Patton Post – August 2024

This being August we are in the peak season for summer vacations for both healthcare workers and accreditation surveyors. Fortunately, this month’s issue of Perspectives does not have any major new standards that have to be implemented in the coming few months. So, if you are sitting by a lake, the ocean, or in the mountains enjoying your time away from the office, continue to do so.

CMS Consent Memo, Revisited:

The most significant issue discussed this month is an explanation from TJC on how they will be assessing the CMS memo QSO-24-10 that was first published in April then subjected to an odd CMS revision and reposted with the original date. See our June and July newsletters for background information. TJC has now explained they will be evaluating the revised CMS language relative to informed consent for sensitive examinations that may be conducted for teaching purposes. TJC explains that informed consent is required if:

• any clinical students will be performing intimate/sensitive examinations for teaching purposes, or if
• these students will be performing any important tasks relative to the surgery.

If the patient is under anesthesia a documented and signed consent form is required. If the patient is not subject to anesthesia, consent is still required, but it can be documented in a progress note. We noted that TJC indicated that they will be updating the survey activity guide, not the standards manual, with this explanation. However, we also see this same information posted as a standards FAQ.

Life Safety Drawings:

This month’s Consistent Interpretation column discusses LS.01.01.01, EP 3 relative to life safety drawings. Approximately 20% of hospitals were scored noncompliant for this issue last year. The guidance/interpretation section provides clarity on the two key problems that can arise:

1. The drawings do not contain all the required elements per the EP
2. The drawings do not reflect renovations, updates or changes

If you look at the EP it specifies the mandatory data elements that must be contained on these drawings. These are:

• Areas that are fully sprinklered if the building is only partially sprinklered
• Locations of hazardous storage
• Locations of all fire rated barriers
• Locations of all smoke related barriers
• Sleeping and non-sleeping suite boundaries, including size
• Locations of designated smoke compartments
• Locations of chutes and shafts
• Any approved equivalencies or waivers.

As 20% of surveyed hospitals are struggling with this requirement, we would suggest self-assessment to verify compliance. First take a look at the drawings and ask the person most knowledgeable about the drawings to point out each of the bulleted items above. Secondly, ask when the drawings were prepared or last revised, and how they are kept up to date. Ask to see how the drawings reflect the changes made on several of the most recent renovations, or areas where rooms have been re-purposed.

As we have also seen situations where no one can get their hands on the drawings quickly, you might want to verify who is the keeper, who is the back up, and where are they stored.

If you are in need of assistance with this task our LSC experts and our CAD team at HBS – Patton Healthcare can review your current set of drawings and verify the Life Safety features based on those drawings.  Our experienced and dedicated team will provide you with an updated set of drawings.  Contact us at:  JenCowel@PattonHC.com

Texting of Medication Orders:

A few months ago, when CMS and TJC changed their rules to permit texting of medication orders using a secure texting platform, we cautioned in our May newsletter about reintroducing potential transcription errors or unfamiliar/non-standardized abbreviations of texted medication orders into the EMR. At that time CMS and TJC only specified that the texting platform had to be compliant with HIPAA and the HITECH Amendment Act.

We recently asked the TJC standards interpretation group a very specific question about texting of medication orders. The question we posed was: Is it acceptable if the provider texts an order on a secure message app and the nurse has to enter that order into the EMR almost as if it were a telephone order? The very clear response from TJC was as follows:

“In accordance with the guidance provided by CMS, this would not be acceptable. The secure texting platform (STP) must be integrated into the electronic medical record system.”

This response certainly has the potential to enhance safety if using texted medication orders, but it likely will reduce the number of electronic medical record platforms that are compliant with the expectation. As this is not yet posted as an available FAQ, we would encourage readers to verify that if their EMR and secure texting platform have this capability before proceeding with or expanding their use of texted medication orders.