With CMS approval, surveys for initial accreditation to participate in Medicare resumed in May, as they could be done virtually—offering the greatest protection against COVID-19, and less pressure and interference for organizations already in the throes of patient surge.
This article was originally published November 18, 2020 on PSQH
Expect The Joint Commission (TJC) to get tougher on water management and infection control, preconstruction risk assessments, workplace violence protections, and kitchen safety.
Don’t be surprised if TJC Life Safety Code®(LSC) surveyors go into places you may not have seen them venture into in years past. The same goes for clinical surveyors, who literally may be getting up in your kitchen—and possibly in the kitchens of any on-site commercial food service if it serves patients or residents.
During one of the ever-popular sessions at the American Society for Health Care Engineering (ASHE) annual conference, top TJC executives reviewed problems and solutions, and offered a rundown of what facility and compliance managers can look forward to during upcoming surveys.
That will include a new water management standard, potential new workplace violence standards, and perhaps revisions to emergency management requirements. In addition, the Environment of Care orientation session is being eliminated, with elements moved to other areas of the process.
Originally scheduled for September, the live ASHE conference was canceled and moved to an all-virtual platform held October 5–7 due to the coronavirus pandemic, which also put a hold on surveys in mid-March.
With CMS approval, surveys for initial accreditation to participate in Medicare resumed in May, as they could be done virtually—offering the greatest protection against COVID-19, and less pressure and interference for organizations already in the throes of patient surge.
Survey visits increasing
TJC started slowly, doing only 38 virtual surveys in May. Then as patient surge came under control in some areas, they conducted 96 more on-site surveys. Finally by September, the number of on-site visits was up to 386, said Tim Markijohn, MBA/MHA, CHFM, CHE, field director for LSC surveyors.
The first week of October alone, TJC had already done 152 surveys on-site and 130 virtually, said Markijohn, and they were expecting to ramp up even more in November and December.
As TJC has indicated in the last few months, they are using several factors to determine whether to conduct an on-site visit, he said. That includes when a facility is due for triennial survey, whether the organization is actively caring for a surge of COVID-19 patients, and whether it is safe to send surveyors into that region.
TJC developed an online dashboard, available to the public, to determine the most recent infection rates in a county or city and evaluate who is ready for survey, Markijohn said. That tool, dubbed the COVID Community Prevalence Dashboard, crunches information from a variety of sources to show a community’s infection rate within two weeks.
The tool can be found under the Resources tab on the top right of TJC’s main page, then clicking on the Research link on the left, then clicking on Operations Support Research, and finally scrolling down to the COVID dashboard link. The dashboard will give you some of the same information that TJC is using to determine if it will show up for survey, which will still be largely unannounced as required by CMS.
However, TJC won’t share what thresholds they use to determine when infection rates are too high, Markijohn said—in part because the thresholds keep changing as COVID-19 surge continues to fluctuate across the country.
Before anyone arrives, your TJC account executive should be reaching out to discuss the state of your organization’s response to the public health emergency (PHE), if you have your Emergency Operations Plan (EOP) activated, and how many COVID-19 patients you are currently treating. TJC has also encouraged hospitals and other organizations due for survey to contact their account executive if they are experiencing a patient surge.
When surveyors do arrive, expect a discussion about your hospital’s response to the PHE to be among the first items on the agenda. That will include whether your organization has activated its EOP and, if so, whether you’ve accepted or implemented any of the CMS 1135 waivers that provide flexibility on several Life Safety and Environment of Care requirements.
The 1135 waivers, which are available only during the COVID-19-related PHE, allow hospitals to delay such things as regular fire drills, inspection, testing and maintenance (ITM) on some non-critical systems, more alcohol-based hand rub dispensers needed to ensure infection control, and certain requirements in temporary care locations.
ITM of critical systems such as emergency generators, portable fire extinguishers, and fire suppression and response systems is not included in the waivers.
“We want to know what impact COVID has had on your organization, so that we know whether or not the waivers are appropriate for your organization, and if so, have you accepted those,” said Markijohn.
TJC and others have warned that once the PHE is lifted, the waivers will no longer be allowed and hospitals will be responsible for catching up to the needed ITM and documenting its completion.
Markijohn stopped short of encouraging hospitals to continue with ITM of noncritical systems, but he noted that, based on information gathered in the field, “most organizations have continued to do the inspection, testing and maintenance that they did before the public health emergency.”
Be prepared to show when your EOP was activated, what waivers you chose to take advantage of, and your plan for catching up to ITM not done during the PHE.
Where will you see LSC surveyors, and for how long?
While much of your on-site survey will look like pre-pandemic surveys, there are changes.
For instance, TJC has expanded the role of the LSC surveyor. Previously, clinical surveyors visiting off-site emergency departments or hospital-based ambulatory surgical sites also checked for LSC problems. Now, to allow the clinical surveyors to focus on quality of care, the LSC surveyors will also visit those sites. And that could mean the LSC surveyor will be around an extra day for each freestanding emergency department or ambulatory surgical center.
The number of days the LSC surveyor is on-site is already dependent on the square footage to be surveyed. Be aware that the square footage the facility manager or a consultant may come up with could be different from the determination of the surveyor, warned Jim Kendig, MS, CHSP, HEM, CHCM, LHRM, field director for LSC surveyors.
“Any space that serves a patient or resident—‘resident’ is typically a nursing home resident—any space that serves a patient or resident needs to be surveyed by the Life Safety Code surveyor,” said Kendig.
That could include a building that houses a service for patients, but not the patients themselves.
“In your POB (your physician office building) or in your MOB (your medical office building), if you have your lab, your laundry, your kitchen, or anything along those lines, we’re going to go in and survey that space because it serves a patient or resident,” Kendig said.
“Similarly, if you have a McDonald’s or Subway in the main lobby as part of your healthcare occupancy, if we see patients or residents receiving services from that, we will survey that space.”
Once on-site, an LSC surveyor will calculate the square footage of all the healthcare occupancies and any of the business occupancies that serve patients. The LSC survey will be two days if that calculation remains under 1 million square feet, but anything over that adds a day, said Kendig. That is in addition to the time added for LSC surveys at the freestanding emergency departments or ambulatory surgical centers.
What else will surveyors be looking for?
That kitchen in the business occupancy or lobby won’t be the only kitchen to get increased scrutiny.
There is a new kitchen tracer checklist that has been expanded from two to three pages—two pages for the clinical surveyor to check and another page for the LSC surveyor, said Kendig.
He suggested using the checklist to review your facility’s compliance, adding that you can reach out to him or Markijohn for a copy.
Also get a copy of NFPA 96-2011, Standard for Ventilation Control and Fire Protection of Commercial Cooking Operations. Kendig noted two areas in the kitchen that LSC surveyors said continue to confound compliance managers.
One is a requirement that deep fat fryers be installed with at least 16 inches of space between the fryer and any nearby surface flames from adjacent equipment.
Kendig reminded facility managers that the only exception to that is when there is at least an 8-inch high steel or tempered glass baffle between the fryer and the surface flames.
Also, anytime staff move cooking equipment, they should be careful to return it to its appropriate place under the overhead fire suppression nozzle, according to the location design, warned Kendig.
NFPA 96-2011, section 12.1.2.3.1 requires there to be an “approved method” to returning the equipment to the exact spot, noted Kendig, illustrating the point with a photo of permanent wheel chocks to indicate where the equipment rests.
However, wheel chocks are not required specifically. Kendig, who has experience in hospital facility management, said he would use an “L” marked on the floor to indicate equipment positioning.
Other survey changes upcoming
TJC is also revising other parts of the survey process for Life Safety (LS), Environment of Care (EC), and Emergency Management (EM) standards:
Look for a new pre-construction risk assessment checklist, which is currently being developed along with Sylvia Garcia-Houchins, MSN, RN, CIC, director of infection prevention and control.
That means TJC will be focusing more than ever on infection control in the environment of care.
Remember that TJC surveyors will want to go to the construction and renovation sites on day one, as soon as possible, said Kendig.
Among other things, they will be looking for the appropriate pressure relationships to maintain infection control and whether the means of egress are clear, he said.
The questions for the Basic Building Information (BBI) component of the electronic Statement of Conditions have been updated, but are awaiting upload by TJC’s information technology department, said Kendig.
The BBI was revised with the help of the LSC surveyors who were asked what questions to include. Those changes will be available, hopefully, in 2021, said Kendig.
Under element of performance (EP) 7 of LS.01.01.01, under which hospitals are required to manage the physical environment to comply with the LSC, hospitals are also required to keep their BBI up to date.
As of January 2021, there will be no formal opening EC session, said Kendig. Instead, elements of that session will be folded into three other parts of the survey process.
First, the LSC document checklist has now been expanded to include some EC elements, said Kendig. That is likely to lengthen the LS document review session, he noted.
Second, some elements of EC have been added to the LS building tour. They will be part of the document review checklist.
And finally, on the advice of some of the clinical surveyors, the EC elements in radiology and CT areas will be handed over to the physician or nurse surveyors on the team. The clinical tracers are being updated to include those EC elements, said Kendig.
Look for those updates to be included in the January 2021 Survey Activity Guide, he said.
TJC is also looking at revising the EM session as well as instituting some interim EM standards for the duration of the PHE. There is also a review overall of the EM standards and EPs, said Kendig.
He did not review what those changes might be, but said the hope was to have the revisions in proposal stage by July 2021 with a goal of implementation in 2022.
The changes will likely increase the EM session from 60 minutes to 90 minutes, he said.
As previously announced, deficiencies related to ligature risk and patient self-harm will longer be scored under EC.02.06.01, the catch-all standard that requires a “safe and functional environment.”
Instead, problems will be scored under National Patient Safety Goal 15.01.01.
TJC is concerned about escalating problems with workplace violence in healthcare and is exploring a new standard specifically about ensuring workplace safety against violence.
And finally, TJC is in the final review stages of a new standard on water management focusing on mitigating risk of the spread of infectious diseases such as Legionnaires’ disease.
That could be implemented as soon as July 2021.
A.J. Plunkett is editor of Inside Accreditation & Quality, a Simplify Compliance publication.
Expect The Joint Commission and other accrediting organizations (AO) to begin resolving many of the unresolved follow-up surveys remotely once CMS provides clarification to an apparent broader approval for so-called “desk audits.”
The remote follow-up surveys will only involve those hospitals that do not face an immediate threat to life (ITL) or condition-level deficiency, according to sources within the accreditation community.
Onsite unannounced surveys will still be conducted for complaints.
More on what the virtual surveys will look like and how far CMS will let AOs go with virtual surveys is still be worked out.
CMS has allowed remote surveys for initial accreditation and for certifications not related to reaccreditation since the beginning of summer.
Since then, all the AOs have been gradually expanding their survey activities, both virtually and on-site.
Inside Accreditation & Quality has reached out to the AOs as well as CMS for confirmation and details and will update this as information becomes available.
Here are some lessons learned in Minneapolis during the civil unrest earlier this year after George Floyd died during a police arrest, the details of which went viral on social media.
This article was originally published November 4, 2020 on PSQH.
This year has been brutal on many levels, especially in healthcare.
There’s the coronavirus pandemic. The cold and snow of winter, the broiling heat of summer, the fury of hurricanes and wildfires, earthquakes and riots. And now finally Election Day and its aftermath, which promises at least extended stress during the vote counting and at worst, civil unrest.
Hopefully not.
But CMS requires an all-hazards approach to emergency management. So here are some lessons learned in Minneapolis during the civil unrest earlier this year after George Floyd died during a police arrest, the details of which went viral on social media.
The Department of Health and Human Services’ Assistant Secretary for Preparedness and Response (ASPR) offered up these observations from its Technical Resources, Assistance Center, and Information Exchange (TRACIE), which gathered the information from two key experts in the area: ASPR TRACIE’s Senior Editor, Dr. John Hick, also serves as an Emergency Medicine Physician for Hennepin County Medical Center, located in downtown Minneapolis, and Seth Jones, Hennepin Healthcare system’s Emergency Preparedness Program Manager.
Two hospital incident command structures (HICS) operated simultaneously—one to manage COVID-19 and the other managed the civil unrest response. Depth in each HICS position developed during the COVID response facilitated the transition of team members to the new HICS.
Daily regional COVID-19 calls temporarily became civil unrest calls. Plans to quickly ramp up emergency department (ED) and security staff and ensuring staff access to Hennepin County Medical Center (HCMC) were top priorities.
Highways leading into the city were closed to deter people from entering and to reduce the rapid movement of demonstrators, but this also impacted staff commuting to work.
Many staff used public transportation to report to work. When the system shut down, HCMC allowed staff to park in a designated lot for free.
HCMC provided staff food, drinks, and cots. Many staff stayed over the weekend and could take cots to the space of their choosing (while adhering to social distancing guidelines) or a conference room set aside for this purpose.
Continuous and accurate communication to staff was vital to ensure staff had the information needed to feel safe coming to work during this time.
The hospital was not damaged, but three offsite locations were. Staff watched via security cameras as these clinics were broken into; one sustained fire and water damage and may eventually be declared a total loss. As they watched protesters demolish and raid one pharmacy, the HCMC Security Operations Center dispatcher announced that the police were on their way over the intercom system. Staff called 911 numerous times but could not get through (capacity could not keep up with call volume). The next day, staff secured the medication at multiple community pharmacies, agreed that life safety was the priority, and made the decision to keep security resources at HCMC’s main campus rather than at the community clinics knowing these clinics would be “soft targets” going into the weekend.
Looting and fires contributed to patients reporting with multiple gunshot wounds, injuries from falls, and burns. Rubber bullet wounds were very common and included soft tissue, skull fracture, and eye injuries. Issues associated with other riot control agents (e.g., pepper spray and tear gas) were not that common. There was also an increase in patients with stab wounds.
Rapid and accurate internal messaging was crucial because the situation changed so quickly. Bringing in the National Guard and implementing the curfew was helpful; when the curfew was announced, staff could choose alternate routes and plan for parking. Once officials realized that some of the “bad actors” were waiting for sunset on the outskirts of town, the governor closed access to the highways and changed the curfew time on the fly. While this undoubtedly prevented criminal behavior, it caught some staff off guard. HCMC encouraged staff to report early, offering them sustenance and a place to rest.
Maintaining staff morale is important, particularly when multiple incidents occur simultaneously. HCMC has a “warm line” staff can call for behavioral health assistance. Social distancing has changed how some of this care is delivered. HCMC recently opened a wellness center in the library. To encourage self-care and communication, posters ask staff to share what they are using (e.g., movies or television shows) to get through this challenging time.
Healthcare facility access controls were already in place for COVID-19; many facilities implemented additional controls and occasionally sheltered in place.
Supplementing EMS personnel was more difficult than usual due to staff off due to COVID-related quarantine.
CMS also requires under its Emergency Management CoP that hospitals include the possibility of a cyberattack as part of its all-hazards risk assessment.
Review your hospital policies about preventing ransomware and other outside cybersecurity attacks on your electronic health information systems. The Department of Health and Human Services (HHS) released a joint advisory along with the FBI and the Cybersecurity and Infrastructure Security Agency (CISA) earlier this week warning hospitals and health systems about an "increased and imminent cybercrime threat."
The advisory described the tactics, techniques, and procedures used by cybercriminals to infect healthcare providers with Ryuk ransomware, according to HealthLeaders.
The notice also listed two key findings: Cybercriminals are targeting the Healthcare and Public Health (HPH) Sector with Trickbot malware, which can lead to "ransomware attacks, data theft, and the disruption of healthcare services," and that these challenges will be heightened for organizations dealing with the ongoing COVID-19 pandemic, according to HealthLeaders.
Hospitals are required under the Medicare Conditions of Participation (CoP), Medical Record Services, to ensure that “unauthorized individuals” cannot gain access to or alter patient records. Deficiencies can be cited under Tag A-0442.
CMS also requires under its Emergency Management CoP that hospitals include the possibility of a cyberattack as part of its all-hazards risk assessment.
The Joint Commission (TJC) requires hospitals, under Information Management standard IM.02.01.03, to maintain “the security and integrity of health information.” That includes under element of performance (EP) 2 having a written policy addressing among other things, the “intentional destruction of health information.”
Hospitals are required under EP 5 to protect “against unauthorized access, use, and disclosure of health information.”
In addition, hospitals can be cited under Emergency Management standard EM.01.01.01, which states that the all-hazards risk assessment should include possible “human-made” emergencies, including cyberattacks.
The other accrediting organizations, including DNV-GL Healthcare, HFAP, and the Center for Improvement in Healthcare Quality, all have similar standards and requirements.
Consultants have said that CMS is pressuring TJC and other AOs to step up inspection of cybersecurity in hospitals as ransomware and other attacks have continued.
Warning offers guidance
The joint warning by the FBI, CISA, and HHS on the current cyberthreats include detailed information how healthcare organizations can respond.
The warning states: “CISA, FBI, and HHS suggest HPH Sector organizations review or establish patching plans, security policies, user agreements, and business continuity plans to ensure they address current threats posed by malicious cyber actors.”
The warning includes these suggested network best practices:
Patch operating systems, software, and firmware as soon as manufacturers release updates.
Check configurations for every operating system version for HPH organization-owned assets to prevent issues from arising that local users are unable to fix due to having local administration disabled.
Regularly change passwords to network systems and accounts and avoid reusing passwords for different accounts.
Implement application and remote access allow listing to only allow systems to execute programs known and permitted by the established security policy.
Audit user accounts with administrative privileges and configure access controls with least privilege in mind.
Audit logs to ensure new accounts are legitimate.
Scan for open or listening ports and mediate those that are not needed.
Identify critical assets such as patient database servers, medical records, and telehealth and telework infrastructure; create backups of these systems and house the backups offline from the network.
Implement network segmentation. Sensitive data should not reside on the same server and network segment as the email environment.
Set antivirus and anti-malware solutions to automatically update; conduct regular scans.
If your organization faces a ransomware attack, the alert says “CISA, FBI and HHS do not recommend paying ransoms. Payment does not guarantee files will be recovered. It may also embolden adversaries to target additional organizations, encourage other criminal actors to engage in the distribution of ransomware, and/or fund illicit activities.”
Best practices
In addition to network best practices, the warning includes these best practices to battle against ransomware:
Regularly back up data, air gap, and password protect backup copies offline.
Implement a recovery plan to maintain and retain multiple copies of sensitive or proprietary data and servers in a physically separate, secure location.
The alert also suggests these “user awareness” best practices:
Focus on awareness and training. Because end users are targeted, make employees and stakeholders aware of the threats—such as ransomware and phishing scams—and how they are delivered. Additionally, provide users training on information security principles and techniques as well as overall emerging cybersecurity risks and vulnerabilities.
Ensure that employees know who to contact when they see suspicious activity or when they believe they have been a victim of a cyberattack. This will ensure that the proper established mitigation strategy can be employed quickly and efficiently.
The lengthy alert also carries a vast number of other best practices as well as technical aspects of the detected threats to help inform information technology specialists as they address the potential threat.
As of January 1, 2021, you will have one less thing to worry about: The Joint Commission (TJC) is eliminating its requirement that hospitals set a goal toward achieving a 90% vaccination rate under Infection Prevention and Control standard IC.02.04.01.
That standard requires hospitals to offer a flu vaccination to its licensed independent practitioners and staff.
Under Element of Performance 5, hospitals were told to set “incremental influenza vaccination goals, consistent with achieving the 90% rate established in the national influenza initiatives for 2020.”
Be aware that while the goal has been deleted, the rest of the standard remains in effect.
And IC experts and emergency planners have encouraged hospitals to step up flu vaccinations along with the general public as the nation continues to battle the rising cases of COVID-19 from the 2019 coronavirus pandemic.
Earlier this month, HHS extended through January 21 the national emergency declared in March because of the pandemic.
“Organizations should continue to strive to increase compliance with influenza vaccinations and take action to improve vaccination rates,” according to TJC’s announcement. “Moving forward, The Joint Commission will not score noncompliance if the organization has not reach 90%, but instead will review that organizations have a goal to improve influenza vaccination rates and have leadership support and processes in place to support achievement of these goals.”
Training and educating staff, and verifying the training and the effectiveness of the cleaning are keys to a good EVS program.
This article was originally published October 27, 2020 on PSQH
Assess your environmental cleaning protocols, ensure staff are trained properly, and verify the effectiveness of both as CMS increases scrutiny of infection prevention and control during the coronavirus pandemic.
Earlier this year CMS cited hospitals for not following their own policies and failing to ensure environmental services (EVS) personnel followed standard procedures for infection control during cleaning, including instances of cross-contamination of surfaces.
In one example, a hospital was cited under Condition of Participation (CoP) §482.42: Infection Prevention and Control and Antibiotic Stewardship Programs, which according to CMS’ State Operations Manual (SOM), Appendix A, states:
“The hospital must have active hospital-wide programs for the surveillance, prevention, and control of HAIs [healthcare-acquired infections] and other infectious diseases, and for the optimization of antibiotic use through stewardship.
“The programs must demonstrate adherence to nationally recognized infection prevention and control guidelines, as well as to best practices for improving antibiotic use where applicable, and for reducing the development and transmission of HAIs and antibiotic resistant organisms.
“Infection prevention and control problems and antibiotic use issues identified in the programs must be addressed in collaboration with the hospital-wide quality assessment and performance improvement (QAPI) program.”
The hospital was cited under the SOM A-Tag A-0747 after, among other things, surveyors watched an EVS aide clean an operating suite between procedures by removing the suction canisters and basin containing bloody secretions and placing them on a surgical table.
“Then without changing his contaminated gloves, he retrieved bottles of solidifier, multiple times from his pockets. The same staff member was later observed failing to clean all surfaces of a Bear Hugger, surgical table, and a standing circular tray, then cross contaminating a surgical table by placing a dirty pillow on the previously cleaned table surface,” according to the CMS deficiency report.
In another example, a hospital was cited under tag A-0747 for the same CoP, which says hospitals should have an infection prevention and control program with documented policies and procedures that employ “methods for preventing and controlling the transmission of infections within the hospital and between the hospital and other institutions and settings.”
That hospital was cited after CMS surveyors observed an EVS worker cleaning a patient room, using a wet towel to wipe a garbage can, “then proceeded to wipe the sink, walls and window sill with the same towel, until intercepted by the facility’s staff.”
Training and educating staff, and verifying the training and the effectiveness of the cleaning are keys to a good EVS program, says Robert Albrecht, a former environment of care director at a hospital in Washington, D.C., who now offers cleaning services and consulting through his own firm as president of Infection Prevention Systems in Havre de Grace, Maryland.
Assessment and evaluation
Begin the evaluation of your environmental services program with an assessment of cleaning protocols, which should include a full evaluation of products, equipment, and supplies, combined with the frequency and thoroughness of your processes, says Albrecht.
You should already have an inventory of products, supplies, and equipment you use as part of your program. Make sure that inventory is updated with new products, new chemicals and their safety data sheets (SDS), and any new procedures, especially anything that requires new steps or products because of the coronavirus pandemic, notes Albrecht.
Standard operating procedures (SOP) should include any area-specific systematic cleaning. This includes how frequently the cleaning is done, how quality assurance is performed, and how personnel training is recorded, he says.
Remember that CMS and other surveyors will be comparing procedures and SDSs with manufacturers’ information for use of any products.
Some cleaning supplies are meant to be used as part of a system with specific equipment, such as a microfiber wipe or a disposable paper towel, notes Albrecht.
“The frequency of use is usually dependent on the healthcare provider’s assessment,” he says. As you are evaluating your SOP, make sure cleaning systems and frequency of use are aligned, he urges.
“The assessment is solely to identify what products are used in conjunction with the SOP and if there is synergy to effectively clean while disinfecting specific areas,” says Albrecht. “The proper use of products is either determined through direct observation, elimination of visible debris, or by analytical methods. Once an assessment has been conducted, then recommendations can be made to enhance, rewrite, or accept the existing protocols by EVS directors.”
Training
Hospitals generally train EVS staff how to use products based on manufacturers’ recommendations and the procedures needed for various areas, whether it’s turning over a room or cleaning public areas, notes Albrecht.
But the theory of cleaning vs. sanitizing vs. disinfection is generally not included as part of the overall program. And it needs to be, says Albrecht. “Just like any trade, staff must know the fundamentals before they can implement an effective cleaning protocol,” he notes.
EVS personnel should understand the following:
Cleaning is the removal of organic and inorganic debris and is the first step in disinfection or sanitization.
Sanitizing is treatment of a cleaned surface to effectively destroy microorganisms to a certain degree for public safety purposes. “This term is used frequently in the food production and food service industry,” says Albrecht.
Disinfection is the destruction of microbial contamination to a level that is higher than sanitizing but lower than sterilization.
Staff should be educated on products, policies, and procedures at date of hire, during their first weeks on-site, and whenever there are changes to the system or to equipment, chemical agents, or other cleaning materials.
Then EVS staff should be evaluated on their knowledge levels. “Ask them questions in a manner that affords trust and if possible, privately,” encourages Albrecht.
Remember to retrain and reinforce education if you make changes improvements during the assessment phase, he advises.
How effective is your system?
Finally, you must verify the effectiveness of your cleaning protocols.
“Many facilities are using ATP [adenosine triphosphate] or markers that are illuminated with blacklight, but there are many other systems that can be used to verify the level of cleaning,” says Albrecht.
The important thing is to verify that what you think you are cleaning is actually getting clean.
“ATP is one tool in the toolbox that provides instant results with a high level of accuracy, but it is not the only means we use,” says Albrecht. “The most effective way to assess the level of cleanliness is to use several modes.”
Some modes of assessment are quantitative, he says, such as using ATP, settling dishes, air/swipe samples, or particle counters. Others such as UV markers, white glove testing, or tweezer extraction are qualitative.
Whatever mode the hospital uses, it should use that mode “in a consistent manner,” he says. “Collection of that data should also be recorded and used over time to establish baseline levels for the specific facility and compare to like-kind data points either from research or other facilities.”
There are many resources available free and for purchase to help EVS managers. “We use a proprietary method that includes a risk assessment prior to any other work to identify high-risk areas, personnel, and frequent modes of transmission,” says Albrecht.
CMS and other accreditation organizations want to see improvement. And remember it is expected under the infection prevention CoP.
Whatever the method, “we recommend that each facility purchase or create aids that will foster improvement in the level of cleanliness,” Albrecht says.
As many facilities have had their hands full with patient surges from COVID-19, the illness caused by the 2019 novel coronavirus, they'll have work to do to ensure their environment of care is brought up to speed.
Be prepared to explain to surveyors how you will catch up with any inspection, testing, and maintenance (ITM) of non-critical systems that had been delayed because of the coronavirus pandemic.
Update logs and records for any ITM done on critical systems, and make sure you can show that your Emergency Operations Plan (EOP) was activated before you opted for any allowed waivers on maintenance of non-critical systems.
All accreditation organizations (AO) as well as CMS are working on backlogs of surveys delayed by the public health emergency (PHE) declared in March. Waivers will no longer be allowed once that PHE is lifted.
As many facilities have had their hands full with patient surges from COVID-19, the illness caused by the 2019 novel coronavirus, they’ll have work to do to ensure their environment of care is brought up to speed.
Pandemic counts as one EOP drill
Hospitals are able to use their response to the pandemic as one of the two required annual disaster drills as long as the organizations can document activation of the EOP and show a review of their facilities’ performance, says Ernest E. Allen, ARM, CSP, CPHRM, CHFM, a former life safety surveyor and now a patient safety executive with The Doctor’s Company in Ohio.
Under its Emergency Management standards, The Joint Commission (TJC) requires the review to include management of six critical areas: communication, resources and assets, security and safety, staff, utilities, and care for patients.
Documents required by TJC ahead of surveys will likely include information on:
Your facility’s EOP plan
Fire response plans and drills
Fire protection equipment testing, to include quarterly, semiannual, and annual reports
Medical equipment ITM
Utilities
Emergency power
Medical gases
Safety management plans
Annual review
As TJC and other survey agencies have indicated, only surveys for initial accreditation to participate in Medicare will be done virtually. However, re-accreditation surveys may include some virtual elements as documents or patient records are reviewed on a computer and staff are interviewed by video or teleconference.
You may have up to a week to submit some documents to TJC, says Allen.
Surveyors will still avoid COVID-19 hot spots
If you are experiencing a COVID-19 surge, reach out to your accrediting organization. TJC, HFAP, DNV-GL Healthcare, and others have indicated they do not want to interfere with facilities that are managing an ongoing pandemic response.
But expect surveys to intensify in areas where the pandemic response has not been as severe or is easing, say Allen and others.
“Basically, surveys are starting to occur where the COVID numbers are fairly stable,” says Steven MacArthur, a former hospital safety officer and now a senior consultant with The Greeley Company in Danvers, Massachusetts.
That primarily has meant areas in the Northeast, though not exclusively, he says.
While CMS surveys had picked up again in June in Texas and Florida, they were to close out re-surveys for organizations that had received termination notices and had elected to use the Systems Improvement Agreement process to work back into the program, MacArthur says.
Survey activity may also depend on the availability of surveyors, he says.
“I think a lot of where they go is impacted by their ability to field survey teams,” he says.
For example, MacArthur says one of his clients in California had a TJC initial survey at the end of January and was expecting re-survey sometime in March. But then the pandemic was declared and surveys were temporarily suspended.
That facility has since had the follow-up survey, but the survey team was comprised primarily of surveyors from California, including a Life Safety Code® (LSC) surveyor that was part of the January survey.
While AOs are working to identify areas where COVID-19 cases are low, that doesn’t necessarily mean those areas include hospitals that are past due for survey, he notes.
“It does sound like the immediate focus is catching up on the survey activities that are most significantly in arrears/severity,” says MacArthur.
AOs may take a while catching up
MacArthur and others say that from what they’ve been told, TJC and the other AOs may not get caught up on surveys until well into 2021. And while surveys may resume in your area, you may not see the same kind of survey you’ve had in the past.
While CMS has issued deficiencies for failures at hospitals during the pandemic, including facilities that did not follow their own pandemic-related infection prevention and control policies, the federal agency has said it will continue to focus on complaint surveys and closing out cases opened prior to the PHE.
It is also encouraging AOs to review how hospitals have responded to COVID-19 with lessons learned and improvements made to their processes and procedures, rather than scrutinizing cases from during the pandemic.
While that may offer some relief, note that TJC has also said it is changing the role of LSC surveyors in TJC survey teams. Those surveyors will no longer stay on the main hospital campus, but will also visit any off-site emergency departments and hospital-based ambulatory surgical sites.
In announcing the expanded role, TJC noted that these off-site settings have complex LSC requirements and that “the evaluation of the physical environment and Life Safety Code requirements by the Life Safety Code surveyor will allow the clinical surveyor(s) time to focus on the quality of care and services provided in these settings.”
“All other off-site locations that are visited by clinical surveyors will continue to be evaluated for physical environment and Life Safety Code requirements by the clinical surveyor with an enhanced focus on the business occupancy Life Safety Code requirements,” said the TJC announcement.
While the pandemic may not be over yet, you should be making an effort to return to pre-pandemic accreditation and survey readiness, says Deanna Scatena, RN, BSN, assistant director of certification services/accreditation services-standard interpretation dean for HFAP.
Even with waivers and delays in ITM of non-critical systems, you still are expected to provide a safe environment for your patients and staff.
Surveyors are aware of which hospitals have been making use of CMS waivers and know that you could be behind on some requirements, Scatena says—but expect them to ask how you’re going to catch up. “What is your plan so you don’t stay behind?”
The Healthcare Facilities Accreditation Program (HFAP), the oldest CMS-approved hospital accreditation program in the nation, has merged with the Accreditation Commission for Health Care (ACHC) in a move designed to expand both organizations’ reach in the compliance world.
HFAP standards and certification requirements will stay the same and it will continue to operate under the HFAP name as a brand within ACHC, according to information released by both organizations October 20.
The merger was approved by CMS on October 19.
The move “streamlines accreditation and certification services for healthcare providers with multiple survey needs,” according to the announcement.
Merger provides new range of offerings
HFAP holds CMS deeming authority to approve hospitals, ambulatory surgery centers, clinical laboratories and critical access hospitals for participation in Medicare. Meanwhile, ACHC has deeming authority for home health, hospice, renal dialysis, home infusion therapy, and Durable Medical Equipment, Prosthetics, Orthotics and Supplies (DMEPOS).
“Additional HFAP offerings—such as accreditation programs for ambulatory specialty care (office-based surgery), non-deemed accreditation and specialty certification for four levels of stroke care, laser and lithotripsy services, inpatient and outpatient joint replacement and wound care—will expand and complement the ACHC portfolio, which also includes programs for ambulatory care, behavioral health, pharmacy, private duty and sleep,” according to the announcement.
Officially, the merger is between ACHC and the Accreditation Association for Hospitals/Health Systems (AAHHS). AAHHS acquired HFAP from the American Osteopathic Association in a move approved by CMS in 2017 and therefore is the legal entity that entered into the merger with ACHC.
However, HFAP is the only program within AAHHS.
Both HFAP and ACHC customers have been notified of the change.
Surveys, standards won’t change
The merger will not affect accreditation cycles for either ACHC or HFAP customers, according to the announcement. “Current accreditation and/or certification status, account managers and processes will not change. Furthermore, the merger does not require current HFAP customers to undergo an initial survey.”
“Our merger brings existing HFAP customers additional opportunities to be awarded recognition of their programs and a broader range of education,” said Meg Gravesmill, CEO of AAHHS, in the announcement. “As importantly, customers will continue to enjoy the highest level of personalized service and quality they have trusted for decades.”
According to HFAP, programs will continue to use the same standards that have been developed, subject to regular review and updating.
Any certification or accreditation awards will still carry the HFAP label, with a notation that it is a brand of ACHC.
Why is HFAP the oldest?
HFAP was created in 1945 to provide “an objective review of services provided by osteopathic hospitals.” The Joint Commission (TJC) and its predecessors provided similar services to more traditional hospitals.
When Medicare was created in 1965, TJC was named in the law as an accreditation organization (AO) and all others had to apply for approval. TJC did not have to seek approval until the law was changed in 2008.
That meant that since HFAP was approved in 1945 to accredit osteopathic hospitals, it became the oldest CMS-approved AO.
ACHC is a nonprofit AO created in 1986. Besides being a deeming authority approval of home health, hospice, renal dialysis, DMEPOS, and home infusion therapy, it also employs a quality management system that is ISO 9001:2015 certified, according to its website, www.achc.org
Note that the review particularly highlights concerns with infection control and emergency management, the two specific areas CMS is encouraging AOs to look at as surveys resume.
CMS has signaled that accrediting organizations (AO) like HFAP can resume even more surveys in areas where the COVID-19 patient surge is slowing. But what will HFAP surveyors be looking for?
In late August, the oldest of the accrediting organizations released its 2020 HFAP Quality Review, highlighting the problems and trends identified by surveyors during on-site visits in 2019 at acute care hospitals, critical access hospitals, laboratories, and ambulatory surgery centers.
“The Quality Review plays a vital role in our commitment to help continuously improve the quality of care that HFAP-accredited organizations provide,” said Meg Gravesmill, CEO of AAHHS/HFAP, in a statement announcing the release of the review. “This can be used as a self-assessment guide and should be reviewed by organizations as they evaluate their yearly performance. In light of the global pandemic, it is especially important for organizations to heighten awareness of infection prevention and emergency management standards.”
The statement noted “common citations such as insufficient documentation and inconsistent compliance with processes and procedures.”
The review also showed that “healthcare organizations continue to struggle with integrating quality as a driver of documentation and process excellence during accreditation surveys, mirroring past years’ top deficiencies.”
Note that the review particularly highlights concerns with infection control and emergency management, the two specific areas CMS is encouraging AOs to look at as surveys resume.
Here’s a rundown of problems, according to the statement.
Physical environment
Common deficiencies were related to the management of the built environment “and its impact on patient, staff and visitor safety, particularly with regard to infection control. Common examples included issues with eye wash stations, non-compliant air-pressure relationships, and defects in ceiling, wall, floor and other surfaces.”
Citations were also issued related to the NFPA’s Life Safety Code®standards. “Examples of this year’s deficiencies include compliance with standards for smoke alarms and other utility systems, such as emergency generators, as well as compliance with requirements for doors located in exit halls.”
Patient safety
Infection prevention and control citations were down in some areas, but they “did remain the most frequently cited deficiency in 2019. Surveyors identified specific failures of cleanliness and failure to follow policies as written. A few examples include no HEPA filter, construction spaces not being maintained in a negative pressure state, containment barriers being compromised by staff for ease of circulation, and inappropriate traffic flow in the sterile and clean supply rooms.”
Emergency management
Hospitals still struggled with comprehensive emergency preparedness plans, with specific citations including “not having an Emergency Operations Plan (EOP) that considers at-risk individuals, identifies services that hospitals will provide under activation of the plan, and addresses the need for nutritional services.”
HFAP is advising facilities to use “the 2020 public health emergency as an opportunity to review lessons learned. In addition, everyone should review the standards and determine the specific HFAP requirements to be delineated within an organization’s policies and procedures. Most importantly, promote a culture of inclusiveness by increasing the communication between the emergency preparedness office and other relevant departments through frequent committee meetings and drill evaluations.”
Inpatient behavioral health facilities seeking accreditation to participate in Medicare and Medicaid now have a second choice after CMS approved DNV-GL Healthcare’s first application for recognition as a national accrediting organization (AO) for psychiatric hospitals.
Until now, psychiatric hospitals had to be approved by regional CMS survey agencies or The Joint Commission.
The approval provides another option for the nation’s more than 600 psychiatric hospitals, said Patrick Horine, president of DNV-GL, the only for-profit AO of the four authorized to accredit acute care hospitals overall.
Unlike the others, DNV-GL surveys hospitals at least once every three years, as required by CMS, but then also visits hospitals in each off year to ensure they are maintaining patient safety.
The annual survey schedule helps hospitals to stay ready and stay focused on helping patients safely, Horine told Inside Accreditation and Quality recently.
During surveys at psychiatric hospitals, the survey team will have at least one member with a background in behavioral health, said Horine.
The CMS approval is effective through July 30, 2024.
DNV-GL added its psychiatric hospital standards as an appendix to its National Integrated Accreditation for Healthcare Organizations (NIAHO®) program standards for hospitals, which can be found online.
As required for CMS approval, the NIAHO® standards area based on CMS Conditions of Participation (CoP), but are also integrated with the "ISO 9001 Standard for the formation and implementation of the Quality Management System,” according to DNV-GL information.
Hospitals, acute care or psychiatric, do not have to become ISO 9001 certified, although it is encouraged as a path to better quality assurance and performance improvement, said Horine.
For more on DNV-GL’s new program and other updates to DNV-GL’s survey and accreditation process, see future issues of IAQ.
