January 2018 PHC Newsletter

by dawnconrey
Patton Healthcare Consultants

Accreditation – Compliance – Patient Safety

January 2018

Inside This Issue

  • Perspectives
    • New Suicide Risk Recommendations for Partial, Day Treatment, and IOP Services
    • Change to the Credentialing and Privileging for Pathologists at Contracted Labs
    • New PC Requirements for Maternal and Newborn Care
    • Things to Share with Facilities Leadership: Consistent Interpretation
  • EC News
    • Revisions and Issues with LS.02.01.35 – Review and Self-Assess
    • Lessons Learned from Hurricane Harvey – EOP Committee Take Note
  • 2018 Customer Survey Activity Guide
    • Changes to the Day One Document List: Action Required Now
    • Revisions to System Tracers and Patient Tracers Focus on Pain and Emergency Management
  • CMS Updates
    • CMS Memo Summarizes Ligature Risks in Hospitals
    • CMS Offers a Modification to the Texting Prohibition
  • Happy New Year!

January 2018 PHC Newsletter


New Suicide Risk Recommendations for Partial, Day Treatment, and IOP Services:

This month’s Perspectives describes the results of their December 8, 2017 ligature task force and expands upon their discussion about ligature safety into residential, partial, day treatment and intensive outpatient services. The same numbering sequence used in their November issue is used again, adding recommendations 14, 15 and 16. Recommendation 14 simply states that above mentioned program facilities need not be ligature free. Recommendation 15 is the most complex, stating that these organizations should conduct a risk assessment to identify elements in the environment that residents could use to harm themselves, visitors or staff. Furthermore, those items that have a high potential for harm that can be removed should be removed such as scissors, or sharp cooking utensils, and locked until needed. In addition, staff should be trained to be aware of the elements in the environment that may pose a risk to a resident who could develop serious suicide ideation. Staff should be trained to keep the patient safe until they can be stabilized or transferred to a higher level of care. Lastly, recommendation 16 requires an organization to have policies and procedures implemented to address how to manage a patient who may experience an increase in symptoms that could result in self harm.

CMS has weighed in on ligature safety now also and their advice is remarkably consistent with that of TJC.  See this month’s CMS section.

Change to the Credentialing and Privileging for Pathologists at Contracted Labs:

Joint Commission announced this month that pathologists who provide external oversight of a contracted laboratory will no longer require credentialing and privileging by the Joint Commission accredited hospital. This deviates from a long-standing practice requiring credentialing and privileging for any type of licensed independent practitioner providing contracted services remotely. Joint Commission identified the logic for the change, that since the external laboratory must be compliant with CLIA regulations, it can be assumed that these pathologists are qualified and competent to perform diagnostic services. The contracted pathologist who provides services directly onsite at the hospital either in the laboratory or reviewing specimens will still require the hospital to credential and privilege them.

 New PC Requirements for Maternal and Newborn Care:

Perspectives also discusses three new PC requirements relative to maternal and newborn care. These will be EP’s 14, 15 and 16 at PC.01.02.01, effective July 1, 2018. EP 14 requires that upon admission to Labor and Delivery, the mother’s status relative to HIV, Hepatitis B, Group B strep, and syphilis be documented in the medical record. EP 15 then states that if the mother’s status is unknown because there was no prenatal care, then testing will be performed to identify the status. Since the Group B strep results will not be available for 24-48 hours, hospitals may choose not to perform the test, but rather to just administer prophylactic antibiotics. Lastly, EP 16 requires that if the mother tests positive for the previously mentioned diseases, then that status is also noted in the medical record for the newborn.

Things to Share with Facilities Leadership: Consistent Interpretation:

There is another in the series of articles entitled Consistent Interpretation. This one does not appear to point out inappropriate scoring, but rather points out the significance of a wide variety of issues that can be scored under LS.02.01.35, EP’s 4, 5, and 14. This is a great one to share with facilities leadership and to self-assess how your hospital is conducting preventative assessments to avoid these RFI’s.

EP 4 is where they score anything that it tied off, touching or somehow connected above the ceiling to the fire sprinkler pipe. Nothing can be connected to or resting upon the sprinkler pipe. The question to pose in self assessing is what is our process to periodically inspect this invisible space above the suspended ceiling, and what do we do in terms of an inspection process after staff or a contractor have been working above the ceiling? Joint Commission reports this EP was scored in 58% of hospital surveys in the first half of 2017.

EP 5 is where they scored damaged or dirty sprinkler heads. This was scored in 39.4% of hospital surveys in the first half of 2017. The self-assessment question to ask here is; what is our process to inspect and/or periodically clean sprinkler heads?

EP 14 is the potpourri standard where almost anything concerning fire suppression not scored in a more exacting EP can be scored. They highlight missing escutcheon plates around sprinkler heads, broken ceiling tiles allowing the passage of fire and smoke above the suspended ceiling, an inadequately designed Ansul suppression system in the kitchen, a blocked fire extinguisher, an unlabeled fire department connection and behavioral health staff not being assigned keys to locking fire extinguisher cabinets. This EP, scored for a variety of issues was identified in 34.5% of surveys in the first half of 2017. Each one of these diverse issues should be examined pro-actively to verify that your organization has a process to prevent these issues from arising on survey.

EC News:

This month’s EC News discusses the new requirements for 2018 as a result of aligning with the new CMS K tags. We discussed these last month in the newsletter so we won’t discuss them again, but the article should certainly be shared with facilities leadership as a reminder.

Revisions and Issues with LS.02.01.35 – Review and Self-Assess:

There is also a detailed article on revisions and issues with LS.02.01.35, which coincidentally is the same troublesome standard discussed in Perspectives which we summarized above. As if this standard was not difficult enough already, this EC News article discusses new requirements added to LS.02.01.35 for 2018. EP 8 is modified to exempt clothes closets from having their own sprinkler head if the closet is less than 6 square feet. EP 9 was minimally changed by altering the NFPA reference on which the standard is based, however the text remains the same. This article does give a nice description of the advantages of quick response sprinklers.

EP 10 contains the requirements for placement of portable fire extinguishers. The article points out the nuance that spacing them every 75 feet apart if insufficient. They must be placed no more than 75 feet “travel distance from any point”. The subtle difference is that every 75 feet down a hallway is insufficient, as you must account for the additional travel distance into a patient room.

EP 11 discusses the K type fire extinguishers you must have for combustible cooking media such as vegetable oils and fats. The specific requirement discussed is that you must have signage near the K type fire extinguisher that indicates the automatic fire suppression system must be activated first, prior to attempting to use the K type fire extinguisher. There must also be staff training on this issue.

EP 12 establishes the requirement for an exhaust hood, exhaust duct system and grease removal devices along with a prohibition on mesh type filters above grease producing cooking devices. Although the language is not in the EP, the article does point out an important feature from the NFPA reference that the exhaust duct system must be heavier gauge material than conventional heating and cooling ductwork and have what they call “liquid tight welds” to direct the grease by-products to a safe location.

EP 13 is modified as compared to the EP published at the beginning of 2017, which simply stated that the automatic fire extinguishing system above grease producing devices should control the exhaust fans as designed. For 2018, this is modified to state that the system “deactivates the fuel source, activates the building alarm and controls the exhaust system as designed.”

Lessons Learned from Hurricane Harvey – EOP Committee Take Note:

EC News also has an instructive article on Lessons Learned from Texas hospitals after 2017’s Hurricane Harvey. This should be shared with your emergency management planning committee and decisions made about potential modifications to your own internal EOP based on the lessons learned by Texas hospitals. The lessons discussed include:

  • Highlighting the importance of internal and external evacuation drills.
  • Developing communication plans for alternate care sites
  • Planning to assist vulnerable populations such as dialysis and home ventilator patients
  • Monitoring available doses of vaccines
  • Planning for long term contingency planning for care beyond 96 hours
  • Work on forecasting changing conditions relative to decisions on sheltering in place, suspending services or evacuating.
  • Fortify defenses, including consideration of submarine type doors.
  • Anticipate staff impacts for those who live within the disaster area
  • Arrange for psychological support for patients, staff, leaders and first responders.
  • Consider alternate modes of transportation for supplies and staff, such as boats.
  • Focus on logistics including receiving supplies or patients via helicopter
  • Coordinate and communicate with other organizations potentially impacted such as home care agencies or elderly residential communities.

2018 Customer Survey Activity Guide:

Changes to the Day One Document List: Action Required Now:

In late December, Joint Commission updated the customer version of the survey activity guide without any fanfare or lengthy discussion in its publications. There are some very important changes to the required documents list and some important discussion topics you should be prepared for on system and patient tracers. Everyone will need to modify their day-one binders or flash drives containing these required documents. The following highlights the changes to the day-one document list.

The requirement for providing the EOP, now item 27 for 2018 has been modified to specifically add that the 2018 update should include communications plans.

Item 28 is new, requiring a Continuity of Operations plan. The content for this plan is described in the new EM.02.01.01, EP 12 for 2018.

Item 29 is new, requiring documentation of your completed or attempted contacts with local, state, tribal, regional, and federal EM officials in your service area. The details behind this requirement are in the new EM.02.02.01, EP 22.

Item 30 states you should have documentation of annual training for your EM plans. It is not really clear what they want here, but our assumption is this would be a description of what you have done, maybe some dates and summary statistics of training that has occurred, while individual employee files would contain the evidence that specific individuals have completed the training.

Item 31 requires a discussion of the tracking system you have developed for sheltered and relocated patients.

Item 32 requires an emergency management policy. See the new EM.02.01.01, EP 16.

Item 33 requires emergency management protocols for transplant services. See the new EM.02.01.01, EP 13.

Item 34 requires integrated EM risk assessments, plan and an annual review. See the new EM.04.01.01, EP 1.

Lastly, mandatory document 56 requires the final reports of certification and testing for all primary and secondary engineering controls associated with sterile compounding, including any remediation based on reported results. As we have previously reported, Joint Commission has a cadre of pharmacist surveyors with extensive knowledge of USP 797 that are participating on all home care pharmacy surveys and some hospital surveys and it appears that the life safety code surveyors are becoming very familiar with these engineering reports.

 Revisions to System Tracers and Patient Tracers Focus on Pain and Emergency Management:

In addition to changes to the required documents there are some changes to the system tracers and patient tracers to aide in the evaluation of new standards for pain management and emergency management. We suggest careful attention to the revisions on page 64 and 65 of the document on the EOC and EM session. This may also help explain what TJC is looking for in some of the document requirements. Staff participating in the data management system tracer should be prepared to discuss data being collected to evaluate pain assessment, pain management and safe opioid use. Staff and physicians being interviewed during patient tracers may be asked what the hospital is doing to promote safe opioid prescribing and what non-pharmacologic treatments are available.  Staff and physicians should also be able to talk about their hospital’s use of the states, “prescription drug monitoring database” and show surveyors how to access it.

CMS Update:

CMS Memo Summarizes Ligature Risks in Hospitals:

On December 8, CMS posted SC 18-06 focusing on ligature risks in psychiatric hospitals and psychiatric units of general hospitals. The good news is their guidance seems quite similar in direction to what TJC has recently published and we have discussed. Environmental risk assessments are required as are clinical screenings to detect suicide risk. A perfectly safe physical environment is not mandatory, but absent that safe environment, an effective mitigation strategy must be in place to keep patients safe. In the memo, CMS specifically states they will declare immediate jeopardy if unmitigated risks are identified. However, they also state that unmitigated ligature hazards that do not reach the immediate jeopardy threshold must be corrected within 60 days. We assume this apparent contradiction is due to the potential significance of the ligature hazard and probability of use.  (The good news here is that CMS will entertain requests to extend this deadline to allow for construction, renovation or purchase of new fixtures. Accredited hospitals should start the request process through their accrediting organization. The AO may not grant the request, but the AO can provide their recommendation to CMS for final approval.


 CMS Offers a Modification to the Texting Prohibition:

CMS also issued SC memo 18-10 on December 28th, 2017, again clarifying their position on texting in hospitals. The absolute prohibition has been modified to permit texting of notes between clinicians using secure, encrypted texting platforms. Thus, do nothing unless and until your IT department says they have approved the secure, encrypted platform to protect HIPAA confidentiality. In this same memo, CMS reiterates its past position that texting may not be used for communication of provider orders to staff. This is to be done using the hospitals CPOE system. We would encourage our readers to print and discuss this CMS memo with all interested parties at your hospital before authorizing any change in practices relative to texting.


Happy New Year!

Happy New Year to our readers and good luck during what will undoubtedly be another interesting and challenging year for quality improvement programs and regulatory oversight! This being January, don’t forget about your annual plan evaluations and plan updates for TJC. Not having these on January 1 would likely be accepted on survey, but with each month that goes by, any excuse is less and less appropriate. With the year-long changes in EC and LS standards throughout 2017, there is also risk that your plans are out of date if not thoroughly updated in accordance with all those changes.

Consultant Corner

Happy 2018!  We hope everyone had a safe and joyous Holiday Season!

Assessing suicide risk is a critical step for safe patient care and a smooth survey.
Call 888-PHC-INC1 or email ExpertAdvice@PattonHC.com to conduct a detailed suicide risk assessment.


Thank you,

Jennifer Cowel, RN MHSA

Kurt Patton, MS RPh

John Rosing, MHA

Mary Cesare-Murphy, PhD