Patton Post – November 2022

November 2022

Inside This Issue

Most Problematic EC/LS Standards and EPs:

Last month TJC conducted its annual Executive Briefings presentation, where their program and content experts present on the most difficult standards and new directions the company may be taking.

This month’s EC News has a brief summary of Herman McKenzie’s presentation on the five most problematic EC/LS standards and elements of performance. These are in rank order:

1. EC.02.06.01, EP 1: Interior spaces are safe and suitable
2. LS.02.01.35, EP 4: Nothing should be touching sprinkler pipe above the ceiling
3. EC.02.05.01, EP 9: Label utility shut down controls
4. EC.02.05.05, EP 6: Inspect and maintain non-high-risk utility system components
5. LS.02.01.10, EP 14: Seal the space around pipes, etc., with fire rated material

The article provides insight on how the surveyors go about finding these standards noncompliant and the types of problems that are noticed.

The first problematic standard we have talked about many times before in this newsletter as just about any defect in the environment can be scored against this EP. TJC mentions stained ceiling tiles as one example and nurse call cords in the bathrooms that are wrapped around the grab bar, and left unreachable from the floor.

The challenge is to be able to identify these problems yourself ahead of survey and get them corrected. Having a good internal inspection process, looking for these issues as well as torn or broken furniture, torn stretchers, damaged flooring or anything that looks risky from an environmental perspective.

Sprinkler piping being used to help support other materials above the ceiling is the second most problematic standard. The term “support” is used loosely as in reality anything touching that sprinkler pipe is likely to be scored noncompliant. We see this often on consults and on official TJC survey reports and many times it is noted as observed and corrected on site. This makes it seem as if it is easy to fix, but if it is already been noticed by the surveyor, it really is too late.

TJC recommends educating any staff or contractors who may be working above the ceiling that nothing can be resting on or attached to the sprinkler pipe. Better still is after any above the ceiling work is done an inspection should take place at completion to verify the staff or contractor did not violate the guidance you provided them.

The third most frequently scored standard discussed is utility system controls needing to be properly labeled. Here TJC provides insight on how surveys find this noncompliance by opening electrical breaker boxes and looking for any “spare,” unlabeled breakers that might be in the on position. If the spare, unlabeled breaker is on, chances are it is actually providing current to some part of the hospital or equipment. Thus, the organization has failed to properly label its utility shut offs.

The fourth most frequently scored issue is inspection, testing and maintenance of non-high risk utility system components. Again, TJC shares one method surveyors have to detect noncompliance and this is storing anything within 3 feet of the breaker box, thereby blocking access. In other words, not maintaining the utility system components. We have used pictures in many of our educational programs to help draw attention to this issue of the kinds of materials that get parked in front of breaker boxes, often right in front of the “Do Not Block” sign.

The fifth most frequently scored issue was sealing the penetrations around pipes and cables going through walls. Prevention here is similar to the discussion on sprinkler pipes. Staff performing the above the ceiling work need to be educated on the need to seal these gaps and again an inspection process after the work to verify the work was done in a compliant fashion.

Managing an Evacuation and Lessons Learned:

EC News has an article prepared by the Avista Adventist Hospital in Colorado, describing their actual evacuation of their facility due to an area fire that filled the hospital with smoke. They describe completing their evacuation in two hours and some of the lessons learned from their actual experience.

One such example is the difficulty they experienced in being able to access electronic medical records in the transfer facility and the subsequent work they have done to make this easier if there is a “next time” this has to be done. This article should be shared with your EM team for analysis of your own evacuation planning, should that ever be needed.

Covid Vaccination Requirements of the Workforce:

CMS has one new QSO memo of importance to our readers concerning Covid vaccination of the workforce. This is QSO-23-02 and it replaces the earlier QSO-22-07, QSO-22-09 and QSO 22-11 discussing vaccination requirements and survey scoring. Like the predecessor memos, this one has a series of attachments for providers of all types. The hospital memo is again attachment D.

There is some good news here that the changes discussed should not be labor intensive. CMS is really only changing the types of surveys where this review of vaccination data should take place and how they score the findings. They did not change the basic requirements for what constitutes complete vaccination.

The first change is that CMS expects vaccination data to be evaluated on full initial and recertification surveys, as well as complaint surveys where vaccination is at the core of the complaint. The routine complaint survey on issues such as patient rights or grievances do not require examination of the vaccination data, however the survey team could decide to look at it if something arises during their survey.

The second change is in the scoring, described in the attachment for the provider type. For hospitals they define egregious noncompliance as less than 50% compliance and/or 1 or more missing policies for the staff vaccination program and this would be scored at a COP level. A lesser level of noncompliance would be scored at a standard level. Be careful if you try to print this entire memo as with all the attachments it exceeds 160 pages. All you really need is the 5-page QSO memo and your provider type attachment.

Chapter 797 Has Officially Been Published:

The USP has just announced on November 1^st that the new version of Chapter 797 has been published. This will become the official requirement for sterile compounding in November 2023.  One likely change, that may take a lot of planning and preparation, is the anticipated monthly surface sampling in all classified spaces, rather than today’s twice-yearly sampling. Contracting this task out to a vendor may be very costly, if the vendor even has the capacity to expand to monthly service for all of their clients. Taking on the task internally will require extensive preparation including competency validation, purchase of incubators, space to perform incubation etc. A year seems like sufficient time to prepare, but our advice is to start that planning now as there are many logistical issues to be evaluated in order to be able to start monthly surface sampling on time.