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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 7.3.4.1(2), 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!

We know it will never be easy, but will it ever get easier?

It’s always interesting (and perhaps a bit thrilling) when an announcement comes flying over the transom from our friends in Chicago unveiling “modifications” to the Environment of Care (EC) survey process for healthcare occupancies (e.g., ASCs, hospitals, critical access hospitals), but this ended up being a little less breaking news and a little more of a good news/less-good news situation.

For quite some time now, I have mulled over the general thought that the EC interview session portion of the accreditation survey process really doesn’t yield a lot of findings. My sense of the session is that it’s more of an evaluation of group participation than anything else and it appears that others in a position to do something about it are in agreement, at least as a function of identifying survey vulnerabilities.

At any rate, The Joint Commission recently announced that the EC interview session is going away (good news) to provide more time for surveying in the field, including even more focus on EC stuff for the clinical surveyors during tracers (less-good news). I am certainly not worried about folks getting into “big” trouble during this extra hour of time, but it is another hour of wandering around that is likely to generate at least a few more “dings” in the physical environment.

As the Chicagoans continue to battle the forces of CMS in their pursuit of deemed status and reported shortfalls in the surveying of the physical environment, there is a certain inevitability at play here, so I guess we’ll have to wait and see. My immediate prediction is that there will be an increase in EC/Life Safety findings over the next little while (and perhaps a little while after that…).

Now, if they would only remove the requirements to maintain the safety, security, HazMat, fire, medical equipment, and utility systems management plans—I don’t think they generate very many findings and they really don’t serve any real operational purpose for healthcare organizations. Fire response plans and emergency response plans make sense to me, but the rest of it should be captured through the annual evaluation process. Is it really that big a “step” to go from evaluating effectiveness of the EC plans to evaluating the effectiveness of the EC programs in whole? Somehow I don’t think so…

Hope you are all well and staying safe!

Rollin’, rollin’, rollin’, keep those (fire) door-ies rollin’…

Just because I am fascinated by all sorts of stuff (and I suspect that, since you’re still with me on this, you might be interested in all sorts of stuff, too), I came across a blog post regarding the ins and outs (or perhaps the more appropriate description would be “ups and downs”) of rolling steel fire doors. To be honest, I had no real appreciation of the complexities of these devices, though I certainly l know that anything in their path once activated is likely get a pretty good bruising. That said, I think once you check out the components pieces, you will see that there’s much that can go astray from a mechanical standpoint and remains an important part of your fire door inspection, testing, and maintenance process.

As another example of interesting “stuff” is a product that can be used to protect sprinkled areas that do not have suspended ceilings. I don’t know that everyone is going to have a ton of use for such a product (I first encountered it at an airport terminal in which renovation activities had resulted in the removal of the suspended ceiling but they still needed to provide sprinkler protection), but since it is classified by UL to meet NFPA 13 (recognizing that even the tenets of NFPA 13 can be nudged in any directions by an AHJ), it might just make your life a little easier if you need it. At the very least, check out the short video to get a sense of the product—it’s pretty cool. And if anybody out there has used the product, I’d be keen to hear about your experiences, so please do.

Finally, since I’d hate to let a week go by without some regulatory folderol and hoo-hah, our friends in Chicago have announced some performance element changes for hospitals and other organizations having fluoroscopy services. The new requirements are supposed to be implemented starting January 1, 2021. In looking over the changes, I don’t know that this is of earth-shattering impact (no asteroid, this) but it’s probably worth checking out to ensure that you’re in compliance.

That’s it for this week. Hope you all are well and staying safe. On to November!

Madman Across the Water Management Program

This week brings us something of an unexpected development in the management of the physical environment as our friends in Chicago are seeking comments on a proposed standards revision that more clearly indicates the required elements for water management programs. I don’t know that I was expecting this change, though I suppose it falls under the “one outbreak is one too many” category, nor was I expecting the solicitation of commentary from the field (I look forward to seeing the results of the comment period). It would seem that the proposed performance element is based very closely on the CDC recommendations, which clearly take into consideration the guidance from ASHRAE 188 Legionellosis: Risk Management for Building Water Systems and ASHRAE 12 Managing the Risk of Legionellosis Associated with Building Water Systems, so it doesn’t appear that we’re breaking new ground here.

Additionally, we know from past discussions that CMS has been pretty focused on the risks associated with building water systems (most recently, here, but there are others), so this may be a case of ensuring that everyone is paying attention to the areas of (presumably) greatest risk. And, as near as I can tell, none of the existing COVID-related blanket waivers exempts folks from managing the risks associated with building water systems, so hopefully you’ve been staying with your identified frequencies for testing, etc. And if you haven’t, you probably should be identifying a game plan for ensuring that those risks are being appropriately managed.

Clearly, there’s a little time before these “changes” go into effect (the comment period ends November 16, 2020), but since this is pretty much what CMS has been looking for since 2017 or so, you want to have a solid foundation of compliance moving forward. I recognize with everything else going on at the moment, this might not be a priority, but this is one of those concerns in which proactivity will keep you out of compliance jail.

Until next time, hope you are all well and staying safe!

Is it really transparency if they have to catch you first?

A few months ago, I was working with a facility that, as it turns out, was experiencing challenges with managing temperature and humidity in some of their procedural areas. When I got to the space in question during the building tour, I took particular note of some portable dehumidifiers in a couple of the rooms (one of which hadn’t been emptied in enough time that water was pooling on the floor). In both rooms, the humidity level indicated on the monitoring devices in the rooms was in the 70+ range—a value most surveyors would consider a tad “moist” for a procedural area (my first thought was how high would the humidity be if they weren’t running additional dehumidifiers). At any rate, I asked to see the logs and found enough irregularities to ask to see the perioperative department director. I should mention that this was day four of a four-day consulting gig.

In meeting with the director, I was told that they were embracing full transparency in informing me that they had been experiencing environmental issues in this space for quite some time. My immediate response (which, I will admit, was a bit catty) was: “Is it really transparency if you only tell me after I’ve identified the issue?” I know that sometimes folks like to leave things to see if I can find them (or see if I remember something from the last time I was there) and I think I have a pretty good track record of identifying the various and sundry gaps that can make a good survey go bad in a hurry. But this one really caught me sideways (and continues to) relative to the transparency thing. As I’ve maintained is the case for managing garden variety deficiencies; if folks have to go look for things to fix that have already been identified, it doesn’t strike me as particularly efficient, but that may just be me…

In other news, our friends from Chicago recently published a piece penned by Herman McKenzie, the director of the engineering group at The Joint Commission (TJC); in the piece, Mr. McKenzie provides some insight into what FAQs have been updated, as well as some common concerns in the physical environment. I don’t know if we’ll be seeing Mr. McKenzie as a featured contributor to Perspectives, but hopefully this represents the re-commencement of regular information regarding TJC’s expectations in the physical environment. Generally, September/October is round about the time we hear about the most frequently cited standards during the first half of the year, but I guess that schedule (like pretty much everything else) has been knocked on its keister. At any rate, this link will take you to what’s current (I hesitate to say “new”, just because) in the management of the environment.

Until next time, please be well and stay safe!

I feel like we’ve crossed this bridge before…fire drills are all the RACE!

While the numbers are fairly small (though at almost 30% for a noncompliance rate during 2019 surveys, you could certainly make the case that almost any deficiencies in this area is too much), there remain a couple of common stumbling points when it comes to conducting fire drills. According to the August 2020 issue of Perspectives (get it at your newsstand now!), there continue to be issues with:

  • Not completing/documenting quarterly drills on every shift. I don’t know that there’s a whole lot of mystery here—sometimes you miss a drill. You don’t want to miss a drill; nobody wants to miss a drill! But sometimes the quarter expires so quickly that you don’t realize that a drill was missed until it’s too late. The links below will take you to The Joint Commission’s guidance on the topic, but my best advice is to set a reminder for March 10, June 10, September 10, and December 10 to check fire drill status. That way, you’ve got a couple of weeks if you need to get one in.

https://www.jointcommission.org/resources/news-and-multimedia/podcasts/take-5-the-environment-of-care-fire-drill-matrix-tool/

https://www.jointcommission.org/resources/patient-safety-topics/the-physical-environment/

  • The fire alarm signal was not transmitted on the third shift drills. I absolutely understand why this is still in the mix (as TJC has noted, the allowance for a coded signal for drills between 9P and 5A, does not preclude the transmission of the fire alarm signal). My best advice is to have a line item on your fire drill critique form that goes a little something like: Fire alarm signal transmitted – Yes   No. That way you are providing a surveyor documentation of the signal transmission where you know they’ll be looking.

https://www.jointcommission.org/standards/standard-faqs/hospital-and-hospital-clinics/environment-of-care-ec/000001235/

  • Not enough variation of times when fire drills are conducted; not too much more to say that hasn’t already been said—you have to mix it up—and make sure that the folks conducting the drills understand that once you’ve set up a fire drill schedule, it is to remain unchanged without approval. I know that sounds kind of draconian (and I suppose it is), but our surveyor friends have been rather inflexible on this count and you don’t want to get dinged for a measly 15 or 30 minutes of overlap in your drill times. In the words of the inimitable Moe Howard, when it comes to fire drills—SPREAD OUT! Or, if you’d rather use George Mills’ take on it, you can find that here (with some other Life Safety bon mots).

Now, at the moment, the survey process is not focusing on fire drills as a function of the 1135 Waivers in effect due to the COVID-19 maelstrom. So it would seem that we have a little bit of time to work on the finer points of fire drill compliance. I think the overarching focus is going to end up being (and I think this is likely to be the case with emergency management exercises) is how well you are doing relative to ensuring that “all staff” are participating. For the purposes of the education and training component, I would like to think that if we can demonstrate that everyone in the organization (including the folks in administration) participated, to some degree, over a two-year period, that will result in a finding of compliance during survey. Is it even possible for most places of size to get to everyone, every year? I’m thinking not, but feel free to disagree. I think it may end up going the route of hazard surveillance round frequency—you have to do as many as you have to do to cover the territory you need to cover. So, if in order to be effective, you have to do more than one fire drill per shift per quarter, then that becomes part of the algorithm used for your annual evaluation (or to use the annual evaluation as a place to ensure your clear assessment of the effectiveness of the program). There is always the potential for a surveyor to disagree with your fire drill schedule, as it relates to effective education of staff. Use the annual evaluation to document your assessment of the effectiveness—it may be the only way to keep the survey wolves away from the flock.

So, let’s get the flock out of here…

As always, hope you are well and staying safe. I’ve been traveling some over the past few weeks and, humans being humans, I think we’ve got a ways to go before we wrestle this thing to the ground, so keep those shields up!

Just when you thought it couldn’t possibly get any stranger…

But first (as promised), a word about fire drills (there will be more, maybe next week, depends on what comes flying over the transom…): About a month ago, I mentioned the possibility of a shift in fire drill frequencies for business occupancies from annual to quarterly. This was based on actual experiences during a state/CMS survey in the Southeast. At the time, it seemed a bit incongruous, but the lead Life Safety surveyor was very pointed in indicating that this was the “real deal.” Well, as it should turn out, it appears that somewhere between that pointed closing, and the receipt of the survey report and follow-up, there may have been a little excess stretching of the interpretive dance that we’ve all come to know (and not love). As of the moment, business occupancy fire drills will continue to be on the annual calendar and not the quarterly one. So, three cheers for that!

But the oddest headline of the past couple of weeks revolves around CMS and their “sense” that our friends in Chicago are being, for lack of a better term, overly transparent during the survey process, particularly during exit conferences at the end of each survey day. The thought given voice is The Joint Commission (TJC) is “(p)roviding too much detail or having extensive discussions before or during a facility inspection survey can potentially compromise the integrity of the survey process. Based on the level of detail shared, a facility could correct potential deficiencies mid-course, which would skew the findings and final outcome of the investigation,” (you can read the source article here). Exactly how this determination was made is not crystal clear to me, but it did occur during the process through which TJC’s deemed status was renewed—but only for two years.

For those of you who have participated in surveys over the year, I think we are in agreement that excessive clarity was not one of the hallmarks of the survey process, though it shivers my timbers to think of how they could become even less so. I have noticed a marked decrease in useful information, per issue, in Perspectives over the past few years, so maybe that’s one of the forums that will be less instructive as we enter the post-COVID era of accreditation surveys. We know that much of what goes down during a survey is the result of interpretation of regulations that are as broadly-scoped as they could possibly be (or are they?), so it would seem that we are looking at an even more opaque survey process—holy moley!

Until next time, be well and stay safe. We need each other—and perhaps never more than now!

Yes, I know I said fire drills, but…

Please feel free to accuse me of “dogging it,” but since I am on vacation this week and you all probably need something of a vacation from me, here’s just a quick blast relating to our latest conversation thread.

Hopefully, you noted the recent headlines indicating The Joint Commission’s (TJC) continued status as an accreditation organization with deemed status; you probably also noted that CMS continues to tighten the leash (if you will), approving their accreditation status for only two years. The CMS indicated, among other things that they “…are concerned about TJC’s review of medical records and surveying off-site locations, in particular for the Physical Environment Condition of Participation (CoP).” Talk about waving a red flag in front of a bovine nose or two!

I think we can intuit that the folks from CMS (not unlike, say, The Man from Glad, or UNCLE) were reasonably pointed in their discussions with TJC prior to making the announcement and, in the face of what might reasonably be interpreted as an existential threat, we can expect lots of attention paid to the outpatient setting(s) in general, and a keen focus on all things relating to the care environment. Certainly, the level of angst generated by this “omen” will hinge closely on how widespread your organization is and (potentially) how well your corporate structure compartmentalizes offsite locations. If you’re not sure, one thing you might consider doing is hopping over to TJC’s website for searching accredited organizations and see how your place “shakes out.” Nominally, each of the care locations they think you have should be represented, and it’s always fun to see if what’s there matches up with what you think you have. I can tell you with absolute certainty that there have been some surprises in the past and I have no reason to think the future holds anything different.

So, that’s our missive for this week  and we’ll cover fire drills next time—I wicked promise! Unless something else happens…

Take care and stay safe!