Statement of Conditions PFI List

Q: We are expecting Joint Commission at our hospital soon. Since they will no longer look at the PFI lists, is it advisable to keep our current open PFIs open on their website? I was informed to close out the open PFIs and document under “Other” that they are closed since we are no longer required to report them to TJC. But, I do not want to close out open PFIs on the TJC website for this reason. Please advise.

A: It is totally up to you and your organization. It is true that Joint Commission has said the Statement of Conditions PFI section is no longer part of the survey process, and their surveyors will no longer look at the PFIs you have written. For the record, Joint Commission is encouraging hospitals to continue to use the PFI section in the SOC in order to manage their Life Safety Code deficiencies. In fact, the accreditor has recently said that they will even allow Environment of Care deficiencies to be placed on the SOC PFI section for you to manage. Joint Commission does not have any immediate plans to eliminate the PFI section from the SOC because they feel it is a useful tool for you to use to manage your deficiencies.

But if it were me, I would likely discontinue using the PFI section in the SOC because I think the computerized maintenance management system that most hospitals have would be a better tool to manage my deficiencies. And, I see no reason to leave Life Safety Code deficiencies listed on a Joint Commission document for their surveyors to look at, if I don’t have to. I know Joint Commission says their surveyors will not look at the PFIs you’ve written, but how do we know for sure that they won’t? In your case, I would not have a problem closing out the current PFIs using the “Other” choice.

Changes to the 2018 Life Safety Chapter

A lot has been said and written concerning the changes that Joint Commission has made in regards to their Life Safety chapter for acute-care hospitals, and for good reason. CMS has been working with the accreditor to make changes and additions to bring the LS chapter up to their expectations. So far, it has been a long and arduous project, but we now have the results of Joint Commission’s hard work: The Life Safety chapter of the 2018 Comprehensive Accreditation Manual for Hospitals.

Nearly every standard in the new LS chapter has received some change or addition with their elements of performances (EPs). We have compared the new chapter to last year’s version and summarized all of the changes and additions found in the new 2018 chapter.

If you are interested in reading about all of the changes in a summary format, go to “Tools” on this website, and look for the “Changes to the 2018 Joint Commission Life Safety Chapter” subheading and down-load the free 9-page .pdf document that describes all of the changes that you need to know for 2018.

 

Quarterly Fire Drills

Q: There is a matrix floating around on the web that describes Joint Commission’s compliance for fire drills. It breaks the quarters down as Q1=January, February, March, and Q2=April, May, June, etc. Does this mean that for a first shift drill last run in April, we can have the next drill run in September and still be compliant, + or – 10 days?

A: No, not for Joint Commission. In their Overview to the Environment of Care chapter in the Hospital Accreditation Standards manual, Joint Commission says quarterly or once per quarter means “every three months, plus or minus 10 days”. Now, I’ve heard Joint Commission engineers say they will allow this to be interpreted as follows: If the drill was conducted on April 15, that means three months from April is July. July plus 10 days means August 10 and July minus 10 days means June 20. So, according to the engineers from The Joint Commission, the window of opportunity is 51 days: from June 20 to August 10. That scenario would apply to any date the drill was conducted in April.

But to be honest, the Overview of the Joint Commission manual doesn’t say that. Other people are interpreting the Overview to mean if the drill was conducted on April 15, then 3 months after that is July 15. July 15 plus 10 days is July 25, and July 15 minus 10 days is July 5. That leaves you with a 20-day window of opportunity. 20 days is significantly less than 51 days, so you will be at the mercy of the surveyor to determine which one they enforce.

But in the past year, CMS has stated unofficially that they do not like any scenario that allows more than 3 months for a fire drill. In other words, they don’t mind the “every three months, minus 10 days”, but they don’t like the “every three months, plus 10 days”.

Enforcement Date for the 2012 LSC

Q: Can you provide some clarification? The NFPA 101 2012 edition was adopted July 5th is that correct? Joint Commission and CMS will not be reviewing using this current edition until November 1, 2016 is this also correct? Wheeled equipment once being use for patient care can now remain in the corridor?

A: Yes… CMS adopted the 2012 Life Safety Code on May 4, 2016 with an effective date set for July 5, 2016. However, they soon issued a S&C memo on June 20, 2016, that said while the new 2012 LSC is still effective on July 5, 2016, they will not enforce the requirements of the new code until November 1, 2016. This extra 4 months is needed for the accreditation organizations (AO) to modify their standards to address the new 2012 LSC requirements, submit them to CMS for review and approval, and then train their surveyors and clients. So, a November 1, 2016 enforcement date seems appropriate. This additional 4 months also allows you the opportunity to become fully compliant with the new requirements of the 2012 LSC, so that is a break as well.

While the new 2012 LSC is effective July 5, you will not see the AOs or CMS enforcing any of the new requirements, such as quarterly fire hose valve inspections, annual fire doors inspections, and 5-year internal inspections of the sprinkler pipe until November 1. But during this 4 month period of leniency, healthcare organizations may take advantage of the breaks the new 2012 LSC offers, such as monthly fire pump testing rather than weekly, and semi-annual water-flow switch testing rather than quarterly.

Section 19.2.3.4 (4) of the 2012 LSC does allow certain wheeled equipment to be left unattended in the corridor, provided it meets the following criteria:

  • The wheeled equipment does not reduce the clear width of the corridor to less than 5 feet
  • There must be a fire safety plan and training program to relocate the wheeled equipment during a fire or similar emergency
  • The wheeled equipment is limited to equipment in use; carts in use; medical emergency equipment not in use; patient lift equipment; and patient transport equipment.

In case you’re wondering, computers on wheels are not considered to be medical emergency equipment, so they do not qualify to be left unattended in the corridors for more than 30 minutes.

How the Changes to the SOC Process Will Affect Life Safety Compliance

On July 13, 2016, The Joint Commission issued the following statement:

 “Effective Aug. 1, 2016, changes will become effective to the Statement of Conditions™ (SOC) process that will affect the survey of Life Safety (LS) chapter requirements. Following Aug. 1, 2016, the following changes to survey will occur:

  1. The open Plan for Improvement (PFI) items will no longer be reviewed by the survey team.
  2. The open PFI will no longer be imported into the Final Report.
  3. All Life Safety (LS) chapter deficiencies identified during survey will become Requirements for Improvement (RFI) with a 60-day Evidence of Standards Compliance (ESC). For those deficiencies that require more than 60 days, a Time-Limited Waiver process is available.
  4. Only equivalency requests related to survey events will be reviewed.

The Joint Commission has had the SOC as part of its accreditation program since 1995. The SOC was originally created to allow organizations a process to develop a plan for improvement to correct deficiencies they self-identified within a justifiable time frame based on budgeting and scheduling needs, with Interim Life Safety Measures (ILSM) to ensure patient safety. Initially, these self-identified actions were not documented during survey because the SOC already documented the deficiency. The Joint Commission also created the ILSM process to mitigate risk while resolving the deficiencies. This allowed the SOC process to be the method for organizations to create and submit their Plan for Improvement (PFI), with an amount of time to make the correction that the organization could manage, while still providing a safe environment. Occasionally, an organization would need additional time to complete the corrective action, and The Joint Commission granted extension requests. Many of these extension requests occurred during the six-month automatic extension period.      

CMS has identified required changes to the SOC process, including:  

  • No longer allowing the SOC to document self-identified deficiencies, instead, taking the self-identified deficiencies and converting those to RFIs by the surveyor 
  • No longer allowing more than 60 days for corrective actions unless approved by the CMS regional office
  • The surveyor citing all deficiencies replacing the extension request component with a Time Limited Waiver process, using the Survey-related Plan For Improvement (SPFI) process that will be managed and tracked by the CMS regional office
  • Managing the survey-related equivalency process, as defined by CMS, using Salesforce and the SOC to manage and track the CMS regional office action  
  • Removing the six-month automatic extension
  • No longer granting requested extensions
  • Joint Commission leadership, after reviewing the restrictions being placed on the SOC, has determined that the Basic Building Information and PFI components of the SOC no longer fit the quality assessment program it was originally designed as, and will become an optional management program and will not be a part of the survey process. Post survey, the CMS Time Limited Waiver and equivalency components of the SOC will be used to manage survey-related deficiencies. All questions should go to The Joint Commission Department of Engineering at 630-792-5900.”

 

This is another sad event for patient safety caused by a federal agency that cannot see the positive that the SOC / PFI process had for healthcare organizations. This action by CMS is not a knee-jerk reaction that was not carefully considered; rather this decision by CMS to not allow the hospitals and ambulatory surgical centers to have a process of self-identification of Life Safety Code deficiencies and an incentive to be proactive has been long-coming for years.

Back in 2008 when Det Norske Veritas (DNV) Healthcare received deeming authority from CMS, the new accreditor wanted a system similar to the Statement of Conditions PFI list, but was told by CMS that they could not. Similarly, in 2012 HFAP applied for a system similar to the PFI list but was also denied by the federal agency.

In 2014 when CMS issued their proposed rule to adopt the 2012 Life Safety Code, the public responded with many comments. Quite a few commenters mentioned that CMS should keep the SOC/PFI system and allow all of the accreditation organizations a chance to utilize it.

When CMS issued their final rule on May 4, 2016, they made it very clear that there will not be any Plan For Improvement list in the way that Joint Commission was operating. That was the writing on the wall and it became clear that the major hospital accreditor would have to discontinue its use.

This is a very sad event, because now it is feared that many hospitals will no longer be proactive and self-identify their own Life Safety Code deficiencies because any incentive to do so (i.e. not citing the deficiency on the survey report) has been removed. CMS has struck harder and put a stop to hospital self-identifying the projected completion date, and now makes all LSC deficiencies cited during a survey to be resolved within 60 days of the end of the survey.

Since major LSC deficiencies cannot be resolved that quickly, CMS is now requiring the healthcare organizations to request a time-limited waiver through the accreditor. This is another example of CMS tightening their grip on the accreditation process. In this case, it reduces the level of safety for the patients. Where is the logic in that?

Say Goodbye to Joint Commission’s PFI List

Q: Hello Brad, I hear the SOC as of 8/4/2016 will no longer be used. If time is needed to do a repair for a life safety item we need to apply for a waiver from CMS and if granted, will be for 60 days. how true is this rumor? Please say it ain’t so!

A: Well… it ain’t so as you describe it, but here is the truth:

CMS has told Joint Commission that they can no longer allow hospitals more than 60 days from the end of the survey to resolve a LSC deficiency, unless the hospital has applied for a time-limited waiver, which acts as an extension. This effectively eliminates any positive action the Plan For Improvement (PFI) section of the Statement of Conditions. However, contrary to what you’ve heard, the SOC remains in the format of the Basic Building Information (BBI) section. Joint Commission has said their surveyors will no longer look at the PFI section, and Joint Commission will eliminate the special section at the end of the survey deficiency report that contained the PFIs. Now, all LSC deficiencies will cited in the main portion of the survey deficiency report and will not receive any special dispensation, such as the PFIs used to.

Back in 2014, CMS told Joint Commission that they can no longer not cite a LSC deficiency even if it was listed in the PFI section. So, since July 2014 all LSC deficiencies listed in the hospital’s PFI section were cited in the end of the survey deficiency report and did not require a Plan of Correction (PoC) since it already had one in the PFI list. Fast forward two years, and CMS told Joint Commission again that they did not like the fact there was no PoC for the LSC deficiencies listed in the PFI section, and they did not like the hospital taking more than 60 days to resolve the LSC deficiency without CMS permission.

So… beginning August 1, 2016, the PFI list is effectively defunct, and all LSC deficiencies cited during a survey will need to be resolved within 60 days of the end of the survey. If it cannot be resolved within 60 days of the end of the survey then the hospital must submit a time-limited waiver request to Joint Commission who will then forward it to the proper CMS regional office for their review and approval. Once approved, the time-limited waiver request is good until the next survey cycle where it will become invalid and if the deficiency remains it will be cited again.

Hospitals may still submit regular waiver and FSES equivalencies for LSC deficiencies that are an unreasonable hardship to resolve. That is an entirely different process and they are submitted to the accreditation organization and then it is forwarded to CMS regional office for review and approval.

Joint Commission says the PFI list will still be part of the SOC and hospitals may use it as a tool to manage their LSC deficiencies. But I advise my clients to no longer write PFIs in the SOC and manage their LSC deficiencies with the Computerized Maintenance Management System (work order system). That way, there is no chance of a unscrupulous surveyor looking at the PFI list and then writing those deficiencies into the survey deficiency report.

It’s a whole new world out there and CMS is bound and determined to have everything their way.

Brad Keyes, CHSP

CMS Enforces Different Time-Description

I received the following comment from a reader:

During a recent CMS life safety survey a surveyor stated that my kitchen hood suppression testing intervals were out of compliant even though they’re we’re clearly within The Joint Commision’s plus or minus 20 day window for semi-annual testing. He said CMS goes by the NFPA code (not JC) and that, that window is not in the code so therefore the testing must be completed before the 6 month anniversary. However, he stated that the quarterly inspections and testing can be done in a calendar basis and not by the revised quarterly interval parameters that JC has implemented (every 3 months, plus or minus 10 days).

This is an example where the accreditation organization has developed a thoughtful and practical interpretation of the NFPA standards regarding frequency of inspections and tests. Then CMS comes along and denies the practicality of the interpretation because it is not permitted in the NFPA codes or standards. That’s one of the problems with the NFPA standards is they don’t define time, such as what “semi-annual” or “every 6 months” means.

I’ve heard some state agencies surveying on behalf of CMS actually require the annual inspection or testing activity to occur exactly on the same date as the previous activity, one year later. So if it was last tested on April 15, it had to be next tested on April 15 of the next year, regardless what day of the week that landed on. That was extreme and I hope responsible people came to their senses.

But part of the problem is the people who are interpreting these rules have never worked in a hospital. They seem to not understand that hospitals need a reasonable window of opportunity to schedule these inspections and tests. Facility departments have decreasing resources available to them and it would sure be helpful if the government would just give them a little help now and then by interpreting issues with a little kinder attitude.

Wouldn’t it be nice if all of the authorities having jurisdiction (i.e. CMS, accreditation organizations, state fire marshals, etc.) were on the same page for critical issues like this?

 

Quarterly Testing and Inspection Challenges

Q: What strategies are other hospitals using in scheduling their quarterly fire systems inspections heading into 2014? We are a 3 million sq. ft. campus and our vendor is not always able to schedule us within the tight 20-day window each quarter that Joint Commission will now require. So by definition our schedule will now be in flux, depending on the completion date of the last inspection, rather than set on the same month each quarter. I realize they do not want people to schedule inspections in back to back months, which we do not do, but this seems like it will cause more instability than anything. 

A: I see your dilemma and understand the difficulty in the logistics of your situation. Scheduling a contractor to be onsite within the new 20-day window each quarter will be a challenge to large organizations like yours.

For the record, the Engineering department at the Joint Commission was not in favor of the requirement that quarterly testing and inspections to be performed 3 months from the previous test/inspection, plus or minus 10 days. But the power-that-be above them made that decision.

To answer your question: I do not know what other organizations are doing in regard to challenges with the new quarterly testing requirements. However, I think there is a way you can deal with this issue.

I suggest you contact the Standards Interpretation Group at the Joint Commission and discuss your options concerning the challenges in meeting the quarterly test/inspection window. Ask them if you can have some leeway that would allow you a wider window each quarter for the testing/inspection frequency other than the plus or minus 10 day window. My guess is they will allow it as long as you can demonstrate the hardship in meeting this requirement.

Joint Commission Clarification of Findings

Q: We recently had a survey which resulted in multiple Life Safety findings. We want to clarify away some of these findings, and were told we can only clarify the ‘C’ category findings. Is this true?

A: No, I would not say that statement is true. Any finding may be clarified after the survey as long as the organization provides sufficient evidence that they were in compliance with the standard at the time of the survey. All ‘A’ and ‘C’ listed elements of performance that received a finding from the surveyor may be appealed to the accreditor with an explanation as to why the hospital believes they were compliant. This is called the clarification process, and organizations have ten (10) days to submit their clarifications once the survey report has been posted.

However, standards with ‘C’ elements of performance do have the additional advantage of clarification if the organization can prove they were compliant with at least 90% of the items covered under the standard prior to the survey. Take the example that corridor doors are required to latch (LS.02.01.30, EP 11); If the hospital regularly examines their corridor doors and has documentation that demonstrates at least 90% of the corridor doors did latch, then that information may be used in a written clarification and any finding of a corridor door not latching would eventually be vacated if the accreditor accepts the clarification.

In order to take advantage of this additional ‘C’ EP clarification process, the documented evidence of compliance must be gathered prior to the survey. This would require the organization to have a monitoring program in place that evaluates various features of life safety on a routine basis. That is why the old Building Maintenance Program (BMP), which is optional, is so important as it provides a documented history of compliance at any given time.  Many hospitals choose not to implement a BMP because it no longer provides any direct relief of a finding during the survey, but the program still provides the historical evidence needed for a clarification. And, it is a very good self-assessment program of your features of life safety.

The clarification process seems to be hit and miss, at times. It is dependent on a well-crafted written response with the evidence needed to vacate the finding. The staff in the Standards Interpretation Group at the accreditation organization does not always approve the clarifications the same way. It may depend on who is actually reviewing the clarification.

Contractors During a Survey

images[3]It has always been my belief that as the surveyor team walks in the front door of the hospital on the first day of the survey, all of the contractors should be walking out the back door. For the most part (and I do understand that there are exceptions), contractors should be sent away once you know there are surveyors in the house. Why? Because they will get you in trouble one way or another.

I recently received an email from a reader who shared this story:

During our triennial survey the life safety surveyor asked me how we knew that the fire alarm system signal was received by our monitoring company. I could not immediately answer the question, but we were lucky to have the service contractor in the building doing his quarterly testing and I suggested we ask him.

The service technician explained that the software in the fire alarm control system will indicate if the alarm is received by the monitoring company within the designated amount of time. I was quite happy with the service technician’s explanation until the surveyor said “Prove that it happened at least quarterly for the past 12 months”.

The service technician said nobody could prove it; we just have to take his word for it. [Wrong answer.] The surveyor asked “Don’t you call them by telephone to confirm they received the signal?” The service technician replied, saying “Well, would you trust me if I said I did call?”

The surveyor was correct to ask the questions that he/she did. The service technician was probably answering them to the best of his ability, but the real problem is the facility manager allowed the surveyor to enter into a conversation with a contractor. During a survey, the hospital staff should try and control the process as much as possible. By allowing a surveyor to ask questions of a contractor, the facility manager lost control of the situation and will suffer any consequences of what a contractor may say.

Contractors are not trained and educated in the regulatory requirements the same way the hospital staff is (or should be). The contractors may not even know or understand the significance of an accreditation survey, or worse, a CMS certification survey. Service technicians have a tendency to take an attitude that they know more about the system they are working on than the hospital does, and for the most part they do. Otherwise, the hospital would not hire them. But the service technician my not know what specific regulations that the hospital must comply with and therefore may say something to a surveyor that may get you in trouble.

I’m not saying you should not be transparent in your processes, but during a survey, you need to control as much as you can of the survey process. This is not unethical or wrong; it is just smart business. Let the surveyor go where he/she wants; let the surveyor ask questions all they want; but eliminate the potential “loose cannons” that are not very well educated on the survey process by sending them home during the survey.

Another reader sent me an email earlier this year explaining that on a day during the accreditation survey a roofing contractor set a pallet of roofing material right in the middle of the exit discharge of a staff entrance/exit to the hospital. Nobody from the hospital was aware that the roofing contractor was about to do that, but the surveyor noticed it as soon as it happened and it went into the survey deficiency report.

When I was a surveyor for The Joint Commission, I would purposely seek out contractors and ask them what training the hospital provided them on fire safety procedures. Ultimately, contractors are expected to know the same fire response procedures as the staff. Invariably they could not answer the question satisfactory and it would be cited in the survey deficiency report.

I know that in some situations you cannot send the contractors home for the duration of the survey, but it seems that a large percentage of them could. At the hospital where I worked as the Safety Officer, I asked the project management team to send the contractors away during the week of the survey (this was when the surveys were announced). The project managers thought that was a good idea, but we were over-ruled by the COO of the hospital, because he did not want the opening of the new renovated unit to be delayed. That ended up being a costly mistake. The hospital had a policy that every contractor had to receive basic safety orientation before they begin their work on the campus of the organization. Unbeknownst to the hospital, the general contractor brought in a sub-contractor to install flooring in one area, and they did not go through the safety training because the general thought it would be “okay” since the sub was only going to be there for one day. Sure enough, the surveyor found that one sub who had not received the safety training which lead to a finding on the survey deficiency report.

You need to control what you can, and sending the contractors away is the smart thing to do during a survey.