Standards Regarding Environmental Rounds

Q: I am wondering where I can find the Joint Commission/CMS requirements regarding Environment of Care rounds? We have always practiced twice a year for clinical areas, once a year for non-clinical areas. Are these requirements somewhere that discuss exactly what has to be checked for, when, where, etc?

A: The CMS Conditions of Participation §482.41 for acute care hospitals do not directly address the requirement to conduct EOC rounds twice a year in patient care areas and only once per year in non-patient care areas. §482.41(a) says the condition of the physical plant and overall hospital environment must be developed and maintained in such a manner that the safety and well-being of patients are assured. Nowhere in the CoP standard does it address the frequency of routine inspections. However, routine inspections are implied according to the Survey Procedures for §482.41(a) which says: “Review the hospital’s routine and preventative maintenance schedules to determine that ongoing maintenance inspections are performed and that necessary repairs are completed.” Again… this standard does not stipulate the frequencies and does not differentiate between patient are areas and non-patient care areas.

However, Joint Commission recently changed their requirements regarding inspection frequencies. The old Joint Commission standard EC.04.01.01, EP 12 used to say you must conduct environmental tours every 6 months in patient care areas… and EP 13 used to say you must conduct environmental tours every 12 months in non-patient care areas. Now, in the 2017 Comprehensive Accreditation Manual, they eliminated EPS 12 and 13, so the organization must now rely on EP 1 which says the hospital establishes a process for continually monitoring the environment.

So, where the Federal government is vague… the Joint Commission has made now changed to be equally vague. But, if you chose to inspect less than twice per year in patient care areas and less than once per year in non-patient areas, you will need to have documentation, such as a risk assessment, to demonstrate your process is effective.