Patton Post – April 2024

April 2024

Inside This Issue

Fire Door Inspections:

There is a very helpful article in this month’s issue of EC News on inspecting fire door assemblies. EC.02.03.05, EP 25 requires these doors to be inspected on an annual basis, but again the EP language does not spell out all the required details and nuances of this inspection process. Note 3 to this EP provides multiple NFPA manual references that do spell out these required details, providing you actually look up each NFPA manual reference.

The good news is that the author of this article has included a link to an inspection checklist he has developed that includes these requirements. Be sure to click on this link and compare and evaluate the author’s tool with your own. The author also details some frequently seen problems with fire door assemblies such as rating labels that are no longer legible, often due to painting over the label. If this paint cannot be removed, you will have to have a company come in to rerate the assembly and put on new labels. Of course, a much better and less expensive technique is to educate the staff or contactors to the need to protect those labels during the painting process.

The author also points out the need for an accurate inventory of fire doors, including the verification of inventory from one annual inspection to another, unless you know that you have actually gained or lost doors during the year. The issue of fire door inspections is very frequently scored because an inspection was missed, an inspection was cursory and missed required elements of the evaluation, or the surveyors note that a fire door is actually nonfunctional because of an alignment defect or latching mechanism failure.

We see many accreditation reports where the surveyor has noted a defect as “observed and corrected on site.” Organizations appear to find it easy to correct many of the identified defects, but you still have the RFI and need to explain corrective/preventative actions in your post survey evidence of standards compliance. The value to a thorough annual fire door inspection process cannot be overstated.

ICRA, PCRA, Life Safety Inspections, and ILSM:

This month’s EC News includes the second part of the article discussed last month on ICRA, PCRA, ILSM, and construction safety. In this Part 2, the author describes issues that should be examined during your construction project such as barrier maintenance/inspection processes, security for tools and the construction site where theft or patient harm could occur to people who wander into the poorly secured area. They also advise cleanliness inspections during the project to ensure that contamination of patient care areas is not occurring.

One suggestion provided is tacky mats to help contain dust spreading from the construction site. We would also suggest inspecting those tacky mats as we sometimes see them looking like the same tacky mat has remained in place since the beginning of time, negating its effectiveness. This article is certainly worth sharing with your staff responsible for construction oversight, development of ICRA and PCRA processes and/or inspections of projects, as well as administrative leaders who make rounds.

Spring Cleaning:

EC News also contains an article on “5 Tips for Spring Cleaning,” which can mean taking a look at the facility for any damage that might have occurred over the winter including leaks, mold, tripping hazards, etc. When we earlier discussed the Perspectives article on the most frequently scored elements of performance, we noted that the catch all environmental defect EP, EC.02.06.01, EP 1 is on the list with over 200 organizations cited with a high risk finding due to a miscellaneous environmental defect, thus considering this spring-cleaning checkup is good advice.

This article also mentions the potential for expired cleaning chemicals, sterilants, pesticides, or test strips. The guidance to inspect for such expirations is followed by advice to risk assess which chemicals are in use and if corrosive products are present, and verifying a plumbed eyewash is available to staff using those chemicals. These chemical warnings go hand in hand, as some chemicals fall into disuse and other new chemicals are started in use, meaning you want to verify the Safety Data sheets are available for chemicals in use and that any location that has started to use a new corrosive substance has access to a plumbed eyewash, or find an alternative for the corrosive. We often find this risk and noncompliance in outpatient areas where they may be purchasing their own chemicals or contracted cleaners are purchasing chemicals different from those in use at the main site, that may contain corrosives.

Discharge Planning:

CIHQ published two recent blog posts last month discussing discharge planning. The first March blog, “5 Tips for Discharge Planning,” provides tips which are general in nature and advisory. This post can be found in their Medical Records category from the CIHQ Blog Archive page.

The second March blog is entitled “Performance Improvement in Discharge Planning,” and it provides guidance on issues to monitor to help evaluate the quality of the process. With QAPI becoming an increasingly important factor in accreditation or CMS surveys these tips are very timely. Specific suggestions include monitoring hospital readmission rates and potentially preventable reasons for readmission, as well as post-acute provider communication that CMS addressed in 2023.  This post can be found in their Discharge Planning category from the aforementioned archive page.

Validation Surveys:

DNV posted a new podcast on Spotify in March entitled “A New Model for Validation Surveys; How CMS Coordinates for Accreditation Organizations,” and they provided a brief discussion of how the new CMS concurrent validation process works.

This same podcast also provides an update from DNV on new deeming applications they have developed for ambulatory surgical centers and psychiatric hospitals. The podcast also discussed a new cybersecurity standard they have developed as well as an optional certification process for cybersecurity. Lastly, they discussed a risk assessment process exploring risk of artificial intelligence and a new behavioral health education program on high-risk issues in caring for behavioral health patients.

Dialysis Surveys:

On April 2^nd, Patton Healthcare Consulting’s very own, consultant Gloria Legere, RN, MS, JD, CPHQ, CISCI delivered a compelling webinar for ACHCU Educational Resources on acute dialysis.  Dialysis: Surveyor Eyes is a comprehensive overview describing the process to survey hospital dialysis units and details every regulatory compliance focus area from what dialysis is, to the dialysis environment, dialysis supplies, dialysis machines, and water quality, to the patient and staff.

This webinar dives deep into what the acute dialysis unit survey might look like from a surveyor’s standpoint.  Photographs of potential compliance issues in the dialysis setting are exemplified throughout, asking viewers to identify what is wrong with the picture. Fortunately, each is then accompanied by red arrows and/or an explanation pointing out each potential compliance issue.  Watch the webinar to learn more about best practice solutions and sample tracer questions or download the slides for some easy reading.

Home Health Manual Rewrite:

CMS had a busy month with several new QSO memos, one of significant importance to home health agency readers and two for hospital readers. The home health agency memo is QSO-24-07, which rewrites Appendix B of the State Operations Manual. This change was brought about by recent new and final rules promulgated by CMS that changed the COPs and resulted in necessary changes to the interpretive guidance.

If you operate a home health agency you will want to download and begin to analyze the entire 128-page memo. There are changes to the COPs, interpretive guidance, survey protocols and tags. We anticipate that accrediting agencies will be providing detailed guidance to their surveyors and clients soon, as they begin to modify their processes to come into compliance with the new CMS expectations.

EMTALA and Release of QIO Reports:

On March 27^th CMS issued QSO 24-09 relative to EMTALA and the referral process to the QIO and potentially the HHS Office of Inspector General. CMS works with the QIO for medical opinions relative to potential EMTALA violations and later sanctions or monetary penalties. The QIO will produce what is called a 5-day report to determine if they believe an EMTALA violation occurred. This 5-day report is shared with the hospital, physician, and complainant.

Later upon request of CMS the QIO will produce a 60-day report that CMS uses to determine if the case should be referred to the OIG. During the QIO investigation process the hospital and physician are contacted to provide additional information relative to the care provided. CMS indicates in this memo that the 60-day report MAY NOT be shared with the hospital or physician until after the OIG has completed their investigation and closed the case. This memo should be shared with your attorneys, medical staff, and ED leadership, analyzed, and education provided as needed to ensure everyone understands the importance and risk of these processes.

Informed Consent Process:

On April 1, CMS published QSO 24-10 relative to guidance on the informed consent process. This is an interesting memo that discusses examinations or invasive procedures that may be performed by medical or advance practice professional students on patients undergoing anesthesia. The QSO includes recent references, including from the New York Times and Annals of Surgery Open that provide important background information about the concern.

Basically, patients may be receiving pelvic or rectal examinations by a student, for teaching purposes, while the patient is under anesthesia, and if so, consent should be sought in advance. The reference from Annals of Surgery Open was particularly helpful in explaining the issue.

CMS has revised the interpretive guidance for A-0955 to include guidance of a well-designed informed consent process to now include consent for this practice if applicable to your organization.

QAPI Revisited:

At the beginning of this month’s newsletter, we mentioned changes TJC was making to the system tracer process and their focus on QAPI. This caused us to wonder what types of issues CMS is scoring during its surveys relative to QAPI. CMS publishes a massive Excel spreadsheet of all complaint survey findings on all issues. The current spreadsheet encompasses 2017-2023. There are 11 A-Tags in the State Operations Manual relative to QAPI. These are as follows:

1. A-0263: QAPI program

2. A-0273: Data collection and analysis

3. A-0283: QI activities

4. A-0286: Patient safety

5. A-0297: PI projects

6. A-0308: GB oversight, appropriate to complexity and breadth of services

7. A-0309: Executive/GB responsibilities

8. A-0315: Resources are made available to analyze

9-11. A-0320, A-0321, A-0322: Relative to a multihospital unified QAPI program

We sorted that spreadsheet by A-Tag to find the QAPI issues that are most frequently scored by CMS hospital surveyors. These are likely to be higher risk issues during an accreditation review and the Joint Commission’s OQPI system tracer. The four most frequently scored QAPI tags were:

1. A-0263 – 612 findings: This is the first tag in the QAPI section and scoring this tag identifies the COP to be out of compliance. Noncompliance with this tag could be result of significant and/or multiple findings in other QAPI tags that results in a conclusion that the overall QAPI program is deficient.
2. A-0286 – 593 findings: This tag is the patient safety, medical errors, and adverse events tag. Issues scored here could relate to failure to identify or report errors, failure to prevent, or failure to analyze the event.
3. A-0283 – 423 findings: This is the quality improvement tag which requires selection of measures and data collection for high risk, problem prone processes. Issues scored here can be a failure to collect meaningful measures, failure to improve, or a failure to measure a problem prone issue related to the issue CMS is investigating as part of their complaint.
4. A-0273 – 373 findings: This also requires data collection and analysis, somewhat similar to A-0283 above but it also requires 3 specific features; use of Medicare quality measures including hospital readmissions, analysis and improvement in measure data, and detailed direction from the governing body to utilize these measures.

If readers wish to analyze additional scoring patterns from CMS, the spreadsheet can be downloaded into a zip file containing two massive spreadsheets, one for findings 2010-2016 and the second for findings from 2017-2023 as discussed above.

If you would like to just look at the QAPI data discussed above, we have created a spreadsheet of only QAPI findings available for download.