September 2017 PHC Newsletter

by dawnconrey
Patton Healthcare Consultants

Accreditation – Compliance – Patient Safety

September 2017

Inside This Issue

September 2017 PHC Newsletter


New Medication Management Standards – What to do Now:

We hope everyone had a pleasant summer and you are all geared up for another “academic year” of survey readiness. We last published in July so in this month’s newsletter we will be discussing requirements or content updated in the August and September editions of Perspectives and EC News. The July Perspectives discussed the new Medication Management requirements, which take effect January 1, 2018. These were not republished in Perspectives, but they were posted to the Joint Commission website June 28th and they are still available at this time for downloading from the prepublication section of the “Standards” section. There are 6 changes relative to medication management, but only 5 should take any thought or effort to implement. The 6th one is a modification to RC.02.01.01 requiring the date and time of administration of medications to be in the medical record. We believe this to be an already well-established practice in hospitals, so this one should be easy. Do take a look at procedural and operative documentation of medications though to ensure that those include date and time.

Essential Medication Refrigerators need Emergency Electrical Backup:

There is a new requirement under EC.02.05.03 to establish and implement a policy for emergency electrical backup for essential medication refrigerators and automated dispensing cabinets (ADC). This does not require every refrigerator, or ADC to be connected to emergency power, but you do have to have a sufficient number to enable products to be stored properly and be accessible. At a minimum, you want to take a look at existing devices to determine which are already connected to emergency power, and determine if that number sufficient. In addition, you will need to develop 2 policies to cover medication refrigerators and ADC’s since both elements of performance include a D for documentation. One other suggestion for this one, so you look like you are really on top of things, is to make a minor modification to include a sentence or two about this process in your Environment of Care Utilities plan for 2018.

Define Approved Method for Wasting Medications:

MM.03.01.01, EP 4 is modified and this is an interesting one to take a look at. Joint Commission has added a requirement to include a statement about your approved method of wasting medications after a provider has accessed them and prior to administration. There are currently 5 content points that should be addressed in this policy, and now a 6th has been added. The curious thing about this requirement is that the policy expectation has been around for many years, yet many hospitals we visit, don’t actually have a written policy. They have practices that have not been documented in a policy. So, take a look and verify that your hospital has a written policy that addresses the control of medication between receipt by an individual healthcare provider and administration of the medication that includes safe storage, handling, wasting, security, disposition and return to storage. A key question that surveyors might ask about this requirement is: do you permit staff to carry medications in their pockets or in fanny packs, and please show me the policy that discusses this issue? In this case, would the fanny pack or pocket meet the proper temperature storage expectations for “safe storage” of the medication? Also, what happens to the medication or fanny pack at the end of the day if there are still medications remaining? Can they be returned to storage?

“Signed and Held” Medication Orders:

MM.04.01.01, EP 1 currently discusses the types of medication orders that are acceptable for use in your hospital and each should be described and authorized in written policies. For 2018, Joint Commission has added to this list of medication order-types to include “signed and held” orders. They don’t require that you use them, but if you do, their proper use should be governed by a written policy. As you consider this issue, do take a look at the FAQ/Interpretation posted under the PC chapter using the title: “Orders – cancelling and rewriting orders following a procedure or transition in care.” Now, this is unfortunately a little convoluted, but TJC expects that care, treatment and services are based on the most recent orders, and the most recent assessed needs of the patient. Signed and held orders are commonly used for post-operative orders and sometimes providers want to write these orders prior to conducting the procedure. Prior to EMR technology, TJC just prohibited this practice, but with the EMR, TJC has relented and now says signed and held orders can be entered electronically and, if conditions warrant (i.e., the patient’s post-operative condition is as was expected), the post-operative orders can be released. The challenge for nursing and pharmacy is to know if it is appropriate to release the orders and implement them. If the provider releases the signed and held orders after a procedure, then you know that the provider has determined it is safe and appropriate based on their current assessment to release those new orders. However, if the provider expects nursing staff to release them upon arrival in the new care location, then some formal handoff is needed to allow the nursing staff to know it is still appropriate to release those orders written prior to the procedure. So, this new requirement will take some thoughtful discussion and policy development if you intend to use signed and held orders.

Define Medication Overrides to Review:

There is also a new EP 16 for MM.08.01.01 that establishes a policy expectation to identify the types of medication overrides that will be reviewed for appropriateness and the frequency of review. TJC also states that 100% review of overrides is not required. So, three things will need to be done. First, develop the policy expectation for which overrides will be reviewed. Second, develop the policy expectation for how often you will be analyzing this issue, and third, actually conduct and document your analysis. For those organizations that do perform an end-of-year summary for all the requirements in MM.08.01.01 you would also want to add this new issue to your analysis summary.

All of these new requirements take effect 1/1/18 so now is the time to develop the policies and processes so each is implemented prior to the end of the year.

The Clarifications and Expectations column continued in July and August discussing LS.02.01.30, EP’s 1 – 15. Hopefully EP’s 16-25 will be discussed in the October Perspectives. Both articles should be shared with your facilities leadership team and, given what we will talk about later in this newsletter about frequently scored standards, should be a focus of rigorous self-assessment. Joint Commission boxes each EP inside what they call a “Standards Connection.” Four basic questions should be asked about each requirement. 1. Do we do this or do we have this? 2. What evidence do we have that validates we know we do this or have this? 3. What is the re-inspection frequency for this issue that keeps us on top of the requirement? Lastly, when we conduct our self-assessments, how often do we see zero defects?

Focus on the Top Scored –  Scoring Frequency Accelerates!

#1: The September Perspectives posts the first half year of 2017 most frequently scored standards. The specific standards scored frequently is not surprising, they are again the “usual suspects,” however the frequency with which they are being scored has risen dramatically. The most frequently scored standard is LS.02.01.35, which back in 2016 was the 4th most frequently scored standard. In the first half of 2017 this standard was scored in 86% of hospital surveys! This is the extinguishment standard and there are many facets and unique requirements underneath it. These include not connecting anything above the ceiling to sprinkler pipes, the long standing 18” rule for storage, keeping sprinkler heads clean and the new requirement added as a result of changing to the 2012 LSC to keep at least 6 spares of each type of sprinkler head in use in the hospital. We have seen this requirement for spares surprise many organizations and the issue about not connecting anything to the sprinkler pipe or having wire drape over the pipe has been going up in recent years also.

#2: The second most frequently scored standard is LS.02.01.30, which was the standard discussed in the Clarifications and Expectations column in both July and August. There are 25 different elements of performance under this standard and 74% of hospitals have been scored noncompliant in the first half of 2017. Issues such as self-closing doors in hazardous areas, properly installed alcohol gel dispensers, corridor door latching, smoke barrier doors with minimal gaps and smoke dampers in smoke barrier walls not protected by automatic sprinkler systems are all covered by this standard. Remember in 2017 zero defects are permitted. No longer is 90% adequate so if you are finding defects during your regular inspections, you will want to increase the frequency of inspections and preventative maintenance.

#3:  EC.02.05.01 is the third most frequently scored standard at 73%, up from 57% in 2016. This is a utilities standard with 19 elements of performance. The one EP that has been highly problematic is EP 15 for maintaining appropriate air pressure relationships, temperatures and humidity. Too often air pressure, temperature or humidity is not where is should be on the day the surveyor is present, or there is documentation that it has been out of range and no one has documented any actions taken to bring it back into range. A key to making this work successfully is audible and visual alarms that tell staff that temperature, humidity or air pressure is out of range. Too often these parameters are out of range when the surveyor is present and no one has even noticed. A second key to success is an automated documentation system that mandates documentation of efforts taken in order to clear the alarm notice.

#4:  The fourth most frequently scored standard is IC.02.02.01 which deals with high level disinfection and sterilization. We have talked about all the things that can go wrong with this standard in previous editions of this newsletter. The bad news is the frequency of scoring has gone up to 70% of hospitals from 60% in 2016. The surveyors are clearly getting better and better at evaluating these requirements and hospitals are not keeping up.

#5:  Surprisingly EC.02.06.01 is the fifth most frequently scored standard holding steady at 68% of hospitals surveyed in 2017. What is surprising here is that this is where suicide ligature issues are scored, and that has had a lot of additional scrutiny in 2017. It is also somewhat of a potpourri standard where just about any defect or hazard in the physical environment can be scored.

New to the Top 10:

There is one new standard that made the top 10 list this time and that is EC.02.05.05, which has been scored in 60% of hospital surveys in 2017. This standard has one element of performance requiring a PCRA type analysis before utilities repairs, and 6 additional EP’s requiring inspection and documentation of utilities systems. If one comes on the list, then one must go off and that was PC.02.01.03. This standard requires protocols to be documented in the medical record and most likely has not diminished in importance, it’s just that other standards have risen in frequency of scoring that caused it to be replaced.

As always, we would advise preparing for these 10 frequent flyers, and self-assess often and rigorously. We often get questions from hospitals about really obscure standards that are infrequently scored. They are infrequently scored because even the surveyors perceive them to be obscure, or not survey-able. Spend your time and energy on the hot topics that are scored almost everywhere. Standards that have 20 or more elements of performance and multiple hidden details that are embedded in NFPA or AAMI references are where we would suggest focusing.

More Focus on LSC & Environment of Care (EC):

Although we all keep seeing the scoring of LSC issues going up, it’s not enough yet, apparently. In the September issue of Perspectives TJC announced a change to the scheduling rules for the LSC review in that organizations with multiple sites providing general med/surg inpatient services greater than a mile from the main hospital campus, now these additional inpatient sites of care will each add 2 days to the LSC review instead of 1. In addition, CMS published its annual report to Congress on the comparison of CMS and accrediting body findings. This was published in SC Memo 17-40 on July 28. The bad news is it again reflects an unacceptably high disparity rate, meaning CMS is finding more COP deficiencies than the accrediting bodies and LSC remains very problematic. These reports are always published using 2-year-old data, and during the analysis phase TJC may have already started corrective action, but readers should expect a continued heavy focus on LSC and EC issues going forward. Appendix B of the report provides a breakdown on the types of LSC/EC issues identified by CMS, but not identified by the individual accrediting bodies. The CMS frequent flyer list published in this disparity report includes sprinkler issues, means of egress, fire and smoke barriers, hazardous areas, electrical, doors and fire alarm issues.

Sentinel Event Statistics: First Half 2017

Perspectives provides a first half year summary of sentinel event statistics as reported by healthcare organizations. The most frequently reported sentinel event in the first half year of 2017 was falls, 49, and the second most frequently reported sentinel event was suicide, 43. This was followed by unintended retained foreign objects or URFO’s 41, and wrong patient, wrong site, wrong procedure surgery 35. These are very high numbers of mostly self-reported events, which are the tip of the iceberg. In addition, given the emphasis in 2017 on ligature identification and mitigation this year, this being the 13th year since the development of the universal protocol and 15th year since the NPSG on fall prevention was first published, its apparent that much more remains to be done.


The August and September editions of EC News duplicate the earlier mention of the Clarifications and Expectations Column published in Perspectives. The August EC News has an informative article on “improving Communication between physical environment personnel and clinical staff.” While it does not contain new action items, it is worthwhile reading material for members of your interdisciplinary environment of care committee, just to help them understand each other’s perspective. There is also an OSHA related article on safe patient handling that again is worthwhile reading for an EC or safety committee, while also reviewing your own employee injury reports.

The September EC News has an article on Legionnaires’ disease. This was likely added as a result of the CMS SC memo 17-30 on legionella. In the EC News article, Joint Commission lists the standards it has which should be evaluated in the context of the CMS memo on legionella prevention. The CMS memo and this EC News article should be discussed and analyzed at both infection control and environment of care committees.

Joint Commission Online:

Monitoring BH Patients Progress Requirement and Database of Tools:

The August 30 edition of this weekly newsletter mentioned a database on behavioral health measurement tools that TJC has compiled for behavioral health providers. As you might remember the behavioral health accreditation manual has a new standard taking effect 1/1/18 requiring providers to measure and monitor patient progress using standardize tools. While there are many such tools published in the professional literature, TJC has compiled a subset in a database for your use. This listing can be access through the Joint Commission website at:


Another Look at Legionnaires Disease:

The above referenced CMS memo on Legionnaires’ disease is probably the most important of their several memos issued this summer.  In this memo, CMS establishes an expectation that healthcare facilities: “have water management policies and procedures to reduce the risk of growth and spread of legionella.” Then CMS identifies 3 expectations that its surveyors will be looking for in policies, procedures and reports documenting implementation of the water management program.

  1. Conduct a facility risk assessment to identify where legionella and other waterborne opportunistic pathogens could grow and spread in the facility water system.
  2. Implement a water management program that considers the ASHRAE industry standard and the CDC toolkit and includes control measures such as physical controls, temperature management, disinfectant level control, visual inspections and environmental testing for pathogens.
  3. Specify testing protocols and acceptable ranges for control measures, and document the results of testing and corrective actions taken when control limits are not maintained.

There is not a lot of specific content or how-to details in the CMS memo, but fortunately they mention guidance from ASHRAE 188 published in 2015 on prevention of Legionellosis which is available for purchase and the free 2016 CDC toolkit which basically helps facilitate implementation of that ASHRAE standard. The CDC toolkit is 32 pages in length and has many checklists and graphic depictions of potential issues that make for an easier read for most of us. The CDC toolkit identifies 7 specific elements of a water management program that should be in place and they are:

  1. Identify a water management team
  2. Describe the building water systems using text and flow diagrams
  3. Identify areas where legionella could grow and spread
  4. Decide where control measures should be applied and how to monitor them
  5. Establish ways to intervene when control limits are not met
  6. Make sure the program is running as designed and is effective
  7. Document and communicate all the activities

Link to Top Scored CMS Findings:

There was also CMS SC memo 17-43 issued on August 22, 2017. This memo does not have action items you have to worry about, but does mention a new searchable database CMS has established which provides information on CMS survey findings and frequencies. While many of the issues we discuss in this newsletter are actionable, this is more one for taking a look at when time permits, only because it is interesting. CMS has created a database they call QCOR, or quality, certification and oversight reports. The link to this database is contained in the CMS memo. This database allows you to run reports by provider type to identify the most frequently scored clinical issues or life safety code issues. In looking at just surveys conducted in 2017 you will find the top 5 clinical tags scored are A-0395, A-0144, A-0749, A-0115 and A-0396. These are RN supervision of nursing care, patient rights to care in a safe setting, infection control program, patient rights, and nursing care plans, respectively. With the exception of infection control, these are quite different that the most frequently scored TJC clinical issues. You can also analyze just life safety code reviews and thus far in 2017 the top 5 K tags were K-0353, K-0321, K-0363, K-0372 and K-0918. These are sprinkler systems, hazardous areas, corridor doors, smoke barriers and electrical systems respectively. Here you can see greater correlation between what TJC is finding and what CMS is finding in 2017.

No matter whose survey you are expecting it is useful to know what your colleagues are getting scored for on survey from both CMS and TJC. That way you can be ready, no matter who knocks on your door.


Consultant Corner

Hope everyone has enjoyed their summer and wherever you are, we hope that you are all safe with the weather recently!

Have a wonderful month!

Thank you,

Jennifer Cowel, RN MHSA

Kurt Patton, MS RPh

John Rosing, MHA

Mary Cesare-Murphy, PhD