Patton Post – February 2026

February 2026

Inside This Issue

Surgical Fires:

The lead article in the February issue of EC News has a great refresher article on prevention of surgical fires. They include some actual examples of surgical fires that have been reported and the conditions that were believed to have led to these fires. They also provide detailed guidance on preventative practices to help reduce the risk of surgical fires. Most importantly, EC News again brings home the details that used to be in the standards that are derived from NFPA references, including guidance on surgical area fire drills that are not specifically mentioned in the 2026 standards manual, but remain NFPA expectations where hospitals must be compliant. We would strongly advise sharing this article with your operating room leadership and facilities management and using it as a resource in refining your prevention and drill activities.

Hazardous Chemicals and Eyewash Stations:

EC News has an equally good refresher article on handling hazardous chemicals and establishing and maintaining appropriate eyewash stations. This issue is very frequently scored noncompliant by JC and seen very often on our consultative surveys. The issues we commonly see include:

• Corrosive or other chemicals which require an eyewash in use in locations without an eyewash
• An eyewash is present but the eyewash:
• Has not been inspected weekly
• Access is blocked by equipment or furniture
• Access is blocked by a locked door
• Distance to the eyewash is too remote from chemical use area
• The eyewash is not plumbed and cannot provide 15-20 minutes of flushing
• The eyewash does not provide tepid water
• The caps are off the eyewash, and the outlet is grossly contaminated
• Staff don’t know how to use the eyewash

We also sometimes note an eyewash present in a location where hazardous chemicals are no longer in use. Conversely, we also see newly introduced hazardous chemicals in use, either independently purchased by the work area, or brought in by contractors such as a cleaning service. We suggest sharing this EC News article with your safety, facilities and EOC committee and more importantly assessing your risks for one or more of these common flaws. Also take a look at your last JC report to determine if this was a prior finding, as you don’t want it to reappear on your next survey.

Kitchen Tracer:

The third refresher article is on kitchen safety issues that will be examined by life safety code specialists, and it provides what are now the missing details from the NFPA standards that have been deleted from the JC standards. Do take a look at this article and use it in conjunction with the kitchen tracer tool contained in the 2026 Survey Process Guide (SPG). The kitchen tracer tool provides issues to examine, and the EC News article provides detailed explanations of what and why these issues are of importance.

Accreditation Process Chapter (ACC):

Now that the manuals are online and include all the policy and process chapters, not just the standards, we suggest reading The Accreditation Process (ACC) chapter. This chapter includes what are called decision rules, or the rules Joint Commission will follow if you encounter significant problems on survey leading to any form of adverse decision. This is a chapter in the manual that most organizations never read until an adverse outcome occurs.  It is best to know what is instore for you if some adverse decision should occur and the ACC chapter’s decision rules spell out exactly how things proceed and how they can escalate if you are not successful in clearing an issue. For example,  if you have condition level findings, you get a Medicare deficiency survey and if you fail to clear that Medicare condition, you have a second Medicare deficiency survey. If you are not successful with that second survey CMS will be informed and evaluate your organization and your accreditation status will be downgraded to accreditation with follow up after CMS clears you to proceed again with Joint Commission.  It is by no means a fun read, but it is informative and may help you to focus colleagues on preventing any adverse situations rather than facing the downward spiral of additional consequences from repetitive failures.

DNV: They are offering a webinar on February 19^th entitled “Operational Excellence through Effective Management Systems.” Information about this program can be obtained using their Events page.

ACHC: In January, ACHC posted a resource “DMEPOS Update” for providers of durable medical equipment, prosthetics, orthotics and supplies, or DMEPOS. There was a new CMS final rules for these providers posted 12/2/25 and ACHC has provided a concise summary and explanation of the final rules for providers.

Excepted Activities:

On February 2, 2026, CMS published QSO 26-04 addressing what activities would continue and what activities would not continue in the event of another government shutdown. CMS again describes what they call “excepted activities,” meaning those activities that are permitted to continue and those that are not. For example, investigations of potential immediate jeopardy situations can continue, but lower level complaint investigations would not. Initial surveys would not be conducted, and certification processing of initial Medicare surveys conducted by accreditors would not be processed by the states. Follow up visits necessary to prevent provider terminations may also continue.