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As we relive our lives in what we tell you…

While it is always my intent to be amazingly timely in posting things, sometimes items that I’ve earmarked for sharing end up languishing in my draft emails folder. And, as I was poking around trying to decide what to run with this week, I came upon an item that, while a little long in the tooth in terms of when it was published, should still provide some food for thought (and action) as we navigate the waters of preparedness. There are always things to do and events to plan for, but you’ll probably want to review the document to look over the updates.

As usual, there’s nothing that I see that makes me crazy, but I also know that, in the hands of some surveyors, what looks like flexibility to folks with practical experience can become “the only way.” So you might want to check out the review tool being used in a certain Midwest state very close (so close they are the same) to our friends from Chicago. At some point, I suspect that the conversations during survey are going to turn to “What about the next one?” (as we venture further into the realm of emerging infectious diseases, or EID), so it’s probably a good idea to start planning along those lines. Hopefully the next one doesn’t get here for a very, very long time, but…

A couple of general thoughts regarding some of the changes:

Play nicely with others: collaboration versus isolation. In one of those ever-shifting dualities brought on by the pandemic, there’s been a lot of “distancing” (social or otherwise) that has only (at least to my mind—feel free to disagree) increased the degree of difficulty when it comes to meaningful collaboration. At least now we can get folks to “visit” from time to time, but a lot of the most difficult situations, conditions, etc., over the last year or so were very much accomplished “on the fly.” I think we all try to live by the “stronger together” ethic, but I guess it just proves the point that the whole 96-hour thang is very dependent on the event(s). That said, if you are accredited by our friends in Chicago, be very certain that you have met the requirements for evaluating emergency response activities, have a documented review of your emergency inventory, reviewed your HVA, evaluated your emergency response plan/emergency management plan/emergency operations plan. It doesn’t have to be complicated, but there is some indication that shortfalls will be cited. Please take an hour this week and make sure all those little duckies are in neat rows.

The umbrella can provide protection for a lot of different events: we did touch on this earlier in the year, but I’m glad to see that guidance is being provided to surveyors that it is not necessary to have response plans/protocols for every possible event. That said, you want to make sure that you have a good cross-section of folks participating in the planning process, particularly with the whole EID issue. Infection control and prevention folks are amazingly important when it comes to planning for emergencies (but after the last 12 months or so, you really didn’t need me to tell you that), but there are other folks in your organization that have a part to play in the planning. I think one of the critical performance metrics going forward will be the general concept of continuity as it impacts operations across the continuum of care. Your planning must key on how the place stays in business over the long haul (recognizing we’re still “hauling” to a fair degree…) and you really want to include consideration of continuity as a specific evaluation element. We now know that we can appropriately to a really long event, but the hows and whys are going to be key as we move out of response into recovery mode.

I think you folks “got this,” but it never hurts to look preparedness in the eye from time to time.

Don’t let weighing in weigh you down…

In what I would term an interesting move (I don’t know that I would go so far as to call it unprecedented, but it might well could be), our friends in Chicago are rearranging the deck chairs in the Emergency Management chapter. It does seem like it’s more of  a consolidation than a wholesale rewrite, but the strategy of setting up new standard and performance element numbers makes this potentially a big deal (as we know, surveyors tend to focus on the stuff that has changed since the last survey visit, so if you’re using the existing numerical indicators, you’ll likely need to change—or get rid of them entirely). I suspect this may have more to do with trying to align the existing EM standards et al. with the CMS requirements (It will be interesting to see if they end up developing a crosswalk—probably when it’s adopted).

While I can’t say that I’ve digested the whole thing, it does seem like they removed a lot of the specifics relating to the management of LIP volunteers (including an allowance for organizations to forego the use of volunteers, a strategy they had never really “approved”; I know a couple of instances in which organizations were cited for declining to use volunteers), but it makes me wonder what degree of specificity is going to come into play when they start surveying to this.

That said, I don’t see anything that’s giving me heartburn; since CMS based Appendix Z on much of the TJC standards from 2007-ish, what was once old (and abandoned) is now fresh and new and cutting edge. I have the same hopes for myself over time…

At any rate, the critical processes are still represented. I think it will show over time that some of the specificity of the current standards pushed folks to do things that didn’t necessarily make sense from an organizational standpoint, but I guess we’ll have to wait until the final version is out and about and able to take care of itself. I’m guessing substantive changes are not likely to be made at this point, but they are asking for comments, so if you’ve got a mind to say something, I would encourage you to do so.

Next week we’ll chat a little bit about some recent interpretive dances from the perspective of Perspectives. Stay tuned!

If this is really accurate, how big of a deal is this to you?

First off, I will indeed stipulate that any instance of workplace violence, whatever causative factors might be in play, is at least one too many instances of workplace violence. We deal with what appears to be an increasing potential for angry (and I’m using that as a catch-all—there are so many shades in the spectrum of rage) feelings to be acted upon, sometimes at the most minute of stimulations (I was going to use provocation, but I have certainly witnessed instances of acting out in response to so little, it boggles my mind). In response, it appears that our friends in Chicago are pushing towards a more demonstrative focus on issues related to workplace violence through the establishment of some new standards in the EC chapter.

From a practical standpoint, I don’t know that there’s anything so “new” here that folks are going to have to reconfigure their programs. In all likelihood, the elements being promulgated are among the things that you’ve been looking at for more than a little while (I did remember a time when workplace violence wasn’t quite so prevalent in healthcare and there were some places for whom this was not a topic of great consideration). So, the things that will clearly be a focus in the coming survey cycle include: an annual analysis of workplace violence prevention considerations, which would in turn result in mitigation of risk elements that cannot be resolved; monitoring of workplace violence occurrences, including reporting and investigation of said occurrences; providing education and training appropriate to the risks of workplace violence in the organization; and the participation of organizational leadership in these efforts, through establishment, and ongoing implementation, of a workplace violence prevention program. I am paraphrasing a wee bit here (you can find the verbiage here) but I guess the question I keep coming back to is: who isn’t doing this? I cannot imagine that there is a healthcare organization in the United States that is not struggling with this to some degree; the effective management of the risks associated with workplace violence.

The other interesting note from the above-referenced materials is the characterization of workplace violence occurrences being underreported, which may very well be the case, but it begs the question of what that actually means? There are certainly many points in the occurrence “chain” in which something might go unreported—and I suspect we have room for improvement there, if only in getting folks to the point where they’ll speak up. But underreporting beyond someone choosing not to speak up seems fraught with peril; the occurrences that come to the attention(s) of committees, services, etc. are not easily dismissed, etc., particularly as a function of regulatory reporting. I suppose this is one way to “leverage” an existing program by playing the compliance card (XYZ agency requires us to do this, etc.), but given the difficulties associated with the retention of staff, etc., how is it not in everyone’s best interests to have an effective process? I do not believe that we are in the habit of knowingly placing folks at risk without some level of preparation, but I also know that, for a fair number of safety professionals, the competing priorities that tend to reduce the opportunities for providing direct education to frontline workers are more bountiful than ever. I think we need to try and use the numbers to advance the cause of education and preparation for staff to deal with these ever-more-likely-to-happen events.

Time has come today: There’s late and there’s LATE

Depending on where you are, you may be bumping up against process elements that are causing certain activities to be “late,” even beyond the grace periods you’ve woven into your management plans, etc. And with the Delta variant becoming more and more of a factor, there is a fair likelihood that the challenges of scheduling activities, particularly those provided by resources external to your organization. I wish that I had a “magic bullet” for this, beyond invocation of the ongoing Public Health Emergency and making use of the 1135 Waiver process (remember when it was really unclear as to what that all meant?). But I think those items should be enough, with a little judicious planning and discussion, to get you over the compliance hump. If you need a primer on that process, be sure to visit the CMS website dealing with such things.

As a somewhat related aside, it does appear more than likely that our friends from Chicago (and, likely, others of the regulatory persuasion) will be moving towards a full embrace of the remote review of documentation. And while that may end up reducing a surveyor day or two from future surveys (they do have a lot of documents to review, so that time would shift from the onsite schedule), it also increased the importance of making sure that your committee minutes, annual evaluations, and other foundation documents provide as much compliance information as possible. Clearly document what waivers have been adopted and for how long; clearly document any risk assessments/mitigation strategies for compliance gaps or shortfalls. While I won’t ask you to “air out your dirty laundry,” you absolutely want to be forthcoming on the impact COVID response has had on normal operations. And if something is late, document the issue resulting in the tardiness of the activity and, again, use the risk assessment process to clearly document that you’re not putting folks at risk while things are sorting themselves out.

As a final note, the Chicagoans are working very diligently to try and get things back on track from a survey perspective, so if you’re expecting them any time soon (or they haven’t shown up yet), I think you need to plan on seeing them before the end of the first quarter of next year. That’s not to say there might not be outliers, but they’re definitely going to be knocking on your door before you know it.

Thanks for all you’ve done and continue to do. It’s made all the difference!

Protection is improvement, improvement is protection: Keeping folks safe from workplace violence

When it comes to the management of workplace violence considerations, I think we all have experienced the many, many ways in which these risks can manifest themselves in the healthcare environment. And now that the tides of COVID appear to be receding, the sense of gratefulness that existed (at least for a little while) seems to be on the decline as well. Now that ambulatory volumes are picking up and waiting rooms are becoming more congested, tempers grow ever shorter and put your frontline folks back to the more traditional risks associated with managing those interactions. It’s hard to say whether the folks not working in healthcare are sufficiently with familiar with the stresses and stressors endured by folks working in healthcare over the past 15-18 months, but it does seem that the sense of healthcare workers as “heroes” (which they most definitely—as they were before the pandemic and will be when we’ve moved on to the next thing) is not enabling good behaviors on the part of patients and their families as might have the case a year ago. In my own, very informal, data collection, there are an awful lot of sick people that are now comfortable enough to seek treatment for long-standing issues, which likely means that folks are scared (but not COVID-scared) and folks that are scared can have a tendency to lash out. This points to making sure that our workers are as well-prepared to deal with patient (and family) concerns before things escalate to the point of violence.

To that end (kind of), our friends in Chicago are implementing a number of “new” requirements to provide a framework for the survey of workplace violence concerns and how effectively hospitals are managing those risks. You can find the details of the standards (they’ll become effective on January 1, 2022) here. There’s also a resource page related to workplace violence.

In noting the use of quotation marks around the “new” requirements, I don’t know that the programmatic elements they’ll be looking for are anything beyond what is typically administered in a credible safety program. I don’t know that I’ve been to an organization in the last decade or so where workplace violence was not an issue to some degree. But much as we’ve had to work hard to protect workers during COVID and in light of the expansion of protections to whistleblowers, I think we should be approaching this as an opportunity to cover as many bases as possible in ensuring all staff (throughout every level of your organization—organizational leadership is clearly on the hook for supporting this endeavor) are effectively prepared to manage the risks associated with workplace violence, particularly de-escalation education. When you break down the requirements, it’s a fairly straightforward “ask”; beyond establishing a mandated frequency for review of the workplace violence prevention program, I don’t think that there’s anything here folks aren’t already doing to some extent. I suspect the education component may require some “ramping up,” particularly if the existing education programs were aimed at an identified group of “at risk” staffers; at this point, anyone working in healthcare, regardless of the environment in which they work have to be considered at risk and would benefit from de-escalation, etc. education. Also, if you’ve not made a concerted effort to include folks in leadership positions in your organization—they need refreshers, too.

So, what will they be looking for?

  • An annual worksite analysis of the workplace violence program, including mitigation or resolution of risks identified in the analysis, based on an analysis of the work environment, investigation of incidents, analysis of supporting policies and procedures, education programs, etc. As a somewhat related aside, keep an eye on your OSHA 300 logs to make sure any occurrences are being captured and communicated (especially to leadership—more on that in a moment);
  • An workplace violence training/education program (at time of hire, annually, when changes occur) for leadership, staff, and licensed practitioners; there is an allowance for determining the contents and to what extent workers need the education (based on their roles and responsibilities), but I don’t see where you can draw the line such that any group (or individual, for that matter) would rule out of the education. And for those of you with skilled nursing facilities, you could argue that they are working in one of your highest risk environments (second, perhaps, to the behavioral health environment), so you need to make sure that you’re including them in the education mix.
  • From a leadership perspective, there needs to be an individual designated leading the workplace violence prevention program (developed by a multidisciplinary team—can be existing) that includes policies and procedures; a process to report incidents and manage the data associated with trends, etc.; a process for follow up and support to folks affected by workplace violence (victims, witnesses); and reporting incidents to the governing body.

My best consultative advice, particularly if you are in the survey window, is to start working on pulling these elements together if you have them or to work to start looking at these considerations as a function of the requirements. Recognizing that the requirements are surveyable by some regulators beginning in January, there are other regulators who are predisposed to looking at this right now. Unfortunately, workplace violence occurrences are going to happen, but we need to consider every occurrence as an opportunity to improve the process and then act on the analysis. This is not going to be a simple fix, but if we can get everybody on the same page in terms of competencies, etc., in this regard, we should be able to demonstrate improvement over time.

If there weren’t challenges…

…it really wouldn’t be an event that requires emergency response.

Somehow over the last little while, the fundamental nature of what constitutes an emergency and, even more importantly, what an appropriate response looks like, appears to have morphed over time. Now we seem to embrace the expectation that whatever happens, hospitals are going to be right on top of things (in a way that, frankly, doesn’t seem to apply to them that would sit in judgment, but that might be something of an editorial comment). But really, can you imagine what would have happened a year ago when pretty much everybody else was working from home, suspending normal operations, etc. (in full recognition that healthcare facilities don’t have the option of opting out of such things)? Now a lot of folks (and no, I’m not going to name names—if you don’t know, then it’s probably just as well) are playing catch-up and generating a wee bit of chaos as they get back to it. Happy happy, joy joy!

At any rate, I do hope that all the surveyors out there kicking the EM tires are paying close attention to some of the information contained in the CMS updates to the emergency preparedness requirements, including:

  • It’s OK for your response process to be the same for multiple risks/hazards
  • Your HVA/program must address each type of hazard, but your policies and procedures can indeed be consolidated (can you imagine how many binders you would need?!?)
  • It is not the job of the surveyor to analyze the appropriateness of the identified risks; their job is to make sure that your program (including policies and procedures) align with your risk assessments (speaking of your risk assessments, they must be demonstrably facility-based/community-based and they must include staffing considerations; emerging infectious disease planning must be in the mix—no surprise there)
  • It is OK (and certainly much more effective) to have each organization’s EM person “show” the requested elements as opposed to surveyor “browsing” of the plan, etc. (the CMS guidance encourages the use of crosswalks to more quickly/readily identify where the component pieces “live”)
  • It is also OK to have your documentation in whatever format makes sense: hard copy, electronic, etc.

I think these are fairly representative of a common-sense approach to surveying compliance with the EM standards; I guess we’ll see how things unfold in the field…

Just a few odds and ends to wrap things up:

  • They encourage the use of the ASPR-TRACIE checklists; lots of good stuff there and well worth poking around and discovering.
  • Emergency power—you have to have what is required by the Life Safety Code® (LSC)/COP for your facility; but please remember that any additional emergency power considerations must be maintained in accordance with the LSC (and, by extension, NFPA 110 et al). I think some folks have this sense that anything not required by the LSC/110 combo can be maintained in whatever fashion they like. This seems to be drawing a line in the sand that they’re not buying it (again, I guess we’ll see what happens in the field—maybe anything that is not LSC-related isn’t offered up for scrutiny); also, they do not allow extension cords to directly connected to generators; generator must interface with facility through transfer system.
  • Functional exercises, mock disaster drills and workshops can be used to count towards the activation requirements (by the way, long-term care facilities are on the hook for annual education; everyone else can go with biannual).
  • Inpatient facilities need to have two years of documentation present; outpatient facilities have to have four years available.
  • Emergency plans are expected to evolve (mutate?) over the course of a long-term event (and I think we know a little something about that…), your plan should include provisions for monitoring guidance from public health.
  • Your plan must include provisions for tracking staff when electronic payroll systems, etc., not available—for example, power outages, etc. consider check-in procedures for on-duty and off-duty staff.
  • Your plan must include a process for communicating with the various AHJS (and, boy howdy, aren’t there an awful lot of those kicking around); as well as provisions for surge planning. As for staffing, while the use of volunteers is optional, there is an expectation that you will have a process for managing them. Over the years, I’ve run into any number of folks that were not at all inclined to deal with volunteer practitioners, but I think the days when that was a reasonable decision point are rapidly fading into the distance.
  • Your plan must also include a process for evacuating patients that refuse to do so; I figure there must be some empirical information that drove the inclusion of this in the guidance. I’m presuming that you have a process already for dealing with recalcitrant individuals, including patients, so I don’t know that this breaks any ground.

Now that I’ve finished typing this, I really don’t see a lot that I would considering troubling or, indeed, troublesome. I would imagine that a lot of this stuff has become rather more hard-wired than not over the past 15 months or so, if it were not already. I think there were a lot of common lessons learned, though the “equation” for “solving” the challenges is probably unique to every organization (unless you’re part of a system in which the facilities are virtually identical). From a compliance standpoint, I think you folks should be OK, but please reach out if you feel otherwise.

So, with June bearing down on us, I trust that you all continue to be well and are staying safe. See you next week!

Take me to your leaders…

I believe that we’ll be able to wrap up the emergency management stuff next week—though I have one or two ideas percolating that I might move to the front of the queue, but certainly before May gives way to June (unless something really interesting pops up out of nowhere…).

With our friends from Chicago returning to the playing field, there was some discussion of a modification to the session with organizational leadership, primarily involving moving the session to the opening of the survey and to have that session focus on leadership’s involvement with response to the pandemic over the last little while. The exact rationale for this strategy (which has since, more or less, gone away) kind of escapes me because I really don’t think the last 12-15 months could have been successfully navigated without some level of interest/action/participation, etc., on the part of hospital leadership teams pretty much everywhere on the globe. That said, I do suspect that the level of interest in all things emergency preparedness have probably not been as widely appreciated as they are right now (soon we will chat about making the most of this moment—but that’s for another day).

At any rate, with the unveiling of the new guidance (I don’t know that there’s necessarily anything “new” that’s going to come out of any of this, but I guess we’ll have to see, but this seems more like a recapitulation or codification than it does a significant change), there continues to be a concerted aim towards clarifying the necessity of organizational leadership participating in the emergency preparedness activities as a baseline expectation (an expectation I think we’ve all shared, yes?). Again, from a practical standpoint, your hospital, in all likelihood, would not have endured the last little while without the active participation/interest/whatever you care to call it from your leadership group. If someone managed to do so (and that doesn’t mean in spite of their participation), I’m keen to hear that story. But in the infinite wisdom of the regulatory monarchy, the following topics of conversation could be raised during any survey event in which leaders are queried about their EM roles:

  • How did the organization encourage collaborations with the available coalitions (local/regional/state: remembering that community partners are defined by each organization)?
  • How did the organization prepare for and manage staffing?
  • How did the organization prepare for and manage evacuation (including planning for the evacuation of patients that do not wish to be evacuated)?
  • How did the organization ensure that communications are collaborative and align with the methods/structures, etc., of the AHJs in the mix?
  • How did the organization promote participation in exercises and engage in the after action report process?
  • How did the organization ensure ongoing preparedness in the face of changes/shifts in community or other partners?
  • How did the organization identify what services would be provided under what circumstances?
  • How did the organization align continuity of operations and business continuity (we’ve had plenty of opportunity to look at this, I would think)?
  • How did the organization effectively manage the delegation of authority, including succession planning considerations?

In almost any other point in modern history, it might have proven to be somewhat burdensome to bring leaders up to speed in advance of a survey, but I can’t imagine that there are too many leadership groups out there that wouldn’t have more than enough practical experience (even if they never completed IS-100 and IS-200). Going forward, I think it’s going to be really helpful to keep the last year in everyone’s heads as a function of how we manage preparedness. It’s not just about regulatory compliance—it’s ensuring that providing care in a safe setting continues to be the number one priority of emergency response.

Hope you all are healthy and staying safe. Somehow I get the sense that we’re not quite done with this (though I would be more than happy to be proven incorrect in that sense), but we will prevail! See you next week!

Forever in debt to your priceless advice…

Continuing on with our discussions of the unusually revelatory April issue of Perspectives, we shall now turn to the life safety-related items, starting with the sweetness of suites (though this may result in some tart-y findings).

One of the most anticipated elements related to the adoption of the 2012 edition of NFPA 101 Life Safety Code® was the full-on acknowledgement of suites. One of things I still find curious/amusing about the whole suite designation thing is there have classically been any number of patient (and other) spaces in healthcare that were clearly designed within the suite concept—even going back to design elements present in the ’70s (yes, I am that old—the ED in the first hospital in which I worked was an area of open patient “positions” with, I think, a trauma room that had a door). The postanesthesia care units (PACU) is the example that springs most quickly to mind—I don’t know that there was ever a time when PACUs were subdivided into individual rooms. From an operational standpoint, the design of a suite makes perfect sense for such care locations. Another area that was frequently “suite-ified” was the critical care unit, though those often had doors, but not necessarily doors that positively latched.

At any rate, one of the primary clear benefits of the suite design is the subtle shifting of “corridors” into “communicating spaces” (and now, as indicated in the April Perspectives, “aisles”), allowing for a fair amount of operational flexibility when it comes to the management of equipment, supplies, etc.  I guess there is something of a quandary when it comes to how much of this information is shared with staff at point of care/point of service—mostly based on the “if you give them an inch…” logical fallacy (more info on that sequence can be found with a web search; I wouldn’t advise it, though, as it is rather a rabbit hole). At any rate, the latest issue of Perspectives is (more or less) throwing down the survey gauntlet when it comes to clear width of spaces within a suite, invoking NFPA 101-2012, which sets a minimum width of egress at 36 inches in all facilities or portions of facilities classified as a healthcare occupancy. Soooooo, any spaces in which there are fewer than 36 inches of clear width are probably going to be cited; my gut instinct tells me that this will be most relevant to emergency department spaces, where the activities of the day tend to lean towards more blurry lines when it comes to egress paths. The other thought that popped into my head, based on the “portions of facilities classified as a health care occupancy,” is that there may be some patient rooms that might not make the 36 inches between the foot of the bed and the adjacent wall. That may not be an issue, but in my mind’s eye, I can see some tight squeezes…

The other life safety-related item in the April Perspectives deals with the (perhaps final) curtain call for the Building Maintenance Program (BMP) strategy for maintaining certain life safety components. While I can’t necessarily refer to the BMP as an anachronism, it’s been more than a decade since there was an particular survey benefit, though I believe—at least it was the last time I was able to look—the electronic Basic Building Information does include a question asking if the organization is using a BMP. Is anybody willing to hop on their TJC portal to see if the question is still there? That said, I don’t think CMS ever really accepted the concept of the BMP as an alternative means for managing life safety deficiencies (much as the PFI process was eventually kicked to the curb). I just checked the JCR portal for the standards manuals, and the BMP entry is still there, so I guess it’s taking a couple of bows before the curtain comes down for good.

As always, I trust that you all are well and staying safe. I just received my second dose of the vaccine the other day, so hopefully this will make traveling a simpler proposition. I guess every day brings us another day closer, so let’s keep the party going!

Remote control: Don’t forget to close the loop

It would seem that the likelihood of ongoing remote surveys is growing in relation to the number of organizations awaiting survey. To be honest, I’ve not seen an official accounting of where the various accreditation organizations (AO) are falling relative to survey delays. That said, I can’t imagine that there must be a fairly significant backlog of surveys to be conducted, so I suppose we’d best be prepared for at least some of that process to occur remotely—particularly document review. To that end, if you missed this news item, I think it will help provide an understanding of how the process is evolving (mutating?!?); the focus of the piece is how DNV is administering the process, but there are certainly some clues as to how the process in general is likely to “exist” over the next little while.

One thing I hadn’t encountered before (or if I had, it was lost in the slipstream of last year) is the COVID data being provided by CMS. It appears that the information is updated on a regular basis (at this writing, the most recent information was for the period ending December 23, 2020) and while it is labeled as Nursing Home Data, CMS feels that the data is applicable to survey planning for hospitals. It appears that unless you are in a “green” county (you’ll see what I mean when you download the spreadsheet), then you probably won’t be seeing a “live” survey team (will we have to face zombie survey teams?). In traveling the past few months and living in a state that requires a negative test before returning or self-quarantining, I can tell you that those green windows sometimes don’t stay open for very long. Fortunately, I have not yet been in a position where I have tested positive away from home—probably my second worst fear; the worst fear being to bring this stuff back home to share with my family.

That said, my own practice has been very much “out in the field,” with a mix of some remote document review. I really do miss the interaction of document review with the folks who are actually responsible for the critical processes. It’s very difficult to have an appreciation for the process when you can’t discuss the operational challenges, the process for making corrections, etc. One of the “common” themes I’ve noted is that the documentation provided remotely tends not to include evidence of corrective actions; certainly this is something I’m accustomed to asking for when I’m doing onsite document review, but I don’t know of too many surveyors that wouldn’t be looking to “close the loop” on any identified deficiencies as soon as they find them in the documentation and it’s tough to really hold someone’s feet to the fire relative to producing corrective action documentation when you are not “in the building” with a specific ending point for the survey. There are certainly any number of surveyors who will cite an organization for failing to provide evidence of corrective actions and I think remote document review only increases the potential for missing pieces of the puzzle.

So my consultative recommendation is this: Make sure that you attach evidence of corrective actions to any documentation you might provide remotely to a survey team. You know you’re going to be asked for it anyways, so you might as well get ahead of the “ask.”

That’s it for this week. I hope you continue to be well and stay safe—we will get through this!

As I look out the window, it’s snowing, which reminds me that we’ve got to keep turning with the world, so I will let you get back to it. Until next time, hope you are well and staying safe. For those of you who are in the process of receiving the vaccine, thank you for your service!

Be afraid, be very afraid…but do it anyway!

Something of a mixed bag this week: Basically a couple of brief items with some interpolative commentary.

First off, in what is probably not really a surprise, the feds have not updated the status of the Public Health Emergency (PHE) (here’s the most recent correspondence in this regard) in a little bit, but I am hopeful that our sprint towards the New Year will prompt a revisitation. I guess one of the key thoughts moving forward is at what point are regulatory surveys impacted. It would seem that we are in a bit of a spike in cases (though how one can tell definitively is something of an art form), based on the information provided to folks traveling in and out of Massachusetts (which would include yours truly). While I can’t say that I’m getting used to being swabbed, I suspect that between now and Christmas, I’ll have a few more opportunities to embrace the swab.

At any rate, I’d be curious as to how folks are “falling” within their normal accreditation survey cycle. Early? Late? Pretty much on time? At some point, something’s going to have to give (and maybe that something involves virtual building tours and the like). I guess at this point all we can do is “stay the course,” and wait for the vaccine distribution challenge (we know it’s coming sometime)…

In other news, our friends in Chicago announced a revision to one of the performance elements dealing with the life safety implications of maintaining fire suppression systems. You might recall we chatted a bit about this back at the beginning of July, at least in terms of the whole spare sprinkler thang. If you accept (as I pretty much have at this point) that any change to a physical environment standard or performance element is “designed” to provide an opportunity for generating more findings (the sterling being the impending focus on the ambulatory care environments), then I think it would be prudent to really kick the tires on your spare sprinkler maintenance program to ensure that you are meeting not just the requirements of the revised performance element, but also the other related requirements. (The blog post above should serve as a good starting point, if you are so inclined.)

As always, please be well and stay safe. I appreciate everything you are and everything you do!