Sep 09 2016

CMS Announces New Rule on Emergency Management

Category: BlogBKeyes @ 12:00 am
Share

Well… here it is. CMS has announced that they will publish their Final Rule on the new standards for Emergency Management. It appears the new rule will not be published in the Federal Register until September 16, 2016, which is a week away, but take time now to read their press release below… and start learning all the changes you will need to know.

According to the press release, the new rule becomes effective 60 days after it is published in the Federal Register, which would be November 15, 2016. But it also says the new requirements will not be enforced until November, 2017, so the healthcare organizations and the AOs have a year to get ready for these changes.

CMS News

FOR IMMEDIATE RELEASE September 8, 2016

Contact: CMS Media Relations (202) 690-6145 | CMS Media Inquiries

CMS finalizes rule to bolster emergency preparedness of certain facilities participating in Medicare and Medicaid

Today, the Centers for Medicare & Medicaid Services (CMS) finalized a rule to establish consistent emergency preparedness requirements for health care providers participating in Medicare and Medicaid, increase patient safety during emergencies, and establish a more coordinated response to natural and man-made disasters.

Over the past several years, and most recently in Louisiana, a number of natural and man-made disasters have put the health and safety of Medicare and Medicaid beneficiaries – and the public at large – at risk. These new requirements will require certain participating providers and suppliers to plan for disasters and coordinate with federal, state tribal, regional, and local emergency preparedness systems to ensure that facilities are adequately prepared to meet the needs of their patients during disasters and emergency situations.

“Situations like the recent flooding in Baton Rouge, Louisiana, remind us that in the event of an emergency, the first priority of health care providers and suppliers is to protect the health and safety of their patients,” said CMS Deputy Administrator and Chief Medical Officer Patrick Conway, M.D., MSc. “Preparation, planning, and one comprehensive approach for emergency preparedness is key. One life lost is one too many.”

“As people with medical needs are cared for in increasingly diverse settings, disaster preparedness is not only a responsibility of hospitals, but of many other providers and suppliers of healthcare services. Whether it’s trauma care or long-term nursing care or a home health service, patients’ needs for health care don’t stop when disasters strike; in fact their needs often increase  in the immediate aftermath of a disaster,” said Dr. Nicole Lurie, HHS assistant secretary for preparedness and response. “All parts of the healthcare system must be able to keep providing care through a disaster, both to save lives and to ensure that people can continue to function in their usual setting. Disasters tend to stress the entire health care system, and that’s not good for anyone.”

After reviewing the current Medicare emergency preparedness regulations for both providers and suppliers, CMS found that regulatory requirements were not comprehensive enough to address the complexities of emergency preparedness. For example, the requirements did not address the need for: (1) communication to coordinate with other systems of care within cities or states; (2) contingency planning; and (3) training of personnel. CMS proposed policies to address these gaps in the proposed rule, which was open to stakeholder comments.

After careful consideration of stakeholder comments on the proposed rule, this final rule requires Medicare and Medicaid participating providers and suppliers to meet the following four common and well known industry best practice standards.

1. Emergency plan: Based on a risk assessment, develop an emergency plan using an all-hazards approach focusing on capacities and capabilities that are critical to preparedness for a full spectrum of emergencies or disasters specific to the location of a provider or supplier.

2. Policies and procedures: Develop and implement policies and procedures based on the plan and risk assessment.

3. Communication plan: Develop and maintain a communication plan that complies with both Federal and State law. Patient care must be well-coordinated within the facility, across health care providers, and with State and local public health departments and emergency systems.

4. Training and testing program: Develop and maintain training and testing programs, including initial and annual trainings, and conduct drills and exercises or participate in an actual incident that tests the plan.

These standards are adjusted to reflect the characteristics of each type of provider and supplier. For example:

  • Outpatient providers and suppliers such as Ambulatory Surgical Centers and End-Stage Renal Disease Facilities will not be required to have policies and procedures for provision of subsistence needs.
  • Hospitals, Critical Access Hospitals, and Long Term Care facilities will be required to install and maintain emergency and standby power systems based on their emergency plan.

In response to comments, CMS made changes in several areas of the final rule, including removing the requirement for additional hours of generator testing, flexibility to choose the type of exercise a facility conducts for its second annual testing requirement, and allowing a separately certified facility within a healthcare system to take part in the system’s unified emergency preparedness program.

The final rule also includes a number of local and national resources related to emergency preparedness, including helpful reports, toolkits, and samples. Additionally, health care providers and suppliers can choose to participate in their local healthcare coalitions, which provide an opportunity to share resources and expertise in developing an emergency plan and also can provide support during an emergency.

These regulations are effective 60 days after publication in the Federal Register. Health care providers and suppliers affected by this rule must comply and implement all regulations one year after the effective date.

For more information please see a blog by Dr. Lurie, HHS assistant secretary for preparedness and response, and the CMS Survey & Certification – Emergency Preparedness webpage.

 

Tags: ,


Aug 04 2016

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

Category: BlogBKeyes @ 12:00 am
Share

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?

Tags: , ,


Mar 02 2016

CMS Enforces Different Time-Description

Category: BlogBKeyes @ 12:00 am
Share

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?

 

Tags: , ,


Dec 18 2015

Multiple Delayed Egress Locks in the Path of Egress

Category: BlogBKeyes @ 12:00 am
Share

Q: I have heard you state that once the 2012 edition of the Life Safety Code is finally adopted hospitals will be allowed to have more than one delayed egress locks in the path of egress. I understand that the 2000 LSC only allows one delayed egress lock in the path of egress, but I cannot find it written in the 2012 edition that more than one delayed egress lock is permitted in the path of egress. Can you explain this to me?

A: You won’t find it written in the 2012 LSC that more than one delayed egress locks can be used in the path of egress because it is not written in the LSC anywhere. In the world of the Life Safety Code, unless it is otherwise stated, you are permitted to do something as long as the code does not prohibit it. This concept may be contrary to some people who look to the LSC for permission to do something. But, this method of interpreting the LSC will get you in trouble if you are not familiar with the entire content of the code, because the reference that prohibits something may be located in a different chapter or section than the one you are looking at.

But, getting back to delayed egress locks: Section 7.2.1.6.1 of the 2000 and the 2012 editions of the LSC discusses the requirements you must follow to utilize delayed egress locks. Nowhere in section 7.2.1.6.1 does it prohibit more than one delayed egress locks in the path of egress. But to fully understand the issue, we must look at section 18/19.2.2.2.4 of the 2000 LSC, which has Exception No. 2 which says: “Delayed-egress locks complying with 7.2.1.6.1 shall be permitted, provided that not more than one such device is located in any egress path.”

So, there is this exception in the healthcare occupancy chapters of the 2000 LSC that limits delayed egress locks to just one in the path of egress. As section 4.2.2.2 of the 2000 LSC states, where specific requirements in the occupancy chapters differ from the general requirements contained in the core chapters, the requirements of the occupancy chapters shall govern. That is why multiple delayed egress locks are not permitted in the path of egress in a hospital.

The 2012 edition of the Life Safety Code changed all that, but not by writing something new into the code. They did it by deleting the substance of the exception that limited the number of delayed egress locks in the path of egress. Take a look at section 18/19.2.2.2.4 (2), which says: “Delayed-egress locks complying with 7.2.1.6.1 shall be permitted.” The reference that limited delayed egress locks to just one in the path of egress in healthcare occupancies was deleted.      

So, that is why when the 2012 edition of the Life Safety Code is finally adopted, you will be able to have more than one delayed egress locks in the path of egress in hospitals, provided you meet all of the requirements.

If you want to start using the 2012 edition now on the issue of delayed egress locks, before the new code is adopted, CMS (and the accreditation organizations) will allow you to do so through the use of the categorical waiver, as outlined under the CMS S&C memo 13-58-LSC, issued August 30, 2013. For a full review of CMS S&C memo 13-58-LSC, click on this link:  http://www.cms.gov/Medicare/Provider-Enrollment-and-Certification/SurveyCertificationGenInfo/Policy-and-Memos-to-States-and-Regions.html

Tags: , ,


Dec 02 2015

When Will CMS Adopt the 2012 Life Safety Code?

Category: BlogBKeyes @ 12:00 am
Share

Q: When will CMS adopt the new 2012 Life Safety Code? It seems they are taking a long time to do it.

A: I don’t know when CMS will finally adopt the 2012 Life Safety Code, if at all. They certainly have made formal statements that they are considering adopting the 2012 LSC; in December 2011 they announced that they are reviewing the 2012 edition for consideration of adoption, and in April 2014 they published a proposed rule of adopting the 2012 LSC and requested the public to send them comments, which they did. But since then, there has not been any official announcement concerning the adoption of the 2012 LSC. Some people think the adoption is a political event, tied to Congress and the President’s approval, which is not true. It may be political, but contrary to popular myth, Congress does not have to vote on approving CMS adopting a new edition of the LSC, and the President does not have to sign it into law. The last time I talked with an official representative from CMS’s home office in Baltimore, they said the decision when to adopt the 2012 LSC is now in the hands of their lawyers. Stay tuned…

 

Tags: ,


Jan 15 2015

More on the CMS S&C Memo Concerning Power Strips

Category: BlogBKeyes @ 6:00 am
Share

12-120-878-TS[1]I received a question from a reader that I was unable to immediately answer. The question dealt with the use of power strips in a business occupancy: Did the categorical waiver to allow the use of power strips described in the  S&C memo 14-46-LSC, issued September 26, 2014 apply to business occupancies? The reader explained that the physician office building where he worked did not have hospital grade receptacles so it did not make sense to him that using UL listed power strips was necessary.

My immediate thought was the CMS issued categorical waiver would only apply to healthcare occupancies because NFPA 99 (2012 edition) does not apply to business occupancies. NFPA 99 is referenced by the healthcare occupancy chapter in section 18.5.1.3 of the 2012 LSC, but it is not referenced by the business occupancy chapters in the same LSC.

But, since I was not sure, I asked the question of a reliable source at CMS and they said the 2012 NFPA 99 Section 3-3.2.1.2(d)2 pertains to the minimum number of receptacles in all Patient Care Rooms.  Patient Care Rooms is defined as any room of a health care facility wherein patients are intended to be examined or treated.  In addition, the 2012 NFPA 99 Section 10.2.3.6 pertains performance criteria and testing for patient-care-related electrical appliances and equipment.  Patient-care-related electrical equipment is defined as electrical equipment that is intended to be used for diagnostic, therapeutic, or monitoring purposes in the patient care vicinity.

As these definitions do not make a differentiation based on occupancy,  it is CMS’s understanding that 2012 NFPA 99 power strip requirements would be applicable in all health care facilities in rooms where patients are intended to be examined or treated regardless of occupancy classification.

So, the answer to the question is the categorical waiver applies to all patient care rooms, regardless of the occupancy classification. This means if you want to use power strips in a physician exam room in a medical office building that is a business occupancy, you need to follow the guidelines in the S&C memo and only use UL listed power strips. However, for other areas of the business occupancy that are not considered patient care rooms, the NFPA 99 requirements concerning UL listed power strips do not apply. But it is wise to purchase only UL listed power strips since you cannot control where they may end up.

Tags: , ,


Oct 01 2014

CMS Issues Categorical Waiver on Power Strips

Category: BlogBKeyes @ 3:00 pm
Share

12-120-878-TS[1]CMS issued a new S&C memo 14-46 in late September that made allowances for healthcare organizations to utilize power strips in patient care areas.

CMS has determined that the 2000 edition of the Life Safety Code contains provisions on the use of power strips in health care facilities that may result in unreasonable hardship for providers or suppliers. Further, CMS says an adequate alternative level of protection may be achieved by compliance with the 2012 edition of the Life Safety Code, which has extended allowances on the use of power strips in patient care areas.

CMS has determined that the 1999 edition of NFPA 99 Standard for Health Care Facilities, section 3-3.2.1.2 (d)(2) which requires a sufficient number of receptacles located so as to avoid the need for extension cords or multiple outlet adapters, is outmoded and unduly burdensome. NFPA 99 is referenced in part by the Life Safety Code. Power strips are also known as multiple outlet adapters, multiple-plug adapters, and relocatable power taps.

CMS says by contrast, the 2012 edition of NFPA 99 has extended allowances for use of power strips in ‘patient care rooms’, which replaces the term ‘patient care areas’.

The requirement in the 1999 edition of NFPA 99 for sufficient receptacles to be located in all patient care areas as to avoid the need for power strips has been removed in the 2012 edition. In place, the 2012 edition has increased the minimum number of receptacles in patient care rooms for new construction.

Effective immediately, CMS is permitting a categorical waiver to allow for the use of power strips in existing and new health care facility patient care areas/rooms, if the provider/supplier complies with all applicable 2012 NFPA 99 power strip requirements and with all other 1999 NFPA 99 and 2000 Life Safety Code electrical system and equipment provisions. NOTE: This applies to patient care rooms in all occupancies; not just healthcare occupancy. So does apply to patient care rooms in business occupancies as well as ambulatory care occupancies.

A patient care room is defined as any room in a health care facility wherein patients are intended to be examined or treated. This definition appears to include operating rooms and procedure rooms as well and is not limited to just healthcare occupancies.

The CMS S&C memo 14-46 describes basic requirements that health care facilities must comply with in order to use the new categorical waiver.

  • Patient bed locations in new health care facilities, or in existing facilities that undergo renovation or a change in occupancy, shall be provided with the minimum number of receptacles as required by section 6.3.2.2.6.2 of the 2012 NFPA 99.
  • Power strips may be used in a patient care vicinity to power rack-mounted, table-mounted, pedestal-mounted or cart-mounted patient care related electrical equipment assemblies, provided all of the conditions are met in section 10.2.3.6. They do not have to be an integral component of manufacturer tested equipment.
  • Power strips may not be used in a patient care vicinity to power non-patient care-related electrical equipment, such as personal electronics.
  • Power strips may be used outside of the patient care vicinity for both patient care-related equipment and non-patient care-related equipment.
  • Power strips providing power to patient care-related electrical equipment must be Special Purpose Relocatable Power Taps (SPRPT) listed as UL 1363A or UL 60601-1.
  • Power strips providing power to non-patient care-related electrical equipment must be Relocatable Power taps (RPT) listed as UL 1363.

The categorical waiver is available to all health care providers and suppliers and need only to document their decision to use the waiver, stating that they comply with all of the requirements to do so. This document must be provided to the surveyor team at the entrance conference. Organizations wishing to use the categorical waiver need not apply for them or wait until they are cited to use them.

To review the CMS S&C 14-46 memo, follow this link:  http://www.cms.gov/Medicare/Provider-Enrollment-and-Certification/SurveyCertificationGenInfo/Downloads/Survey-and-Cert-Letter-14-46.pdf

Tags: , ,


Jul 01 2014

Congratulations! CMS Approves The Joint Commission for Six More years

Category: BlogBKeyes @ 6:00 am
Share

I suspect most of you didn’t give this much thought, but ever since 2009, The Joint Commission has had to apply to CMS for their deeming authority to survey hospitals and other healthcare organizations on behalf of the federal agency for Medicare & Medicaid reimbursements. Joint Commission was approved by CMS in 2010 for 4 years, which would expire this year if they did not re-apply.

Re-apply they did and this time it appears CMS was waiting for them and gave them a huge list of things they needed to change about their standards and practices, or they would not receive CMS deeming approval. In all, CMS identified at least 52 specific items that Joint Commission needed to address before they would receive the deeming status that they needed to stay in business.

To their credit, The Joint Commission did the work necessary to comply with the CMS demands. The changes they made that would be most notably in the physical environment areas, include:

  • Open PFIs will be cited on the final survey report;
  • Agreeing that only CMS can approve equivalencies;
  • Issuing two new Elements of Performance (EPs) which address the requirements for the organization to conduct risk assessments when determining the best equipment maintenance strategy, under EC.02.04.03, EP 24, and EC.02.05.05, EP 6;
  • Issued new EC.02.02.01, EP 18 requiring radiation workers to be checked periodically;
  • Issued new EC.02.02.01, EP 19 requiring procedures for trash storage and disposal;
  • Changed EC.02.03.01, EP 10 to include the phrase “and report fire alarms”;
  • Changed EC.02.05.03 to add the rooms “intensive care, and emergency rooms”.

You might be surprised to learn how hard The Joint Commission has been working to re-write their standards to comply with CMS’s demands. It is easy to think of the largest accreditor as an agency that perpetuates itself year after year, but that is not the case anymore. They have a boss (CMS) that they have to report to, and follow their directives. One indication of the seriousness of this issue, is usually The Joint Commission announces changes to the standards six months before they become effective. The fact that most of the changes mentioned above are effective July 1 (or July 2), 2014, and were only announced to the public during June, says they deviated from their normal practice to satisfy CMS.

It must have worked, since CMS published a statement in the Federal Register on Friday, June 27, 2014 announcing their approval for The Joint Commission as a deeming authority, for another six years. I seriously mean this when I say Congratulations! to The Joint Commission for this achievement. I know it must have been difficult.

Tags: ,


Jun 06 2014

Changes With Equivalency Requests for The Joint Commission

Category: BlogBKeyes @ 11:00 pm
Share

imagesO752ZQ8RAs a result of the June 4, 2014 online announcement by The Joint Commission which identified major changes for the Statement of Condition Plan for Improvement (PFI) list, they also mentioned that beginning July 1, 2014 all equivalency requests submitted to them will be passed along to the appropriate CMS Regional Office for their approval.

What The Joint Commission did not say is CMS will not accept any equivalency requests unless it is submitted as part of the organization’s Plan of Correction. This means, hospitals will no longer be able to submit an equivalency request prior to a survey, but will only be able to submit equivalency requests after the Life Safety Code deficiency is cited in a survey report.

What affect will this have on hospital facility managers? I think both changes involving the PFI list and the equivalency requests has the potential for a huge impact on the overall safety of the physical environment, and it won’t be positive.

In just the two days since Joint Commission announced this change, I must have talked with or emailed with over 20 different facility managers and safety officers of Joint Commission accredited hospitals, discussing what options they have with these new changes. This has many of these individuals very concerned since two key tools are changing on how they manage their Life Safety Code deficiencies.

Allow me to summarize these changes:

1). Beginning July 1, 2014, Joint Commission says all items identified on the PFI list will be cited as deficiencies on the survey decision report. No longer will hospitals enjoy a pass from receiving a written deficiency in the survey report for anything identified on the PFI list. [I talked with one facility manager who has over 200 items on his PFI list and their organization is in the survey window for their triennial survey. He needs to clear those PFIs or risk having them identified on the survey report.]

2). Joint Commission says they will review equivalency requests and send them on to the CMS Regional Office for final action. Since CMS does not accept equivalency requests for LSC deficiencies that have not been cited on a survey report, no longer will facility managers be allowed to be proactive and seek an equivalency for a deficiency prior to a survey.

So, I see a very strong potential for facility managers to discontinue being proactive and identify their LSC deficiencies prior to a triennial survey, since there is no relief from the PFI list and there is no opportunity to seek an equivalency. They very likely will take the stand of wait-and-see if the surveyor finds the deficiency and then deal with it afterwards. I fear our industry may fall back into the “hide our skeletons” concept of over 20 years ago. No longer will some facility managers want to be transparent and self-identify their problems. By failing to self-identify their deficiencies, those deficiencies do not get resolved, and if the surveyors fail to identify them, then they likely will not get resolved at all. How safe is that for our patients?

Do not misunderstand me… I do not advocate facility managers to discontinue being proactive and identifying their LSC deficiencies prior to a survey. In fact, I encourage them to continue as though nothing has happened in regards to the PFI list, and still use it as a tool to manage their deficiencies. But, human nature being what it is, I suspect many hospitals will not be as safe as they once were because some facility managers will no longer be proactive and self-identify their LSC deficiencies.

And, you can forget about the cost effective and economical Traditional Equivalencies that Joint Commission used to accept. CMS will not accept those at all, and will only accept the more costly Fire Safety Evaluation System (FSES) as identified in NFPA 101A.

I think this is a very sad day for healthcare. While I was an advocate for fair play amongst all the accreditation organizations, I wanted CMS to approve the advantage that Joint Commission had with the PFI list and approving equivalencies prior to the deficiency being cited, for all accreditors, not just for Joint Commission. Instead, CMS did not clearly understand the potential actions their insistence will cause.

It looks like CMS will not stop until all the accreditation organizations are homogenized into one big quasi-government group whereby you won’t be able to tell them apart. What good is that?

Tags: , , ,


Jun 06 2014

Follow Up on Changes to the PFI LIst

Category: BlogBKeyes @ 6:00 am
Share

imagesFWHXWLWMSince yesterday, I have received a lot of emails and calls concerning the Joint Commission announcement on changes to their PFI list. On Wednesday, June 4, 2014, Joint Commission published an online article which announced major changes to their survey decision report process, which will become effective July 1, 2014.

Currently, an organization is encouraged to report any Life Safety Code deficiency that they cannot resolve within 45 days of discovery, onto the Statement of Conditions Plan for Improvement (PFI) list, and identify a projected completion date. For many years (20 years?) placing a LSC deficiency on the PFI list provided the organization relief from a surveyor finding in the event of a survey. In the accreditation organization’s announcement on Wednesday, items listed on the PFI list will no longer be free from a surveyor’s citation beginning July 1, 2014.

The reason is the Centers for Medicare & Medicaid Services (CMS) has insisted that the Joint Commission stop this practice, and cite every deficiency that the surveyor sees during the survey. To their credit, Joint Commission has agreed to comply with the federal agency’s directive.

But I have received many emails and telephone calls from facility managers asking “What should I do?” Now that the Joint Commission will cite any item identified on the PFI list, many facility managers are reluctant to self-identify their deficiencies that will likely lead to a surveyor finding.

Let’s remember what the Statement of Conditions PFI list is all about: It is a Joint Commission management tool designed for facility managers to self-report Life Safety Code deficiencies so they can manage the resolution of the deficiency.  The PFI list is there for you to use in order to track the LSC deficiencies to completion. It is not a device in which Joint Commission can say “Gotcha” and hit you over the head.

There is no Joint Commission standard that says you must enter all LSC deficiencies into the PFI list that cannot be resolved within 45 days. Joint Commission does have a Frequently Asked Question (FAQ) on the subject, and the answer they provided is as follows:

The Joint Commission allows resolution of a deficiency by either correcting it immediately (preferred), managing it using a corrective maintenance work order system (with tracking capabilities) with resolution within 45 days, or creating a Plan for Improvement (PFI) and managing it using the electronic Statement of Conditions (SOC).

This is not a standard requirement of the accreditation organization, but more like a recommendation. I see it as an option for the facility manager. He/she does not need to enter the LSC deficiencies in the PFI list if he/she does not want to, especially now that there is no incentive to do so.

But don’t let that short-sightedness be your downfall: It may be better to list all your LSC deficiencies that you cannot resolve within 45 days on the PFI list and risk being cited for them, in order to track and manage each deficiency to a successful conclusion. I guess each facility manager needs to consider all of the alternatives and make their own decision.

For those that missed the Joint Commission announcement, click on the following link:  http://www.jointcommission.org/issues/article.aspx?Article=3hzpYDrgAaZdWi6C%2b1xoxANtx2DFfvVdArnSt2rJ2Yc%3d&j=1752680&e=brad@keyeslifesafety.com&l=9552_HTML&u=28545686&mid=1064717&jb=0

Tags: , , ,


« Previous PageNext Page »