CMS focuses on LSC with increased scrutiny of AOs
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November 1, 2017
Expect The Joint Commission (TJC) and other accrediting organizations (AO) to intensify scrutiny of Life Safety Code® (LSC) compliance as CMS continues to voice concern that the AOs are missing too many condition-level violations.
In a report to Congress on the performance of AOs in fiscal year (FY) 2015, the agency reviewed the number of times its own state surveyors found deficiencies in meeting Medicare’s Conditions of Participation (CoP) against AO survey findings and found that LSC and physical environment (PE) violations posed the greatest challenge among hospitals and other healthcare organizations. FY 2015 ran from October 1, 2014, to September 30, 2015.
“The PE CoP contains multiple standards; however, 94 percent of the PE citations were comprised of the LSC standard within the CoP. Within the LSC standard categories, Fire/Smoke Barrier, Hazardous Areas, Sprinklers, Doors, and Means of Egress were the top deficiency citations not cited by AOs, with the Fire/Smoke Barrier noted in four of the program’s top five missed citations,” according to the report’s conclusions.
Improvements shown, more needed
Overall, AOs have been improving from year to year, since 2000, according to the report, posted online as a survey-and-certification letter to state survey agencies on July 28. But more improvement is needed, especially within the environment of care, said the report’s authors.