The December edition of Joint Commission Perspectives and the November 23 edition of JC Online describes the changes planned for evaluating ILSM’s, or interim life safety measures. Effective immediately if TJC identifies a life safety code defect during a survey, surveyors will discuss that defect with the organization and ask which of your interim life safety measures are going to be implemented in order to protect patients, staff and visitors until the defect can be corrected. The chosen ILSM should come from your ILSM policy.
Cyber Security Addressed
The lead article in the November 2016 issue of EC News is about cyber security. Given that we have just concluded a long presidential campaign where cyber security became a hot button topic, this discussion for hospitals is very timely. The article suggests including cyber attacks in your hazard vulnerability assessment, which must be updated each year. There is also a sidebar reference to a host of cyber security references. We probably all get several emails each week allegedly from FedEx stating they could not deliver a package, or some bank you don’t have an account with stating they need your information and they provide you a zip file to click. Hopefully now that the presidential campaign is over with, we have all been made better aware that clicking any of these links can be dangerous, either to personal information, or your hospitals information. The article is definitely worth sharing with IT and the staff who lead your emergency management planning.
The Joint Commission recently published new EC and LS chapters with two documents posted to the TJC website, one being just the new standards and the second being a side-by-side comparison of the new standards and the old standards. This latter document is the most useful of the two to analyze because it allows you to scan each requirement to see what is identical and what is new. You want someone with great attention to detail and reading skills to read this document and highlight each requirement that is new, or now includes new NFPA references.
On September 8th CMS published Survey and Certification memo 16-38 notifying us of the publication of its final rule for emergency preparedness. The details of this rule were published in the Federal Register on September 16th and the new regulation goes into effect November 16, 2016. Accredited hospitals should have a relatively easy time with this, but the scope of this regulation goes far beyond hospitals. This rule will also affect community mental health centers, residential treatment centers, ambulatory surgery centers, hospice, PACE programs, long term care facilities, intermediate care facilities, home health agencies, comprehensive outpatient rehabilitation facilities, end stage renal dialysis centers, rural health clinics and even your organ procurement organization. Read more
The October 2016 issue of The Joint Commission Perspectives has a must read for your facilities leadership team in its Clarifications and Expectations column. Here George Mills summarizes all the changes brought about by eliminating the regular PFI, the elimination of clarifications for delayed handling of required documents in the survey process, ILSM documentation, time limited waivers and equivalencies. There are many new acronyms to learn too with TLW, time limited waivers, SPFI, survey related plans for improvement, and SCD for scheduled completion date. Read more