April PHC Newsletter

by dawnconrey
Patton Healthcare Consultants

Accreditation – Compliance – Patient Safety

April 2020 PHC Newsletter

Covid MaskWe wanted to do something different with this month’s newsletter for many reasons, the most important of which is almost all of our readers are fully immersed in caring for a huge influx of infectious patients while coping with diminishing resources. Our gratitude goes out to you and your colleagues for the critical support you are all providing to our nation and its people at this time. Thus, we will be brief and to the point, describing a few pieces of information that may prove useful to you now along with one issue that you will want to think about when this crisis is over.

Keeping Up with Essential Information:

covid ballOne issue our readers are always interested in is Joint Commission and CMS surveys. Both entities have ceased routine survey work at this time. In addition, the one new set of Joint Commission standards on perinatal safety that were due to take effect July 1st have been postponed until January 2021.

There has been a lot of professional and public interest as well as media coverage and controversy about the use of hydroxychloroquine and chloroquine lately. Just as we were getting started on our newsletter, the FDA issued a definitive advisory authorizing its emergency use when clinical trials are not available through the national stockpile. The link to the FDA document is: https://www.fda.gov/media/136534/download

CMS issued a press release on March 30th expanding its blanket waiver provisions. Waiver provisions include placement of hospital patients in ambulatory surgery centers, non-hospital buildings, and placing testing services in other community-based settings. They will also permit ambulance services to transport to a wider range of provider types including FQHCs, physician offices, and urgent care facilities. They also mention that hospitals can bill for services they provide outside of their four walls. Emergency departments can use telehealth services to quickly assess patients.

Hospitals may use physician assistants and nurse practitioners to the fullest extent possible under the state’s emergency preparedness plans. CMS has waived the usual physician supervision requirement for CRNAs.  For a complete listing of all the new waived requirements: https://www.cms.gov/newsroom/fact-sheets/additional-backgroundsweeping-regulatory-changes-help-us-healthcare-system-address-covid-19-patient

TJC has created a Corona virus resource page that provides multiple links to important content relative to managing this crisis.  https://www.jointcommission.org/covid-19/?ref=TJCAL20

TJC has a blog post with content of interest relative to reappointing and re-privileging during a disaster. This can be viewed at: https://www.jointcommission.org/resources/news-and-multimedia/blogs/on-infection-prevention-control/2020/03/30/re-appointing-and-re-privileging-during-a-disaster/?ref=TJCAL20

TJC also has an FAQ posted about what to do with FPPE and OPPE requirements during a disaster can be viewed at:


The American Society for Health Care Engineering, or ASHE, has dedicated a portion of their website to COVID-19 resources, many of which are available to nonmembers. Content includes recommendations for converting alternate care sites to hospital space and innovative IV pump placement to help conserve PPE. This content and more can be viewed at: https://www.ashe.org/COVID19resources

ECRI, an independent authority on the medical practices and products, also has a well done resource center.  We encourage you to visit ECRI’s COVID-19 Resource Center. Here, they have the latest information on safe respirator usage and PPE when supplies are limited. They have an insightful article on the use of infrared temperature screening to identify potential infected staff as well as a Q&A link.


We have reviewed this month’s Perspectives and EC News and there is nothing that should concern you in these publications if you do not have time to study them as you usually would. Perspectives has a lengthy article on most frequently scored standards and elements of performance, sorted by where they were placed on the Safety Matrix. However, they provide only the raw number of organizations that got scored in the various colors of the Safety Matrix instead of percentages, making it difficult to draw any meaningful conclusions. The unique thing about this article is that it does show you the most frequently scored elements of performance.

There is one article in EC News that you should share with your Facilities leadership on emergency power systems in EC.02.05.07. One or more elements of performance in this standard is scored non-compliant on hospital surveys in almost 50% of surveys. Within this article is a link to a spreadsheet they have developed for documenting generator tests. It is superbly designed documentation tool that helps to prevent missing some complex aspect of conducting the generator test. Unfortunately, the link is embedded or hidden, and we can’t paste it here, you will have to go to your EC News and click on it. But it looks very valuable to the staff that conduct generator testing.


CMS does not have any new QSO memos since our last mini newsletter was published. We have received many questions about 1135 waivers though. There have been many innovative ideas about what to waive. These state based or individual hospital-based waivers are likely becoming less necessary as CMS continues to expand its blanket waivers. If you are looking for innovative ideas on what to waive, CMS has created a website with all the approved state waivers in one location.    https://www.medicaid.gov/resources-for-states/disaster-response-toolkit/federal-disaster-resources/index.html


masksThe CDC continues to post important new information about COVID-19. They have one portion of their website dedicated to Strategies to Optimize and Conserve PPE and Equipment. Within this area they discuss conservation of eye protection, isolation gowns, face masks, there is a PPE “burn rate” calculator to estimate how many days your resources will last and utilization of ventilators. The eye protection, isolation gowns and face mask pages seem to us to have the most detailed and helpful guidance. This can be found by starting at their landing page for Corona virus, then going to the health facilities section:



covid-19We have previously written about the infrequency of EM standards scoring, however when this current crisis is over, we anticipate that there will be more focus from TJC and CMS, as well as much greater interest on the part of healthcare organizations. During this unprecedented national emergency, it is likely that every day you are identifying something that did not work as you had planned. A needed supply ran into a shortage, you didn’t know who to call in your community to access more resources or team members didn’t understand their roles and functions in the management of the crisis. Whatever it is, be sure to make notes at the end of your day on what worked and what did not. At some point, hopefully in the near future every healthcare organization is going to have a chance to evaluate the functioning of their emergency operations plan. The thoughtful critique you and your colleagues do can eliminate the need for one of your drills in 2020, but more importantly it should guide revisions to your plans so that everyone is better prepared for the next one. Then the next time you do a drill, you will want to evaluate if the flaws you identified during this crisis, seemed better managed.

Another standard you will want to critically evaluate as you prepare your 2021 plans is IC.01.06.01. This is the standard that asks hospitals to plan for an influx of potentially infectious patients. You will certainly have many important insights into this issue that you might not have had previously and want to change preparation plans for the next one.

Consultant Corner

Dear Readers,

Again, thanks for all that you are doing, stay well and best wishes in continuing to manage this crisis.
If we can be of help in researching some regulatory issue for you or offloading some routine
accreditation or regulatory follow up, such as drafting an ESC or corrective action plan, please contact us.

Jennifer Cowel, RN MHSA

Kurt Patton, MS RPh

John Rosing, MHA

Mary Cesare-Murphy, PhD