakes out over the next few months as more “reveals” make themselves known.

In other news, the next edition (2022—can you imagine!?!) of the FGI Guidelines for the Design of Healthcare Facilities is in the development pipeline and the good folks at FGI are looking for comments/suggestions to aid in that development, but the window for doing so is quickly closing. You can check out the skinny here, but please know that the comment, etc., period ends on June 30. So if you have some burning thoughts/suggestions for how we will be managing our future facilities (including renovation activities), now is the time for all good safety professionals to come to the aid of their craft (or something like that…).

To close out this week’s chatter, I would encourage you to (yet again!) check out Tim Richards’ blog regarding medical gas certifications and qualifications. As you’ve no doubt noticed, the ongoing codification of everything has really “leaned” into staff competencies and qualifications, sometimes to the point of really muddying the waters as to what really is required. When it comes to medical gas stuff, I don’t know that you’ll be surprised, but it might be useful information to share with your boss (or your boss’s boss). Check it out here.

Wishing each of you a most festive and safe Independence Day!

He held his head in his hands: Outpatient/Offsite Vulnerabilities

Being something of a quiet week on the compliance front (as we embrace the “dog days” of summer—and spring’s got 10 or so days to go), I wanted to use a recent Joint Commission announcement relative to Environment of Care standards relating to fluoroscopy as they apply to outpatient/office-based surgery practices (which seems rather more logical than not, particularly when one reflects on the Conditions of Participation requirements relating to the management of imaging equipment). You can find the particulars here, but I don’t think that there’s anything that’s going to come as a surprise. To my mind, why would the expectations be any different based on where the equipment “lives”? Just as there must be continuity of care, there must also be continuity of compliance.

Now one could certainly disagree as to how much of a sea change this represents relative to the survey process, but (and I’m going out on a limb here, but it’s a very, very stout one) I think the next significant survey “beachhead” (mixing all sort of metaphors today) is going to be all those pesky little physician practices and clinics and such that dot the landscape and are covered by the “umbrella” of hospital operations (you know, offsite locations that have become “departments of the hospital”). If we accept the premise that the primary goal of the survey process is to generate as many findings as possible (and I accept that premise—the evidence doesn’t really point to much else), then the likelihood of the regulatory folks looking for areas with greater levels of vulnerability seems, again, rather more logical than not.

At any rate, my best advice to those of you with these types of sites is to really kick the tires when you’re rounding. As you are no doubt aware, there can be a lot of resistance when compliance comes to the hinterlands (think about how much angst fire drills can generate!), but the stakes for non-compliance have never been greater and, for the record, one can never be too safe…or too compliant!

Carbon-dating compliance: What happened when…

…and how responsible are you for the sins of the past (turns out, quite a bit).

Kind of a mixed bag of things this week, so please bear with me.

First up, in looking back over the last little while of survey activity, I keep looping back around to one (possibly unanswerable) question: How many of the survey findings being generated are the result of conditions that pre-existed the prior survey? I think we can all agree that there are noncompliant conditions lurking throughout our buildings (including that pesky loaded sprinkler head we talked about a couple of weeks ago), some of which (and perhaps quite a few) are the result of actions or inactions occurring a long time ago (in a galaxy almost too close to home). I’m going to guess there are few of us that have not encountered the angst of having a surveyor pop a ceiling tile or wriggle into some crawl space and find some condition that had previously escaped prying eyes (I suspect that the most common previously undetected finding relates to things attached to sprinkler piping and supports, which supports LS.02.01.35 being the most frequently cited Joint Commission standard). And, as onerous as it may be on the face of it (and every other aspect), we are on the hook for all of it (grandfathering of conditions can help in very limited ways, but there’s really very little in the way of grandfathering noncompliant conditions and practices).

For better or worse (likely more the latter than the former), in these increasingly resource-challenged times, it is almost impossible to ferret out every little imperfection. Particularly in the sense that noncompliance happens in three dimensions—square footage just doesn’t work for this process. So, the questions I ask of you, dear readers, are these:

  • Do you proactively attempt an exhaustive search of your facility from top to bottom (and all the nooks and crannies)?
  • Do you “roll the dice” and correct deficiencies as they appear and if there’s stuff out there, let the surveyors find them?

I’m keen to see how this is going to “split.” I know if we could we would take the higher road of proactivity, but not everyone is in that position.

One other item I’ve been hanging on to for probably longer than I should relates to the management of medical gas and vacuum systems. I would hardly think that this blog is the only resource for information, commentary, etc. (though I do like to think it’s an entertaining and perhaps randomly enlightening one), there is one dedicated to the management of medical gas systems, etc., that I think you’ll find useful (and since it doesn’t publish as often, it’s an easy one to add to your bloggy queue) is sponsored by Compliant Healthcare Technologies (CHT). Recently, Tim Richards at CHT penned a blog post on upcoming changes in NFPA 99 relative to medical gases, etc. As I’ve noted once or twice in the past, I really see NFPA 99 compliance as a likely source of heartburn for facilities and safety folks in the coming survey cycles, so any resource that can increase our operational understanding of what is actually required, etc. gives us a leg up on the survey front. I encourage you to check out the information.

As a final note, it appears that we are gearing up for another wild summer of weather and I wanted to take a moment to send best wishes to those in areas already in the throes of severe weather and those that may find themselves in the same. I do believe that, as an industry, we have done some extraordinary work in the practical preparations to deal with emergencies (I would feel better if appropriate preparedness would “drive” regulatory compliance a little more closely, but perhaps in time) and I trust that we all manage the coming season with minimal impact and disruption.

Immediate Jeopardy: How much do you want to wager?

With best wishes to Alex Trebek!

Over the last couple of weeks, the folks at the Centers for Medicare & Medicaid Services (we know them by the cleverly acronymic CMS) have been busy generating lots of guidance for the folks in the field, healthcare organizations and surveyors alike. One of these missives covers the revision of Appendix Q of the State Operations Manual to provide guidance to surveyors and, (by extension) folks charged with compliance at the organizational level, for identifying Immediate Jeopardy (IJ) conditions during surveys. For those of you that have not had the dubious fortune of encountering an IJ in your organization (and I dearly hope that trend continues), it is difficult to describe the impact this can have on an organization. Short of shutting the place down, I cannot think of a more—oh I don’t know, words really seem to fall short in describing the sheer awfulness of an IJ finding.

But as they say, forewarned is forearmed (more on that delightful turn of phrase here). So let’s chat a bit about how one gets to an IJ.

The pieces that comprise an Immediate Jeopardy finding go a little something like this (the entire notification can be found here):

“To cite immediate jeopardy, surveyors determine that (1) noncompliance (2) caused or created a likelihood that serious injury, harm, impairment or death to one or more recipients would occur or recur; and (3) immediate action is necessary to prevent the occurrence or recurrence of serious injury, harm, impairment or death to one or more recipients.”

I think you could probably imagine any number of scenarios that might fit that particular bill; by the way, one of the revisions to this guidance was a change to (2). In the revision, the term “likelihood” replaced “potential.” While I do think “likelihood” is a somewhat higher bar to meet than “potential,” I still see a lot of room for surveyor interpretation. Hopefully, the administration of this judgment call will be more judicious than not. Time will tell…

Fortunately, we do have the opportunity to get a “leg up” on the process by visiting the CMS surveyor training page and working through the education materials provided there (the education is open to providers, so don’t be scared off by the link). I have not yet partaken of the education (it’s on my to-do list) and I will surely provide an update in this space once I have done so.

Manage the environment, manage infection control risks

In looking back at 2018 (heck, even in looking back to the beginning of 2019—it already seems like forever ago and we’re only a week in!), I try to use the available data (recognizing that we will have additional data sometime towards the end of March/beginning of April when The Joint Commission (TJC) reveals its top 10 most frequently cited standards list) to hazard a guess on where things are heading as we embark upon the 2019 survey year.

First up, I do believe that the management of ligature risks is going to continue to be a “player.” We’re just about two years into TJC’s survey focus on this particular area of concern; and typically, the focus doesn’t shift until all accredited organizations have been surveyed, so I figure we’ve got just over a year to go. If you feel like revisiting those halcyon days before all the survey ugliness started, you could probably consider this the shot heard ’round the accreditation world or at least the opening salvo.

As to what other concerns lie in wait on the accreditation horizon, I am absolutely convinced that the physical environment focus is going to expand into every nook and cranny in which the environment and the management of infection control risks coexist. I am basing that prediction primarily on the incidence of healthcare-associated infections (HAI) and related stuff (and, as was the case with ligature risk, I suspect that having a good HAI track record is not going to keep you from being cited for breakdowns, gaps, etc.). We’ve certainly seen the “warning shots” relating to water management programs, the inspection, testing, and maintenance of infection control utility systems, management of temperature, humidity, air pressure relationships, general cleanliness, non-intact surfaces, construction projects, etc. Purely from a risk (and survey) management perspective, it makes all the sense in the world for the survey teams to cast an unblinking eye on the programmatic/environmental aspects of any—and every—healthcare organization. Past survey practice has certainly resulted in Condition-level deficiencies, particularly relative to air pressure relationships in critical areas, so the only question that I would have is whether they will be content with focusing on the volume of findings (which I suspect will continue to occur in greater numbers than in the past) or will they be looking to “push” follow-up survey visits. Time will tell, my friends, time will tell.

But it’s not necessarily just the environment as a function of patient care that will be under the spotlight; just recently there was a news story regarding the effects of mold on staff at a hospital in New York. TJC (as well as other accreditors including CMS) keeps an eye on healthcare-related news stories. And you can never be certain that it couldn’t happen in your “house” (it probably won’t—I know you folks do an awesome job, but that didn’t necessarily help a whole lot when it came to, for example, the management of ligature risks). Everything filters into how future surveys are administered, so any gap in process, etc., would have to be considered a survey vulnerability.

To (more or less) close the loop on this particular chain of thought (or chain of thoughtless…), the Centers for Disease Control and Prevention are offering a number of tools to help with the management of infection control risks in various healthcare settings, including ambulatory/outpatient settings. I think there is a good chance that surveys will start poking around the question of each organization’s capacity to deal with community vulnerabilities and these might just be a good way of starting to work through the analysis of those vulnerabilities and how your good planning has resulted in an appropriately robust response program.

And the wind blew the echoes of long faded voices: Some Emergency Management thoughts…

While the year seemed to start out relatively quietly on the emergency front (relative being a completely relative and arbitrary term—and perhaps never more so than at the moment), it appears that the various and sundry forces of nature (and un-nature) are conspiring to send 2018 out with a bang. From wildfires out West to curiously damp weather patterns in the East to some funky temperature swings in the middle, it seems preparedness levels are as critical an undertaking as ever (and frequently coming nowhere close to being over-resourced, but I guess there’s no reason that the “do more with less” mantra wouldn’t extend to the EM world), with a likely follow-up of focus by the accreditation preparedness panjandrums (more this than this, but I’m fine with either). And one area of vulnerability that I see if the regulatory noggins should swivel in this direction relates to improvements in educating folks on an ongoing basis (the Final Rule says annual, so that determines a baseline for frequency), including some sort of evidence that what you’re doing is effective. (I see lots and lots of annual evaluations that track activities/widgets without getting down to a means of determining effectiveness—another improvement opportunity!) The other “shoe” that I fear might drop is the inclusion of all those care sites you have out in the community. There are very (very, very) few healthcare organizations that are comprised of a single standalone facility; over time, acquisitions of physician practices and other community-based healthcare delivery settings have increased the complexity of physical environment compliance, including emergency management stuff. I don’t know that I’ve run into anyone who couldn’t somehow, to one degree or another, point to participation of the offsite care locations. But it typically comes as, if not quite an afterthought, then a scenario that kind of “grafts” the offsites into the exercise. And, much as I wish community exercises would include testing of response activities in which the hospital acts in a diminished or non-capacity (there’s always this sense that we’ll just keep bringing folks to the local ED), some of the events of this year have really impacted ready access to hospital services for communities. At any rate, if you have thoughts on how you are (or could be) doing a good/better job at testing preparedness across your whole healthcare network, I am all ears and I suspect that there might be some other attentive ears as well.

In closing for this week (a little late, but this truly shouldn’t be tied to just one day or week), my thanks to all that have served in the armed forces: past, present, and future. Your sacrifices continue to mean so much to our lives and I cannot thank you enough (but with the annual Day of Thanks coming up next week, I will surely try)!

Shine on you crazy fire response plan!

On the things I’ve been doing over the past couple of weeks has been reading through the EC/LS/EM standards and performance elements to see what little pesky items may have shown up since the last time I did a really thorough review. My primary intent is to see if I can find any “Easter eggs” that might provide fodder for findings because of a combination of specificity and curiosity. At any rate, while looking through the fire safety portion of the manual, I noticed a performance element that speaks to the availability of a written copy of your fire response plan. That makes sense to me; you can never completely rely on electronic access (it is very reliable, but a hard-copy backup seems reasonable). The odd component of the performance element is the specificity of the location for the fire response plan to be available—“readily available with the telephone operator or security.”

Now, I know that most folks can pull off that combo as an either/or, but there are smaller, rural facilities that may not have that capacity (I think my personal backup would be the nursing supervisor), so it makes me wonder what the survey risks are for those folks who don’t have 24/7 switchboard or security coverage. At the end of the day, I would think that you could do a risk assessment (what, another one!?!?!?) and pass it through your EC Committee (that kind of makes the Committee sound like some sort of sieve or colander) and then if the topic comes up during survey, you can push back if you happen to encounter a literalist surveyor (insert comment about the likelihood of that occurring). As there is no specific requirement to have 24/7 telephone operator or security presence (is it useful from an operational standpoint to do so, absolutely—but nowhere is it specifically required), I think that this should be an effective means of ensuring you stay out of the hot waters of survey. For me, “readily available” is the important piece of this, not so much how you make it happen.

At any rate, this may be much ado about nothing (a concept of which I am no stranger), but it was just one of those curious requirements that struck me enough to blather on for a bit.

As a closing note, a quick shout-out to the folks in the areas hit by various and sundry weather-related emergencies the past little while. I hope that things are moving quickly back to normal and kudos for keeping things going during very trying times. Over the years, I’ve worked with a number of folks down in that area and I have always been impressed with the level of preparedness. I would wish that you didn’t have to be tested so dramatically, but I am confident that you all (or all y’all, as the case may be) were able to weather the weather in appropriate fashion.

Changing (not so much) perspectives on survey trends: Infection Control and Medication Safety

By now I suspect that you’re probably seen/heard that the survey results for the first half of 2018 are only surprising to the extent that there are no surprises (well, maybe a small one, but more on that in a moment). There’s a little bit of jockeying for position, but I think that we can safely say that the focus on the physical environment (inclusive of environmental concerns relating to infection control and prevention) is continuing on apace. There’s a little bit of shifting, and the frequencies with which the various standards are being cited is a wee bit elevated, but the lion’s share of the survey results that I’ve seen are indicative of them continuing to find the stuff they will always be able to find in this era of the single deficiency gets you a survey “ding.” The continuing hegemony of LS.02.01.35 just tells me that dusty sprinklers, missing escutcheons, stacked-too-high storage, etc., can be found just about anywhere if the survey team wants to look for it.

One interesting “new” arrival to the top 10 is IC.02.01.01, which covers implementation of the organization’s infection control plan. I have seen this cited, and, interestingly enough, the findings have involved the maintenance of ice machines (at least so far) and other similar utility systems infection control equipment such as sterilizers (for which there is a specific EP under the utilities management standards). I suspect that what we have here is the beginning of a focus on how infection control and prevention oversight dovetails with the management of the physical environment. I know that this is typically a most collaborative undertaking in hospitals, but we have seen how the focus on the “low hanging fruit” can generate consternation about the overall management of programs. As I’ve noted countless times, there are no perfect environments, but if don’t/can’t get survey credit for appropriately managing those imperfections, it can be rather disheartening.

Couple other items of note in the September issue of Perspectives, mostly involving the safe preparation of medications. As you know, there are equipment, utility systems, environmental concerns, etc., that can influence the medication preparation processes. The Consistent Interpretations column focuses on that very subject and while the survey finding numbers seem to be rather modest, it does make me think that this could be an area of significant focus moving forward. I would encourage you to check out the information in Perspectives and keep a close eye on the medication preparation environment(s)—it may save you a little heartache later on.

Never say never: The ligature risk conversation continues…

I truly was thinking that perhaps I could go a couple more weeks without coming back to the ligature risk topic, but continued percolation in this area dictates otherwise. So here’s one news item and one (all too consultative) recommendation.

If you took a gander at the September issue of Briefings on Accreditation and Quality, you will have noted that the Healthcare Facilities Accreditation Program (HFAP) isn’t revising their existing standards in the wake of the recent CMS memorandum indicating that The Joint Commission’s (TJC) focus work on the subject of managing physical environment risks and behavioral health patients is an acceptable starting point (and I am very serious about that descriptor—I don’t see this ending real soon, but more on that in a moment). I’m not sure if HFAP makes as much use of Frequently Asked Questions forums as TJC does (and with that use, the “weight” of standards), so it may be that they will start to pinpoint things (strategies, etc.) outside of revising their standards (which prompts the question—at least to me—as to whether TJC will eventually carve out the FAQs into specific elements of performance…only time will tell). At any rate, HFAP had done some updating prior (already approved by CMS) to the recent CMS memorandum, but, in using existing CMS guidance (which tends not to be too specific in terms of how you do things), should be in reasonable shape. You can see a little more detail as to where the applicable HFAP standards “live” by checking out this and this. I would imagine that the other accreditation organizations are looking at/planning on how to go after this stuff in the field and I suspect that everyone is going to get a taste of over-interpretation and all that fun stuff.

In the “dropping of the other shoe” department, recent survey results are pointing towards a more concerted look at the “back end” of this whole process—clear identification of mitigation strategies, education of applicable staff to the risks and mitigation strategies, and building this whole process into ongoing competency evaluation. You really have to look at the proactive risk assessment (and please, please, please make sure that you identify everything in the environment as a risk to be managed; I know it’s a pain in the butt to think so, but there continues to be survey findings relating to items the survey team feels are risks that were not specifically identified in the assessment) as the starting point and build a whole system/program around that assessment, inclusive of initial and ongoing education, ongoing competency evaluation, etc. Once again, I would seem that we are not going to be given credit for doing the math in our (collective) head; you have to be prepared to “show” all your work, because if you don’t, you’ll find yourself with a collection of survey findings in the orange/red sections of the ol’ SAFER matrix—and that is not a good thing at all. We are (likely) not perfect in the management of behavioral health patients and that is clearly the goal/end game of this, but right now anything short of that has to be considered a vulnerability. If you self-identify a risk that you have not yet resolved and you do not specifically indicate the mitigation strategy (in very nearly all circumstances, that’s going to be one-to-one observation), then you are at survey risk. I cannot stress enough that (at least for the now) less is not more, so plan accordingly!

Wagging the dog: Can Accreditation Organizations influence each other?

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

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

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