Patton Post – November 2021

November 2021

Inside This Issue

EC/LS Most Frequently Cited:

The lead article in this month’s EC News is about the most frequently cited element of performance level EC and LS findings, although they also identify the 2021 entire top 10, which includes three clinical standards. The three clinical findings and their position on the top 10 list include:

• #4: 02.01.01. EP 1: General IC findings from dirt, adhesive residue or any potential source of contamination.
• #5: 06.01.01, EP 3: Medication administration issues, most often of which are problems with medication titrations.
• #7: 02.02.01, EP 2: Use of standard precautions and PPE. In this era of Covid, this issue has taken on higher importance than it might have in the past.

The EC and LS findings should not surprise readers of this newsletter. They are so to speak the “usual suspects” that TJC has been finding for many years.

• #1: 02.06.01, EP 1: The official language is that interior spaces meet the needs of patients, but as we have written previously, this is a catch all EP, where just about anything wrong in the physical environment can be scored, from ligature hazards to a stained ceiling tile to a torn mattress cover.
• #2: 02.01.35, EP 4: Piping for sprinklers is not used to support any other item. This one just won’t go away, as there are problems made years ago by staff or vendors, and there appears to be a continuing problem with people using those sprinkler pipes as supports for other above the ceiling items. An above the ceiling inspection program is needed to find the long-standing problems and a follow up inspection whenever someone is working above the ceiling laying cable or ducts is needed to help prevent this from continuing.
• #3: 02.05.05, EP 6: This concerns what are called non high risk utility systems and the requirement is to inspect, test and maintain them appropriately. As with many things from a maintenance perspective the manufacturers guidance is essential.
• #6: 02.05.01, EP 9: Label utility systems. A common source of error with this EP is unlabeled breakers in the on position in an electric circuit breaker utility box, or failure to label the fire alarm circuit in red.
• #8: 02.01.10, EP 5: The hospital meets all other life safety code extinguishing requirements. This is another catch all EP that could be a blocked fire extinguisher to an extinguisher hung at the wrong height.
• #9: 02.02.01, EP 5: The hospital minimizes risks with hazardous chemicals. The so called “eye wash” EP.
• #10: 02.01.10, EP 14: Penetrations through walls and floors. Similar to #2 above, hospitals need to look above the ceiling for current penetrations that were never sealed, or the sealant has dried and fallen out, or someone has just been working above the ceiling, drilled through a wall or floor and failed to seal the penetration when the work was completed. Again, a rigorous inspection program to find the current problems is needed, and a post work inspection process when someone has been working above your ceilings is needed to prevent creating new problems.

We would encourage our readers to circulate this EC News article and inquire about your preparedness on these issues. When we review TJC reports we don’t see a lot of esoteric new findings. We see these issues TJC is warning us about over and over again. If hospitals can get a handle on these very frequently scored standards, they will be much better prepared for survey.

Snow Mitigation Efforts:

As much as we may not want to think about it, winter is coming and along with it in many parts of the country there may be snow. EC News has an article this month on planning out your snow mitigation effort that includes chain of command or continuity of operations considerations, competency issues for certain types of snow removal machinery, and activation of the emergency operations plan.

If your organization is in snow country, we would encourage you to circulate this, along validation that the recommendations contained have been incorporated in your organizations planning.

Alternate Care Site Guidance:

Over the past two years, many organizations have probably gotten much more experienced at creating alternate care sites than they might have earlier. EC News has a discussion about the recent ASHE meeting where there was a session on “Converting Spaces for Surge Capacity.” Insights from that session and some examples of how organizations converted some existing spaces are discussed.

Perhaps most valuable is a link to a new, free guidebook from ASHRAE called the Alternative Care Site HVAC Guidebook. This can be downloaded free of charge using the following link.

USP Chapter 797:

The new chapter that was delayed at the end of 2019 due to appeals has been redrafted and published. In many respects it should look familiar to those who had read the copy planned in 2019.

One change that had been part of the appeal process is they did allow for longer beyond use dating in some instances that likely will be useful to sterile compounding vendors and some really large hospital organizations, but not your average institution.

Issues that had been described in the 2019 version which remain today is for more frequent surface sampling of the compounding environment and more frequent media fill and finger-tip sampling. Media fill and finger-tip sampling will move from an annual retest to an every-6-month test in most organizations.

Those few organizations that prepare what are now called Category 3 sterile compounds will require media fill and finger-tip testing every 3 months. Surface sampling is moving from an every-6-month requirement to a monthly requirement.

These additional workloads, in combination with the continuation of the every-6-month air sampling of the sterile compounding environment will make many of our readers want to reconsider their options of doing Category 3 sterile compounding in house or contracting the process out to a vendor. Many organizations currently use their certifier to perform the every-6-month testing, but monthly tests will have cost considerations and certifiers may not be able to handle the additional workloads.

An official start date for implementation of the latest version of USP Chapter 797 has not been determined, but it is likely to take effect sometime within the coming calendar year. When it does take effect, track record requirements for accrediting organizations begin. Our advice is not to wait until the deadline before having a plan in place.

If you plan to use your certifier to perform additional testing, verify they have the willingness and capability to do so, and that pricing is acceptable to your organization. If you plan to perform internal surface sampling, the USP chapter will require an area sampling diagram, standard operating procedures, and accrediting bodies are going to expect competencies for those who perform, incubate, count colonies, and interpret the results of sampling. Laboratory support will also be needed as any air or surface samples that exceed action levels will need to be identified at a genus level.

Our advice is to start your planning now as there are likely to be many decisions to be made and hurdles to be overcome to get this expanded monitoring up and running. It is always best to start the process, overcome the hurdles, and redesign as needed, prior to the required effective date.

Hospice QSO Memo:

There were no new QSO memos to the hospital industry posted this month, however there was one new QSO 22-01 directed to the hospice industry that caught our attention. It is only two (2) pages long but it describes planned “enhancements” to the oversight of accrediting organizations that perform deemed status surveys of hospice providers.

We noted that CMS desires hospice survey teams be more multidisciplinary, be clear of any conflicts of interest, to have accrediting body surveyors use CMS surveyor training, and perhaps most surprising is to have accrediting body surveyors use the CMS form 2567 to document their findings. Form 2567 has been in use since the days when typewriters were prevalent and creating plans of correction continues to pose challenges to organizations who are used to online fillable forms or word processing applications. We will have to see if these “enhancements” migrate to other CMS deemed status programs.