January 2023
Inside This Issue3
Healthcare Equity Standards: 
Happy New Year to all our readers and we hope that you have a happy, healthy, successful, and safe 2023. There are two important announcements in this month’s edition of Perspectives the first of which is the new standards on healthcare equity are going to migrate from standards into national patient safety goals.
This does not change any of the specific requirements but NPSG is a special category of requirements that may increase the focus and attention they receive from surveyors. If your organization has been slow to implement these new requirements, we would advise accelerating your implementation plan.
Deleted Standards:
The second important 
announcement in Perspectives is much more complex. TJC has completed their analysis of requirements that could be considered for deletion and they have identified 56 hospital EPs that they will delete and another four (4) that they will revise. These deletions become effective February 19, 2023.
To be considered for deletion TJC looked for requirements that met these three (3) criteria:
- The EP is not linked to any CMS COP or state regulation
- The EP has been in effect for 3 or more years
- The EP has been scored 5 times or less during triennial surveys in 2017-2019
Then, TJC tried to analyze why they thought so little scoring took place with these elements of performance and they identified these three (3) potential rationales:
- Organizations are compliant because they have adopted it as standard practice
- The deleted EP is redundant with another EP
- Compliance with the EP is difficult to assess objectively and consistently during survey
In the Prepublication section on the Joint Commission website, and in Perspectives you will find a link where you can download the complete listing of EPs that are being deleted in each accreditation program. The challenge you will have, is determining if you can ignore or discontinue the deleted requirement, or if the requirement still lives because it is embedded elsewhere in TJC’s standards (see rationale 2 above).
When we reviewed the hospital deletions some were easy to guess why they were deleted. For example, LD.03.06.01 EP 5 requires “those who work in the hospital to adapt to changes in the environment.” We assume it is an obtusely worded platitude that surveyors were unable to evaluate during a survey, and therefore seldom scored. There likely was nothing organizations were doing to implement that requirement and deleting it makes sense.
We noted the elimination of MM.03.01.01 EP 9 which required that concentrated electrolytes be kept in patient care areas only when patient safety necessitated immediate use and precautions were implemented to prevent inadvertent administration. This EP likely met rationale #1 above, that organizations were compliant because they had adopted it as a standard practice.
Based on many years of implementing such a requirement, concentrated electrolytes are basically gone from patient care areas and inadvertent, concentrated KCL administration directly IV is a very rare occurrence. So, in this instance the Joint Commission has been largely successful, but does deleting the requirement mean the old practices can be reinstituted or is TJC assuming no one will revert to the old way of doing this? Engineering controls or eliminating access to potentially dangerous agents remain a classic way of preventing such adverse events.
We were also curious about the deletion of the requirements for behavior management practices in PC.01.03.XX. These potentially abusive practices have faded into history and the stand TJC took likely helped contribute to their disappearance. But the question is can these, or will these, practices resurface.
We also noted PC.01.01.01, EP 24 was deleted, and this EP required a boarded behavioral health patient to be in a safe environment that is monitored and clear of items that the patient could use to harm themselves. This EP 24, while deleted, remains a requirement under slightly different wording in NPSG.15.01.01.
We encourage readers to carefully analyze these deletions and be very cautious of reinstituting any formerly prohibited practices. There are many alternative ways of scoring something the surveyor perceives as inappropriate including leadership requirements for compliance with law and regulation.
Revised EM Standards for Home Care: 
The January Perspectives also announced the publication of revised EM standards for home care organizations. These revised standards become effective July 2023. The format closely follows the revised standards published for hospitals last year.
As many of our readers are part of larger, multiprogram or tailored organizations, you may have already updated your organization-wide EM documentation. However, if you did not, or you are a freestanding home care agency, you now have six (6) months to revise your program. A link is provided in the Perspectives article and the prepublication standards are also posted to the Prepublication section of the TJC website.
We would like to draw your attention to the number of “D” elements of performance in the revised standards. Be sure to have appropriate policies and documentation of your compliance or description of how your organization has implemented that new requirement.
Food and Nutrition Products: 
This month’s Consistent Interpretation column discusses PC.02.02.03, EP 11 which requires that food and nutrition products be properly stored. The noncompliance rate with this standard is quite high at just under 38% of organizations being scored last year.
This is a difficult requirement in that compliance is evaluated in the main dietary area, as well as in every small pantry area throughout the organization. As the EP affects hospital supplied food products and any foods brought in by families, in multiple locations, it can be a difficult standard to adhere to.
The surveyor observations section provides insight into how many different problems can be identified in evaluating this EP. The Guidance/interpretation section provides the usual guidance to surveyors where to score and what to score, but there is also one important tidbit for readers.
TJC points out the difference between a food product labeled with a “best by” date vs. those that have an expiration date. TJC states that a “best by” food product should not be considered expired, and is safe to use even if that date has passed. You will often see a “best by” date on commercially processed food products whereas an expiration date would more often be assigned for fresh food products or opened containers of commercial products.
Completing an ESC:
This month’s EC News has a refresher ar
ticle on how to properly complete an ESC. TJC reports that some organizations forget to document the most important aspect, which is actually fixing the observed deficiency. They state that organizations sometimes describe the improvement process, but forget to document that on a specific date, someone corrected the problem.
This seems so obvious, but we see the same thing sometimes when we review a draft ESC for an organization. This article provides a reminder about the content expectations for the “assigning accountability, corrective action and ensuring sustained compliance” sections.
Many organizations like to delegate drafting of corrective actions to different area managers and as this process usually only occurs every three years, and there is always turnover in healthcare we suggest sharing this article any of those managers who will be involved in contributing to your next ESC.
Workplace Violence Standards: 
EC News also has an update on their workplace violence standards which were new at the beginning of 2022. This is both timely and helpful as it is good to learn what organizations are struggling with from new standards, and CMS has now decided to weigh in on workplace violence as a priority, too (see our CMS section).
A start point for the WPV program is the required worksite analysis of risks and TJC mentions that some organizations were cited for not having completed this initial assessment or for having an incomplete WPV assessment. Remember, as surveyors walk through your organization, they may identify potential risks and discuss these with organization staff who may agree that the observation is a risk point or even complain that this risk has been an unaddressed issue.
Later the surveyor can review your WPV assessment and if the issue, perceived as a genuine risk by the surveyor and staff is not identified in the WPV risk assessment, it makes the assessment appear superficial or incomplete. A key point to consider is that when you conduct your WPV assessment you actually want to walk the facility and grounds, talk with staff who work in these areas and review your incident reports to help identify and mitigate the potential risks.
TJC mentions in their article that another deficiency that has been identified is a failure to designate a leader for the WPV program (LD.03.01.01, EP 9). As is customary, this does not have to be the persons sole responsibility, but they should be officially appointed and known to organization staff as the leader of this initiative.
This same EP has four (4) different bullet points, each of which must be compliant and these include requirements to have policies and procedures for reporting WPV, a process to analyze these incidents, a process for follow up, and support to victims and lastly reporting of WPV incidents to the governing body.
Being that we are now in the second year of these standards, surveyors are often more familiar with the requirements and expectations begin to rise based on some of the excellent work they see in some organizations. Now is a good time to take another look at what you designed last year for your program and to refine and strengthen it for 2023.
Your WPV leader and team members should probably also review this EC News article for ideas as they begin their discussions. TJC has many links to WPV resources on their website in what they call their Workplace Violence Prevention Compendium.
Home Care Oxygen Safety:
Lastly, this month’s EC News has an a
rticle for those organizations with home care services on oxygen safety and specifically NPSG.15.02.01, applicable only in home care programs. TJC also provides some recommended best practices and suggestions on how to comply with the different elements of performance. Requirements for improvement arising from this NPSG are quite common and if you have a home care program you will want to share this article with that staff for analysis.
Workplace Violence Standards:
As we mentioned in our discussion on the Joint Commission’s workplace violence standards, on November 28, but after we drafted our December Newsletter, CMS issued QSO 23-04 discussing Workplace Violence – Hospitals. Often these QSO memos have a brief executive summary followed by multiple pages of detailed regulatory language and interpretive guidance detailing their expectations. This QSO only contains a 3-page executive summary which links their WPV expectations
to existing and somewhat generic regulations.
For example, CMS identifies 482.13(c)(2) which is a regulatory requirement to provide care in a safe setting. CMS then expounds that this would include environmental safety, infection control, and security. They further detail that in order to provide care in a safe setting, hospitals should identify patients at risk for intentional harm to self or others. We placed the emphasis on “others” because self-harm has been a major emphasis for several years now, but the risk of harm to others, while mentioned in the existing interpretive guidance has not received the same degree of focus.
CMS further references 482.15(a) which is their emergency preparedness requirements which require an EM plan to be based on a “documented, facility based and community-based risk assessment, utilizing an all-hazards approach.” Workplace violence appears to be one of the potential hazards that should be considered.
CMS also mentions that their EM training and policy expectations should include policies and procedures aimed at protecting both the workforces and patients. Organizations that are accredited should be ahead of this curve with the WPV violence assessment and the strategies you have already developed to protect the workforce.
Organizations that are not accredited may want to look at that EC News article we discussed earlier and use those standards to help you prepare for more intense CMS scrutiny on workplace violence.
Pharmacy Practice News
Medication Errors 2022:
The December issue of Pharmacy Pr
actice News (www.Pharmacypracticenews.com) published an ISMP analysis of medication errors identified and reported during the past year. These summaries are particularly helpful because many of the errors relate to newly identified LASA pairs, product labeling, packaging, technical or electronic infrastructure, and clinical product information that mean the risk of error is universal.
The publication provides six (6) categories of errors and each error within each category should be analyzed by your medication safety team to determine if you have the same risk and what you might be able to do to help prevent that same error from occurring in your organization.
This year there is also a new category of errors identified with Covid vaccines with a surprising assortment of glitches, dosing errors and mix ups. As these vaccines are in widespread use it will be very worthwhile to review each of these errors to determine if you have the same risks.
We also noted one particular medication error involving the direct administration of concentrated KCL intravenously during a code situation. Access to concentrated KCL is an issue we discussed at the beginning of this newsletter, as the element of performance that limited such access is slated for deletion because it appeared to be a problem under control.
We hope that the deletion of the EP does not change your restrictions as the risk posed by this product, while significantly reduced is not entirely eliminated, and if we let down our guard it could worsen.
CDC Health Alert Network
Dental Water Lines: 
On October 31, 2022 the CDC Health Alert Network issued an advisory on Nontubercular Mycobacteria infections associated with dental water lines. This advisory can be located at: https://emergency.cdc.gov/han/2022/han00478.asp#print
We have discussed on multiple occasions the survey scrutiny that water management has been receiving the past few years but have not specifically discussed dental clinics and water lines. If your organization has a dental program, you will want to study this alert and add the management of dental water lines to your overall water management program. Apparently, these lines if not properly maintained can develop biofilms and harbor bacteria that can result in patient infections after dental procedures.
The Morbidity and Mortality Weekly Report (MMWR) back in 2003 published guidance on Infection Control in Dental Settings and within that lengthy document was recommendations for maintaining the dental water lines that may not have been adequately or universally implemented. The 2003 publication can be obtained using this link: https://www.cdc.gov/mmwr/PDF/rr/rr5217.pdf
Consultant Corner
Dear Readers,
Happy New Year! We wish that this year brings optimal health, happiness, and prosperity to you and yours!
Before, during, and after survey – no matter your current state of readiness – we are here to assist you and your organization in accreditation and regulatory compliance. Check out our services at www.pattonhc.com and how we can help you deliver a safer and more advanced compliant patient care. Are you behavioral health? We got you too, please visit www.barrins-assoc.com!
Contact any one us today for a confidential discussion of your needs and how we can help you continuously achieve success.
Jennifer Cowel, RN MHSA
JenCowel@PattonHC.com
Julia Finken, RN, BSN, MBA, CPHQ
julia.finken@hbsinc.com
Kurt Patton, MS RPh
Kurt@PattonHC.com
John Rosing, MHA
JohnRosing@PattonHC.com