Patton Post – December 2024

December 2024

Inside This Issue

Similar to Perspectives, there is nothing in this month’s edition of EC News that would make you stop what you are doing to jump on a new issue, however there are several excellent review or refresher articles that provide some clear guidance on maintaining the physical environment.

Life Safety Code Surveyor Scope of Work:

TJC did make one announcement in EC News that they began earlier in 2024 to have the life safety code surveyors evaluating credentials and competency of key leaders/technicians who maintain the physical environment. Formerly this would have been part of the HR credentials system tracer, and the life safety code reviewer may have provided consultation to the clinical surveyor who conducted that session.

The article announcing this change discusses general qualifications, experience, competence analysis from review of a CV and job description, and they discuss 5 very specific competencies that would be required in certain functions or job titles. These expectations would apply to either staff or a contractor, and in both cases, you will want to obtain this verification of qualifications.

The first discussed is the individual who performs inspection, maintenance and testing (ITM) of medical gas systems must have certification per NFPA either through ASSE 6030 or ASSE 6040. The technician who performs ITM on the fire alarm system must have knowledge of the NFPA Fire Alarm and Signaling Code 72-2010 via certification with either NICET, the manufacturer of your system, the state or local authority, or another recognized certification organization acceptable to your authority having jurisdiction.

The staff who perform fire door inspections must have knowledge of NFPA 80-2010 section 5.2.3.1. There is no national certifier, but you will want to prepare and document a competency for anyone who performs fire door inspections. Some states or cities may require a certification for the individual who performs ITM on boilers/high pressure vessels or fire/smoke dampers. If your community requires such certification you will need to have access to this credential.

Lastly the article reminds us that the staff responsible for hazardous waste handling has training from the US Department of Transportation (USDOT). Here is a link to that DOT training requirement:

https://www.phmsa.dot.gov/sites/phmsa.dot.gov/files/2023-11/Hazmat-Transportation-Training-Requirements-0158-1016.pdf

Fire Drill Requirements:

The December issue of EC News has a helpful review article on fire drill requirements. One difficult issue that hospitals often encounter is adhering to the requirement for “unexpected times” and “varying conditions.” TJC requires that drills not be predictable and must vary by at “least one hour for each shift per quarter, through four (4) consecutive quarters.” The EC News article then adds that it is a “good practice to vary the days also,” and unfortunately good practices sometimes become routine expectations over time.

TJC recommends using their “fire drill matrix” which can be found on their online physical environment portal. If you have not looked at that portal, it has very practical information for those who maintain the physical environment in your organization and some very useful educational material for those administrative leaders who supervise these areas.

This EC News article also explains the nuance about not activating the audible alarms during nighttime drills (9:00PM – 6:00AM), however “all other elements of a drill must be activated.” Clarifying guidance is also provided on additional drill expectations for the operating rooms and hyperbaric chamber area. Lastly, they discuss the required fire drill evaluation process where each drill should be critiqued and in a standard performance improvement format deficiencies noted should be a focus of subsequent drills and the vulnerability corrected.

We would strongly advise using this article as an opportunity to re-review your current process and the documentation of compliance with the drill requirement.

Reducing Corridor Clutter:

EC News also has guidance on reducing corridor clutter, including one photograph. Be sure to read the caption below the photograph to note that the photo demonstrates NON-compliance. The focus of the article is LS.02.01.20, maintaining the means of egress.

There are minimum clear width requirements based on your construction (design approval) year and type of hospital. There is also a sometimes-confusing approved exemption that permits wheeled equipment to be in the corridor, but there are many details to the exemption, all of which must be met. For example:

• You must maintain at least 5 feet of clear, unobstructed corridor width.
• If your design was approved prior to July 5, 2016, you must maintain at least 4 feet of clear, unobstructed corridor width.
• There must be a plan to relocate the wheeled equipment during a fire.
• The carts must be considered “in use” meaning they are moving every 30 minutes or less.
• Emergency medical equipment (crash carts) does not have to be “in use.”
• Patient lift and transport equipment does not have to be “in use.”

The bottom line is that the approved exemption is more limited than many believe, which takes us back to the EC News photograph of noncompliance. As you make rounds, do check for corridor clutter and consider developing options for storage and recharging of all the other wheeled equipment that is often present. Counting on staff to successfully hide, or make it move every 30 minutes when a survey occurs is not a viable strategy.

Lastly, this EC News article also reminds us that medical equipment, including wheeled carts can’t be parked in front of fire extinguishers, eye wash stations, electrical panels, or medical gas shut off valves.

Physical Environment ITHS:

EC News has a timely article about what physical environment issues might trigger an Immediate Threat to Health and Safety (ITHS) decision. We say timely, because CMS has again refined their QSO memo on Immediate Jeopardy situations.

TJC describes situations that might trigger an ITHS including:

• Significantly compromised exits (see prior article on corridor clutter).
• Defects in the fire alarm system, sprinkler system, emergency power supply or medical gas systems.
• Ligature risks, unrecognized and/or not mitigated in the behavioral health area.
• Failure to maintain high risk utilities and medical equipment.
• Significant infection control issues in the environment.

EC News then describes examples of specific situations that they have seen from the list above that have triggered an ITHS decision. The best way we can describe these situations is that they all involve some critical safety system, and that safety system is broken. We have assisted some organizations dealing with the aftermath of an ITHS decision and one factor that often appears is that the organization knew of the vulnerability through internal or vendor conducted inspection, maintenance and testing (ITM) and decided repairs could be deferred.

When you conduct ITM, there is always a published report summarizing the findings. We would encourage readers to also conduct an out-briefing with the inspector to determine if there are any critical issues that must be immediately addressed. We have seen situations where a printed report detailing a critical safety system was delayed by the vendor before mailing, and examples where the report was mailed but drifted internally upon receipt at the hospital, and the critical issues were not addressed. Thus, the importance of an out-briefing with the inspector and a tickler system to be on the lookout for mailed reports, or a failure to receive a final report.

We have also seen examples where the critical problem was noted by the inspector and the organization, but budgetary issues delayed corrective action. While budgetary issues can sometimes delay purchases or hiring decisions, if the fire safety, medical gas or emergency power systems are defective, they must be addressed without delay.

ACHC: Water Management:

In our discussion of The Joint Commission’s Consistent Interpretation column this month we discussed water management programs. We came across an on-demand water management webinar available through ACHCU that might be useful to you. It was originally presented live in October, but now is available on-demand from their website https://achcu.com/hospital-webinars/.

While ACHC will anchor the discussion to its standards the source for any accreditors standards is the CDC and ASHRAE. The webinar goes through a discussion of those original source expectations which is helpful, regardless of accreditor.

AHRQ: Patient Safety Culture:

The Agency for Healthcare Research and Quality has published the results of their 2024 Survey on Patient Safety Culture. Teamwork and the perception that supervisors, managers and clinical leaders consider staff suggestions for improving patient safety ranked quite high, 81% and 80% respectfully. The areas in need for improvement remain response to error and staffing with only 64% and 55% responding favorably to those issues. The full report can be viewed at: https://www.ahrq.gov/sops/databases/hospital/index.html

Hospice Providers and Fraud:

CMS posted four (4) QSO memos this past month that will be of interest to our readers. The first is QSO 25-06, dated 11/13/24 and directed to hospice providers. CMS describes that while the primary focus of surveys is to determine compliance with standards, they are also seeking to detect potential fraud.

CMS describes the training they are doing for state agency surveyors and accreditation surveyors, as well as creation of surveyor skills reviews for state agency surveyors. They then provide some examples of survey techniques during observations, interviews and medical record reviews that might help to uncover potential fraud. For example, during observations they advise surveyors to observe patient surroundings and interaction with hospice staff to identify potential lack of care and support.

During interviews they suggest confidential interviews with key hospice leaders, as well as patients and families to express concerns. During record reviews they suggest verification that the hospice is tracking and responding to complaints. Hospice providers will want to read this memo carefully as this is an additional and risky focus during survey.

Nursing Home F-Tags Update:

On November 18, CMS published QSO 25-07 directed to the nursing home industry. The memo is only 5 pages long, but they have updated and attached the nursing home F-Tags thus in total this is 902 pages in length, so don’t just hit print, to read later. CMS did use their usual format of highlighting the new content in red ink, so if you operate a nursing home you will want to scroll through the entire document to identify new content requirements.

The QSO memo specifically discussed new requirements relative to psychotropic medications and chemical restraints and we identified multiple new expectations that likely will require policy development and training under Tag F605. While nursing homes must be compliant with these changes, hospital readers may find the philosophical approach taken by CMS to be of interest as something that may be applicable across more provider types at a later date. As some state surveyors may survey both hospitals and nursing homes, they may have a different perspective on psychotropic medication use, shaped by these nursing home standards.

A key concept that comes across for nursing home providers is that the medical record must have “adequate indications for use” and a “documented clinical rationale that is based upon a patient’s assessment.” CMS specifically mentions patients transferred to a nursing home from a hospital who are on a psychotropic medication that was started in the hospital without a clear, documented history to support a DSM 5TR diagnosis. In such instances the nursing home will need to conduct an assessment to determine if that psychotropic should be continued.

Critical Access Hospital Space Sharing:

On November 20, CMS published QSO 25-08 for the critical access hospital industry, describing space sharing arrangements between the CAH and other community providers. If the CAH and community provider have a shared space and staffing arrangement to jointly serve patients, the CAH remains responsible to COP compliance at all times. If the CAH leases space to a community provider and the CAH functions only as a landlord the CAH would not be responsible for clinical COPs but would remain responsible for maintaining the safety of the physical environment in that space.

Immediate Jeopardy Process:

On November 21 CMS issued QSO 25-09 which is applicable to all provider types, changing some aspects of the immediate jeopardy process for laboratories and relocating these requirements Q to a new Subpart XI in CLIA 1998. This QSO memo was originally published as QSO 19-09 back on March 5, 2019, and at that time there were various process changes for all provider types. We had summarized those changes in our April 2019 Newsletter if you want to re-review them.

The November 2024 update is much less complex, primarily moving content for laboratories to CLIA. One change specifically noted is a process for a laboratory to eliminate its Immediate Jeopardy situation, and that is to eliminate testing in that problematic performance area.