Inside This Issue
We usually don’t publish an August edition of our newsletter, as in the past we have found that many readers in our organizations are on vacation and interest in regulatory compliance is low. In addition, the brief publishing respite is a nice break for us after traveling throughout the country all year.
This year seems very different with all the pandemic activities and very limited travel to visit clients in person, so we decided to do a brief update. If you are personally enjoying some vacation time off this month—in isolation at a beach, a lake, or in the mountains—there is nothing in this month’s Perspectives or from CMS that should cause you significant anxiety or a longing to be back in the office. Perhaps you might even want to get yourself a cool drink to enjoy while reading this newsletter. To the extent possible, enjoy your socially distant time off.
LSC Surveyors, Scope Expansion:
The Perspectives article that drew our attention describes an expansion of the role of the life safety code surveyors which is probably the most important issue this month. Effective immediately the Joint Commission’s life safety code surveyors will now also visit the hospitals off-site emergency rooms and all hospital-operated ambulatory surgery settings. These locations previously had the physical environment evaluated by the clinical surveyors, not the life safety code surveyors.
This change likely relates to the Federal Register notice on the Joint Commission’s deeming application, which we discuss in the CMS section later in this newsletter. As you have seen in recent years, the thoroughness of the review performed by a life safety code specialist is much more in depth than a life safety code review performed by a clinician. In other words, the off-site emergency rooms and ambulatory surgery centers may experience additional EC or LS findings on your next survey.
CMS also wants a deeper dive of environment of care and life safety deficiencies in business occupancy sites that are under the hospital’s CCN number. While the healthcare occupancies and ambulatory care occupancies site will be reviewed by the LSC surveyor, the TJC clinical surveyors will review the below key elements when they survey a sample of the business occupancies. The list of elements was provided by TJC during a consultant’s forum and is a good punch list for the EOC reviews done. We recommend you incorporate this list of items into your readiness review or EOC review of clinics.
Features to Survey:
- Life Safety Code drawings
- Means of egress
- Locked/blocked exits
- Exit access
- Exit discharge illumination
- Battery back-up
- Corridor widths
- Corridor obstructions
- Visible exit signs
- Above ceiling
- Electrical outlets
- Electrical panels
- Safety Data Sheets (SDS)
- Security / access
- Smoke / fire barriers
- Fire extinguishers inspection
- Mounting and visibility of extinguishers
- MRI locations
- Biohazardous and pharmaceutical waste
- Alcohol-based hand rub (ABHR) dispensers
- Eye wash stations
- Storage rooms
- Medical equipment
- High-level disinfection
- Cylinder storage
- Sprinklers / sprinkler systems
- Fire drills
Perspectives also mentions a field review that has been posted for some potential changes to the standards relative to resuscitation. The changes are in the PC and PI chapters. The level of detail in the draft performance measures you could be required to collect relative to resuscitation is much more prescriptive than usual. This prescriptive nature is sometimes valuable as compared to leaving the selection of measures open.
While many hospitals resist prescriptive requirements, we sometimes see organizations struggle to select new performance measures when the choice is open ended. For example, to this day we still see very limited performance measurement data for the new pain management standards or the suicide prevention safety goal. The important thing to note is that these changes are open for public comment at this time, up until August 10. This is your opportunity to help shape the standards before they become official. The draft standards are posted to the field review section of the TJC website.
Survey Requirements Post National Emergency:
The lead article in this month’s EC News discusses the fact that some inspection, maintenance, and testing requirements may not have been performed during the national emergency and this was waived or approved by CMS. However, after the National Emergency ends and surveys resume, while TJC surveyors will not look back in time to the Emergency period, they will look for 100% compliance with all inspection, maintenance, and testing requirements for the post emergency timeframe.
Although not stated, they could also look for compliance for a timeframe prior to the National Emergency. Basically, this is just a reminder to organizations to resume inspection, maintenance, and testing when conditions permit a resumption of normal activities. This article is also the first of three thematically linked articles in the August EC News, all of which discuss aspects of the recovery from the pandemic conditions and all three should be discussed, analyzed, and used as you begin to resume regular services.
The article then includes a table identifying the specific Joint Commission standards and which elements of performance had inspection, maintenance, or testing requirements officially waived by CMS and TJC.
LSC – Condition Level Findings:
Included in this first article was an interesting description of how life safety code surveyors might identify Medicare condition level findings as compared to only standard level findings. This was insightful because the published rules from CMS are very nebulous and subjective.
This description provides somewhat clearer guidance as compared to just the usual “manner and degree” analysis, although the subjective manner and degree is still part of the analysis.
Standard level: The cited issue is out of your organization’s control, and you provide evidence that an attempt was made to resolve the issue.
Condition level: The cited issue is not out of your organization’s control, and no attempt was made to resolve the issue. (This applies only to those findings that qualify as a condition-level deficiency due to the manner in which and degree to which the organization did not satisfy CoP requirements.)
Last year TJC had developed and shared a kitchen tracer tool with the industry. This month’s EC News has an informative narrative article describing issues of exploration in the kitchen during a survey. To some extent, the article helps to explain items briefly mentioned in the checklist. It also provides great tips for training of the kitchen staff and issues the dietary director can proactively look for to maintain the physical environment. Facilities leadership, dietary leadership, and accreditation staff should use this article to help self-assess and refine activities as needed.
Waiver Tracking Tool & Covid-19 Recovery Prep Checklist:
The second article includes a TJC waiver tracking tool, which identifies all the permissible waivers and allows you to check if it was used and begin to document the steps or actions needed to resume the waived requirement. The third article is even more interesting as is the included tool. This provides a Covid-19 Recovery Preparation Checklist that has broader applicability within the organization for issues you need to consider as you begin to resume somewhat normal services.
While it includes another discussion about waived requirements, it goes well beyond just that issue to include consideration about temporary renovations or modifications made during the pandemic and potential decisions to make these modifications permanent. It also discusses reopening closed buildings and environmental considerations before doing so.
It suggests consideration of staff placement as you bring back furloughed staff and social distancing in the workspace as well as wellness checks upon entry to the building. This third article and tool we suggest discussing with a wider audience such as in an environment of care committee.
There were no new QSO memos issued to the hospital industry this past month. Probably the most significant regulatory news is the notice CMS posted in the Federal Register July 17, regarding its decision on the Joint Commission’s redeeming application. These applications can be approved for up to a 6-year period. In this case, CMS announced it was only approving the application for 2 years. Most importantly, there is no change in deemed status at this time.
CMS and TJC:
With anything emanating from Washington, we assume there is some aspect of politics entering into the decision process. The rationale CMS published for the shorter approval period was interesting. CMS described numerous gaps in the Joint Commission standards and stated TJC has now added them. However, the gaps were to a large extent related to the CMS burden reduction changes and the revisions just announced in QSO 20-07, posted 12/20/19 without interpretive guidance. We did see new standards from TJC published in the March edition of Perspectives in response to these burden reduction changes.
Strangely, CMS also wanted TJC to spend less time on morning briefing, using the theory that if you provide too many details, hospitals might fix these issues throughout the rest of the organization and thus TJC would miss identification of condition level findings. We look forward to visiting the hospital that can immediately implement corrective actions house-wide after leaving the morning briefing.
The one criticism that may be most significant is that TJC needs to modify its survey process for citing governing body (LD) for deficiencies related to severity of physical environment findings. This may lead to more condition level findings cited against leadership when condition level findings are found in the physical environment, or perhaps other chapters also.
As you might remember from our previous discussions of the CMS annual Accreditation Organization “disparity reporting” validation process, CMS and state surveyors continue to find more condition level findings than TJC surveyors. The last published validation survey report was in 2019, using 2018 survey comparisons, which do not reflect any improvements seen using the concurrent validation methodology.
We want to thank our reader who provided feedback on the article we wrote last month, Do You Have a Policy? on Ⓓ elements of performance and policies. Our intent was to describe a method using the E-Edition to proactively identify all of the Ⓓ elements of performance. Then after identification of the Ⓓ elements, use that list to verify that you had all the required policies.
However, our description may have given some readers the impression that every Ⓓ element required a policy and that is not the case. Some Ⓓ elements require policies and some require documentation of effort. In fact, the acronym TJC uses is “RWD”, or requires written documentation. The policy requirements, in addition to the Ⓓ very often include an opening phrase, “The organization has a written policy describing…”.