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Expect door repairs to take time as CMS requirements create backlog of parts


October 1, 2018

 Be prepared to ask for time extensions from your accrediting organization and CMS to bring doors into compliance in your facility. As hospitals deal with ligature risks and Life Safety Code® (LSC) issues, there is a growing backlog of the needed parts and equipment, making it difficult to meet a regulatory requirement to fix deficiencies within 60 days.

You may have to ask for the time extensions more than once, warns Ernest E. Allen, a former surveyor with The Joint Commission (TJC) and now a patient safety account executive with The Doctors Company in Ohio.

“This is a big issue that is only getting bigger,” predicts Tyson G. Prickett, vice president of JT Service Contractor Corp., a regulatory compliance consulting firm in Coral Springs, Florida.

“As more facilities now come into compliance with the annual fire door inspection and now conduct risk assessments for the behavioral units, which identify door issues, there will be nothing but more orders placed and longer wait times to get the products,” says Prickett.

Focus on ligature risk top problem

The main concern right now is the ligature risk assessments that hospitals across the country are scrambling to complete as TJC and other accrediting organizations (AOs) ramp up pressure to meet the specific concerns outlined by CMS late last year.

Hospitals are expected to do a better job of identifying patients at risk of self-harm, and to treat them in an environment that minimizes their ability to injure themselves or others. Facilities who fail to do so often face threats of CMS immediate jeopardy or loss of accreditation, which means possibly losing all Medicare revenue.

Behavioral health units and emergency departments are getting the most scrutiny, with failures most often cited either under CMS’ Conditions of Participation on a patient’s right to treatment in a safe environment or TJC’s Environment of Care standard EC.02.06.01, requiring hospitals to provide a safe and functional environment.

“EC.02.06.01 [where TJC will cite these issues] has been a citation on every survey that I have seen this year whether the facility had an inpatient behavioral health unit or not,” says Prickett.

Document efforts to mitigate risk

After conducting risk assessments and documenting problems, facilities immediately should begin a process to mitigate the identified issues, says Prickett. Detail those mitigation efforts in the same document, he recommends.

Doors are often the problem. “For example, the bathroom door in the patient room has a standard three-hinge system, which is bad, as each hinge could be a possible ligature risk point,” says Prickett. So, “the facility will need to replace that system with something else.”

“Their mitigation process and procedures will buy the facility some time to make the necessary repairs to these identified procedures. However, it is very important to remember that once an issue has been identified, the facility must begin their mitigation process as soon as possible depending on the level of risk.”

CMS and TJC have said that in cases where physical risks cannot be immediately removed, acceptable mitigation includes one-on-one observation of the patient. 

Noting that correcting deficiencies could require extensive repairs, replacement of equipment, or even major renovations, CMS has said it will work with hospitals to provide more time. 

Fire doors remain a concern

Time extensions for fire doors is another issue. 

The requirement with the adoption of the 2012 NFPA 101 LSC for annual fire door inspections has increased pressure on facilities to either repair or replace fire doors. But again a backlog of parts is posing problems, say Prickett and Allen. 

“This is a much harder answer because fire doors are features of the Life Safety Code and therefore they are required to be corrected or repaired within 60 days of notification,” says Prickett. In all cases, facilities must do an interim life safety measure (ILSM) assessment or implement ILSMs “depending on the specific deficiency,” he adds.

TJC scores problems related to the annual fire door inspection under EC.02.03.05, EP 25, but the requirements to conduct the test are seated in the LSC, says Prickett. 

“Therefore, the back-order issue that the entire facility is facing is a huge undertaking in regards to fire doors. There are some other options, although [they are] not cost-effective depending on the fire door deficiency. For example, should the door in question lack a fire-rating label, there are companies that can field certify a fire door.”

However, Prickett could not speak to the “process, price, or CMS/TJC approval of field certification, but I know many facilities that utilize this process. Another option -- again not cost-effective -- is to order extra parts when placing an order to have them in stock for the future.”

“The last solution, but possibly the most important, is planning and architecture. As facilities plan for projects and conduct projects, they should [ensure] all doors installed in the units are the correct type, rating as required, and meet the needs of the unit. This will help facilities moving forward more than anything else,” advises Prickett. 

“As for specific parts, I assume latching devices and closers are probably the biggest issues,” says Prickett, because “there are so many that need to be ordered and only so many that can be produced.”

Time waivers can be requested

For hospitals accredited by TJC, repairs that have parts on back order will probably require completing a request for a time-limited waiver, says Allen. 

“The hospital will need to do this repeatedly until the item is delivered and installed. The back-order notice from the supplier should be included in the response,” advises Allen.

After completing your assessment for ILSM, be sure to document in your request the measures being taken as you await the item on back order, Allen said.

As required by CMS, TJC will forward the time-limited waiver request to the CMS regional office for final approval and has promised to work with CMS on behalf of hospitals to get them approved (ECL 8/15/16). However, approval is not guaranteed, TJC officials have said. In those cases, deficiencies noted on survey must be resolved within the 60 days required under Medicare statutory requirements.

There is hope. CMS is granting the waivers, in some cases for up to five years, according to information released at the recent annual conference by the American Society for Health Care Engineering (ASHE), says Prickett. “But I have not had to assist a facility in requesting one yet, so I cannot provide specifics for the time,” adds Prickett.

“However, I assume CMS will make time decisions on a case-by-case basis and I expect no leniency from them. My best guess is CMS would prefer -- and TJC will assist in the TLW process -- you make the TLW request one time, so always ask for more time than you need. My rule of thumb to my clients is always ask for more time and make CMS say no.” — A.J. Plunkett (aplunkett@h3.group)


CMS S&C 18-06-Hospitals: https://tinyurl.com/CMS-ligature-risk-memo-2017


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