Longer Reports, More LS/EC Findings, Scoring on the SAFER™ Matrix
Thus far, we are not seeing any surprises come out of the SAFER™ Matrix. Surveyors seem to be judicious in deciding when to place issues in the red zone, with relatively few that we are seeing at this time. However, we do see a very liberal sprinkling of findings in the dark orange/mustard color area, which just like the red zone, requires management intervention in the ESC, and a discussion of preventative analysis.
In addition, there will be the conference calls with the CEO about these findings and the repeat analysis will be in sharp focus the next time you are surveyed. We are also seeing an increase in scoring of issues at a COP level with very frequent scoring of the physical environment COP, the infection control COP, the surgical safety COP, and the governing body COP.
Remember also that 2017 is the first year when we have lost the C elements of performance where 90% compliance was acceptable. Today’s surveys are scored on an absolute 100% performance expectation with single observations leading to an RFI. Seeing a 70 page or greater survey report is not that unusual this year. So many findings make the post-survey ESC a much more labor intensive project than in past years. The number of EC/LS findings we are seeing thus far is “off the charts.” We see a significant increase in findings, including at the COP level with these chapters, and it appears that TJC has now achieved its goal of scoring these issues as often as CMS. Organizations are going to need to step it up in order to avoid these heavy hitters.
New Requirements: Inspection of Exit Signs & Testing Battery Specific Gravity:
There are also new requirements as a result of the conversion to the 2012 edition of the life safety code that appear to be surprising people. For example,, EP 1 and EP 4 had new requirements, which were to have started January 1, 2017. EP 1 was a long-established requirement to check battery powered exit lighting once a month, but they added a second aspect to this EP to also require a visual inspection of Exit signs. Forms that were in use in hospitals made it easy to document the inspection of the battery-operated lights, however many organizations failed to add the second component, which was a visual inspection of the Exit sign itself. If you did not change your process January 2017, you will not be able to create a complete track record for this year. Thus, any surveys conducted in 2017 will likely have this EP scored noncompliant if you missed adding this feature. EP 4 is another new requirement to test the batteries used to start your emergency generator. For many years hospitals have been testing their emergency generators and had forms to document these tests. Unfortunately, these forms in use did not include documentation of checking either the specific gravity of an unsealed lead-acid battery, or conductance of a sealed battery.
Subsequent blog postings this month will report on additional findings seen thus fare in 2017. Please stay tuned!
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