New behavioral health standards were announced in this month’s Perspectives. These standards revisions added a fifth EP. It states, when “clinically relevant,” behavioral health organizations must consult other physical healthcare services providers. Furthermore, if obtaining information from those organizations isn’t possible, it requires documentation. In addition, the standard necessitates quantifying the reasons. The difficulty with the wording is “clinically relevant.” The subjective term “treating the patient”and the clinical team’s interpretation creates issues. The biggest challenge, how surveyors define the term “treating your patient.”
Perspectives includes another in their series on Life Safety Code Clarifications and Expectations. This month, it reviews LS.02.01.30, including both current and potentially new requirements effective January 1, 2018. The CMS and TJC are still negotiating new requirements.
Perspectives recently published new medication compounding standards. Although it’s only a small article on page 2 in the publication, it’s worthy of greater exposure.
The lead article in this month’s edition of Perspectives details their revised pain management standards. Initiating and implementation a plan soon is important with the standards due to take effect January 1, 2018.
CMS published numerous new Survey and Certification memos this month. All things considered, these memos should not pose a significant challenge to our readers.
Filling Saline Syringes
The first memo, 17-31, addressed ESRD facilities. It recommends not filling saline syringes for patients from a large volume saline bag. Presumably, CMS surveyors found staff filling saline syringes from a hanging IV bag. That should never be done. As a matter of fact, purchasing saline syringes from a manufacturer is the right process. The FDA considers a saline bag a single dose package. It’s a potential source of contamination if drawing from a bag already hanging on a patient.
New S&C Memo on Cleaning Dialysis Equipment After a Patient Leaves the Space
The second memo, 17-32, is similarly simple and also addresses ESRD facilities. It covers cleaning dialysis equipment, surfaces, tables, chairs, and more. In fact, cleaning should only occur once the patient vacates the location. Again, CMS has reportedly seen staff starting their cleaning activities while the patient is still present. Unfortunately, this could potentially re-contaminate something.
New S&C Memo on Screening for Hepatitis C
The third memo, also addressed to ESRD facilities, discusses that CMS will not cite ESRD facilities if they fail to screen for hepatitis C. Consider hepatitis C based on elevated liver enzymes, in particular ALT. But, routine screening is not required.
New S&C Memo on Revisions to the 2567 Completions Process
The fourth memo discusses the 2567 that hospitals receive as their statement of deficiencies. It eliminates typing the corrective action on their form, near the citation, requirement. CMS will eliminate that placement requirement. Instead, you can address the deficiencies in a separate document. This 2567 form has been a burden for many years. As a matter of fact, a type-able PDF would have been a preferable solution. There is some risk that a redundant or repetitive finding cited under different COP’s might be missed if you are not documenting corrective actions next to each finding.