TJC's New 2009 Scoring System

Transcription

1 TAHFM Interlink 2012 Environment of Care & Life Safety Accreditation Challenges Dean Samet, CHSP, Regulatory Compliance Officer TSIG Consulting cell: Copyright 2012 TSIG Consulting, New York, NY Contents Most Challenging 2011 TJC Hospital Requirements TJC Standards Aligning with Centers for Medicare & Medicaid Services Conditions of Participation TJC Leadership Standards cited for lack of Resources, Accountability and Priorities TJC Tidbits/Clarifications Being Prepared for Survey Most Challenging Top 5 Requirements for Hospital Accreditation in % RC* The hospital maintains complete and accurate medical records for each patient. (*Record of Care, Treatment, and Services) 56% LS The hospital maintains the integrity of the means of egress. (32 EPs) 52% LS Building and fire protection features are designed and maintained to minimize the effects of fire, smoke, and heat. (10 EPs) DStymiest@ssr-inc.com, cell

2 Most Challenging Top 5 Requirements for Hospital Accreditation in 2011 (cont.) 45% LS The hospital provides and maintains building features to protect individuals from the hazards of fire and smoke. (25 EPs) 40% EC The hospital maintains fire safety equipment and fire safety building features. (20 EPs) Noncompliance Issues LS Std: The hospital maintains the integrity of the means of egress. (56%) EP 1- Locked doors in the direction of egress EP 13- Corridor Clutter (Crash/Isolation/Chemo Carts-OK) EP 30- No Exit signs missing Unattended more than 30 minutes: considered storage EP 31- Visible exit signs for any path missing Noncompliance Issues LS Std: Building and fire protection features are designed and maintained to minimize the effects of fire, smoke, and heat. (52%) EP 4- Openings in 2-hour fire rated walls not fire rated for 1-1/2 hours EP 5- Fire door issues (hardware, positive latching, self-closing devices, gaps, undercuts) EP 9- Unsealed spaces around pipes, conduits, ducts, etc. penetrating fire walls/floors DStymiest@ssr-inc.com, cell

3 Noncompliance Issues LS Std: The hospital provides and maintains building features to protect individuals from the hazards of fire and smoke. (45%) EP 2- Hazardous areas are not protected with 1-hour construction or sprinkler protection or both (depending if existing or new occupancy) EP 11- Corridor door issues (hardware, positive latching, gaps, undercuts) EP 18- Smoke barriers not continuous or have unsealed penetrations Noncompliance Issues EC Std: The hospital maintains fire safety equipment and fire safety building features. (40%) EP 1- Supervisory signal devices not tested quarterly EP 2- Valve tamper switches not tested every 6 months; water flow devices not tested quarterly EP 3- Duct detectors, electromechanical releasing devices, heat detectors, manual fire alarm boxes, and smoke detectors not tested annually Noncompliance Issues EC (cont.) EP 5- Fire alarm equipment for notifying off-site fire responders not tested annually EP 10- Fire Dept. water supply connections for auto. sprinkler system not inspected quarterly EP 13- Kitchen automatic fire-extinguishing system not inspected every six months EP 15- Portable fire extinguishers not inspected at least monthly Note: Noncompliance may be due to documentation issues!. DStymiest@ssr-inc.com, cell

4 Effective Feb. 1, 2011 EC , EP 6 Note:1 EP 6 Note 1 Deleted Effective Feb. 1, 2011: Unsealed spaces 1/8-inch wide or less around pipes, conduits, ducts, and wires above the ceiling are permitted. [for existing corridor partitions] Unsealed penetrations with a 1/8-inch gap or less above the suspended ceiling are no longer permitted! EP 6: Existing corridor partitions are fire rated for ½- hour, are continuous from the floor slab to the floor or roof slab above, extended through any concealed spaces (such as those above suspended ceilings and interstitial spaces), are properly sealed, and are constructed to limit the transfer of smoke. Top 8 Noncompliance Issues for Critical Access Hospitals in 2011 Note: Standards and EP findings similar to those found in hospitals for the following (*). *EC (60%) *LS (59%) EC (43%) - CAH only *LS (43%) *LS (42%) *LS (38%) EC (33%) - CAH only EC (31%) - CAH only Stored Emergency Power Supply Systems Standard EC EP 3 Note: Non-SEPSS battery backup emergency power systems [UPS] that the hospital has determined to be critical for operations during a power failure (e.g., laboratory equipment or electronic medical records) should be properly tested and maintained in accordance with manufacturer s recommendations [not NFPA 111]. Note: A UPS is a bridging device, not a SEPSS! DStymiest@ssr-inc.com, cell

5 Aligning TJC w/cms Aligning TJC Standards & CMS CoPs CMS Conditions of Participation Note: Hospitals seeking to obtain or maintain Medicare certification must meet all requirements for participation in the Medicare program. TJC claims that their standards and EPs meet or exceed the Conditions of Participation (CoP) for hospitals. See Code of Federal Regulations, Title for complete list of all regulations that may apply. TJC Aligning with CMS Recent changes to The Joint Commission standards, elements of performance, and notes are a result of TJC demonstrating that its standards are aligned with or equivalent to the Centers for Medicare & Medicaid Services Conditions of Participation (CoPs). These changes allow TJC to maintain CMS deeming authority and better reflect the intent of CMS s CoPs and ensure that both TJC and CMS surveys have similar outcomes. DStymiest@ssr-inc.com, cell

6 Condition-level Deficiencies Scored as AFS10 TJC will conduct an on-site follow-up survey whenever a Medicare Condition of Participation (CoP) is found not to be in compliance at the time of a TJC survey. The org will receive Accreditation with Followup Survey per AFS10. TJC will conduct the survey within 60 days to evaluate the hospital s implementation of corrective action to demonstrate compliance with the CoP(s) in question. Accreditation with Follow-Survey Rule AFS10 The hospital has one or more Condition of Participation (CoP) scored as a Conditionlevel deficiency. Note 1: This rule applies only to hospitals that use accreditation for deemed status purposes. Note: AFS10 related to SOCs & PFIs. Also see AFS13. Accreditation with Follow-Up Survey Rule AFS13 The hospital has failed to implement or make sufficient progress toward the corrective actions described in a Statement of Conditions, Part 4, Plan for Improvement, which was previously accepted by The Joint Commission, or has failed to implement or enforce applicable interim life safety measures. DStymiest@ssr-inc.com, cell

7 EC & LIFE SAFETY EC & Life Safety Survey Tidbits VULNERABILITIES Statement of Conditions: PFI PFIs should be related to the LS Chapter Corridor clutter is not a legitimate PFI PFIs should provide specific information No blanket statements, i.e. penetrations on 3 rd floor Specific references to Life Safety Drawings is acceptable. Example: 32 penetrations as identified on LS Drawing 3 rd Floor, Center Tower dated 3/3/2010 Projected Completion Date is for all listed items (i.e. 32 penetrations ) Rev. EP 1 for TJC Standard EC Std: The hospital manages its environment during demolition, renovation, or new construction to reduce risk to those in the organization. EP 1: When planning for new, altered, or renovated space, the hospital uses one of the following design criteria: 1) State rules and regulations or 2) Guidelines for Design and Construction of Health Care Facilities, 2010 edition* (Effective Jan.1, 2011) *Note: Applies to new construction or renovations only! DStymiest@ssr-inc.com, cell

8 ABHR Dispenser Placement (Detail by: Kendall Lampley SSR CAD Technology Specialist) TJC is now allowing ABHR dispensers to be placed according to the requirements of the 2009 and 2012 editions of NFPA 101, Life Safety Code. For ignition sources such as duplex receptacles and light switches the measurements are taken from the side edges of the ignition source cover plate as depicted in the diagram. Alcohol-Based Hand Rub Dispenser Placement per NFPA NFPA 101, 2009: 18/ (7): Dispensers shall not be installed in the following locations: (a) Above an ignition source for a horizontal distance of 1 inch to each side of the ignition source [cover plate*] (b) To the side of an ignition source within a 1 inch horizontal distance from the ignition source [cover plate*] (c) Beneath an ignition source within a 1 inch vertical distance from the ignition source [cover plate*] (*) As measured from outer edge of ignition source cover plate ABHR Permitted Per Smoke Compartment* 10 gal of ABHR in use (outside storage cabinet) TJC allows one dispenser per room exempt from volume calculation per 2012 Life Safety Code 18/ (6). Max fluid capacity of 0.32 gal. (1.2 liters) allowed for exempted dispenser in a room Max fluid capacity of 0.53 gal. (2.0 liters) allowed for exempted dispenser in a suite Only one exempt dispenser per room or suite allowed (*See Feb EC News) DStymiest@ssr-inc.com, cell

9 Reminder: Open Oxygen Cylinder Storage Oxygen Cylinders How many E sized oxygen cylinders may be stored within 1 smoke compartment without taking any special separation or enclosure precautions? 300 ft 3 25 ft 3 /cylinder = 12 cylinders Applies to all non-flammable compressed gases TJC Medical Gas Storage Requirements in-use vs. in-storage Cylinders in-use vs. in-storage Cylinder(s) secured: On a gurney or wheel chair- in-use On an anesthesia machine- in-use On a rack- in-storage Note: Partial or Empty cylinders are not counted as part of the 12 E-cylinders in storage. (Org. must demonstrate policy & practice for empties being removed in a reasonable and timely fashion) Survey Window Effective January 1, 2011, unannounced TJC surveys will be scheduled any time between 18 and 36 months from the previous full survey. The previous window was 18 to 39 months. Note: This change was made to maintain consistency in the timing of the survey window with CMS. DStymiest@ssr-inc.com, cell

10 Life Safety Code Specialist Surveyor Schedule Effective January 1, 2011, all hospitals and critical access hospitals will have a LSC Specialist Surveyor for: - At least 2 days - 3 days for hospitals > 1.5 million sq. ft. Note: 1 additional day will be added for every 3 buildings classified as a health care occupancy. Life Safety Code Specialist Surveyor Focus LS (Life Safety Chapter/Code) EC (Fire Safety Equipment) EC (Emergency Electrical Power) EC (Emergency Power Testing) EC (Med Gas & Vacuum Systems) LD EP 5 (Resources) LD EP 4 (Accountability) LD EP 2 (High-Priority) Environment of Care Standard EC (References) NFPA 10: Portable Fire Extinguishers NFPA 25: Inspect., Testing & Maintenance of Water-Based Fire Protection Systems NFPA 72: National Fire Alarm Code NFPA 80: Code for Fire Doors & Windows NFPA 90A: Air-Conditioning & Ventilating Sys. NFPA 96: Std. for Commercial Cooking Equip. NFPA 101: Life Safety Code NFPA 105: Std. for Smoke Door Assemblies NFPA 1962: Fire Hose Tests DStymiest@ssr-inc.com, cell

11 Leadership Standard LD EP 5 (Resources) Std: The governing body is ultimately accountable for the safety and quality of care, treatment, and services. EP 5: The governing body provides for the resources needed to maintain safe, quality care, treatment, and services. RFI Example: Evidence that there is a lack of some needed resources. Leadership Standard LD EP 4 (Accountability) Std: The hospital effectively manages its programs, services, sites, or departments. EP 4: Staff are held accountable for their responsibilities. RFI Example: Documentation not available. Leadership Standard LD EP 2 (High-Priority) Std: Leaders establish priorities for performance improvement. EP 2: Leaders give priority to high-volume, high-risk, or problem-prone processes for performance improvement activities. RFI Example: Lack of proof that a high priority has been given when/where necessary. DStymiest@ssr-inc.com, cell

12 Scoring for 2012 based on Criticality Criticality is the immediacy of the impact of noncompliance on quality care and patient safetyrather than the number of noncompliant standards and EPs. Categories: Tier 1) Immediate Threat to Health or Safety (ITHS) 1 Tier 2) Situational Decision Rules (SDR) Tier 3) Direct Impact Requirements (DIR) Tier 4) Indirect Impact Requirements (IIR) ITHS Accreditation Participation Requirements (APR) New Standard APR : The hospital provides care, treatment, services, and an environment that pose no risk of an Immediate Threat to Health or Safety also known as an Immediate Threat to Life or ITL situation. 1 Note: EP 1 reads same as above. Immediate Threat to Health or Safety 1 (ITHS) Definition: Situations identified at survey that have or may potentially have a serious adverse effect on patient health and safety. Examples: 1) Inoperable fire alarm or pump w/o fire watch or ILSM; 2) Emergency generator down for extended period w/o backup; 3) Lack of master alarms for med gas systems; DStymiest@ssr-inc.com, cell

13 More: Immediate Threat to Health or Safety (ITHS) Per the November 2010 EC News, failure to maintain the following four critical facilities systems may trigger an ITHS condition: An unaddressed, [significantly compromised] issue with the: 1) Fire alarm system 2) Sprinkler system 3) Emergency power system 4) Medical gas master panel Note: Also significantly compromised exits NFPA 101 Life Safety Code (Basis for SOC) 2000 NFPA 101 Life Safety Code (Ref. by TJC, CMS, DNV, AOA, Local & State Fire Marshals) Note: CMS & TJC may adopt 2012 LSC in 2013 or CMS released a proposed rule (Oct. 2011) seeking comments on whether CMS should adopt the 2012 edition of NFPA 101: Life Safety Code Preparing for Survey ZZZ DStymiest@ssr-inc.com, cell

14 Tips During Surveys Train staff to not answer questions outside their areas of job responsibilities, e.g., Sorry, I m not able to answer that question. It isn t within the scope of my job responsibilities. Those who accompany surveyors should be knowledgeable about the standards, survey process and environment being surveyed, especially the Life Safety Code survey! Right people at right place have pre-planned back-up staff whenever possible. Know where inspection logs and documents are stored. New & Used Symbols & Acronyms EC LS EM SEA POA EP RFI ESC MOS PFAs ITHS SDR DIR IIR ICS NPSG CA PFI SOC HVA HAI EOP PDA BBI ILSM AFS CVS CoP BS CMS DNV AOA TJC PPR e-app New & Used Symbols & Acronyms EC LS EM SEA POA EP RFI ESC MOS PFAs ITHS SDR DIR IIR ICS NPSG CA PFI SOC HVA HAI EOP PDA BBI ILSM AFS CVS CoP BS CMS DNV AOA TJC PPR e-app DStymiest@ssr-inc.com, cell

15 Who Regulates Your Hospital? Congress Healthcare Integrity Program Contractors Centers for Medicare and Medicaid Services PRRB Suprem e Court OIG Federal Circuit Courts Departmental Appeals Regional Offices Intermediaries Carriers PROs DME Regional Contractors Regional Home Health Intermediaries DEA FAA OPOs SEC Most Hospitals in USA State Level Survey and Certification Courts Attorneys General Medicaid Health Boards Medical Boards Local Governments Licensure -MDH FDA DOT OSHA IRS EPA DOJ FTC FCC HHS/ NIOSH NRC FBI Treasury HSS/ HRSA TJC DOL Chart Legend DEA: FAA: OPO: SEC: IRS: EPA: FTC: FCC: HHS: HRSA: NIOSH: Drug Enforcement Administration Federal Av iation Administration Organ Procurement Organizations Securities and Exc hange Commission Internal Revenue Service Environmental Protection Agency Federal Trade Commission Federal Commerce Commission Health and Human Serv ices Health Resources a nd Serv ices Admin National Institute for Occupational Safety & Health TJC: NRC: DOL: FBI: DOJ: OSHA: DOT: FDA: OIG: PRO: PRRB: The Joint Commission Nuclear Regulatory Commission Department of Labor Federal Bureau of Inv estigation Department of Justice Occupational Safety and Health Admin Department of Transportation Food and Drug Administration Office of Inspector General Peer Review Organizations Prov ider Reimbursement Rev iew Board Questions? Thank You! Dean Samet TSIG Consulting sametd@tsigconsulting.com DStymiest@ssr-inc.com, cell