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CMS focuses on LSC with increased scrutiny of AOs


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.

CMS told Congress it intended to continue working with each of the AOs to ensure that each organization’s standards adequately matched the required CoPs, especially as the standards are being revised to reflect CMS’ adoption of the 2012 NFPA 101 Life Safety and NFPA 99 Health Care Facilities codes.

Moreover, CMS wants the AOs to close the disparities between the number of condition-level violations found by AOs on survey and those found by CMS within a 60-day validation survey window afterward.

“CMS has identified the top disparate CoPs and LSC Categories. The PE/Environment is one of the leading disparate conditions, accounting for 16 to 48 percent of all disparate surveys throughout all of the program types with the exception of HHAs and hospices,” according to CMS’ report, which included performance reports on all AOs for healthcare organizations under CoPs or Conditions for Coverage.

“AOs need to focus their interventions on their top disparate CoPs,” said CMS.

“If the AOs were to focus on the top disparate CoPs with the highest disparity rates, they would have an opportunity to positively impact their disparity rate. For example, if the AOs would address the top five disparate CoPs for hospitals, they could potentially eliminate 48 percent of the disparate citations,” according to the report.

For hospitals, the report covered the performance of all four AOs—The Joint Commission, the Healthcare Facilities Accreditation Program (HFAP), DNV GL-Healthcare, and the Center for Improvement in Healthcare Quality (CIHQ). (For a more detailed look at how CMS rated the AOs, see p. x.)

During 102 validation surveys following within 60 days behind an AO survey, CMS found 40 condition-level deficiencies missed by AOs, for an overall disparity rate of 39.22%.

CMS also did a breakdown of missed LSC violations, and created a top 10 list of LSC categories where disparities between AO and CMS findings ranged from almost 11% down to just under 2% (see table below).

What deficiencies has CMS found?

A look at CMS deficiency reports filed during FY 2015 offers a look at what, in particular, CMS surveyors were looking for then and what you might expect all surveyors to focus on now.

Even though the version of LSC in effect in FY 2015 was different than today—the 2000 edition of the LSC was still in force under regulation—the basic problems identified with smoke and fire barriers, fire doors, fire alarm and fire extinguisher systems, and hazardous areas remain top challenges also identified year to year by The Joint Commission.

Here are the top AO challenges identified by CMS and examples of survey findings taken from deficiency reports filed in FY 2015 and made available through the Association of Health Care Journalists’ HospitalInspections.org site (note that the reports generally do not specify whether a CMS survey was a validation survey or a complaint survey):

Means of egress—Surveyors checking exit discharge lighting from morgue storage at an older hospital found half of the lights “at multiple exits” did not function properly. The deficiency report cited NFPA foot-candle requirements, and surveyors apparently had measured the available lighting and found it to be less than a fifth of the foot-candle illumination required.

In another area, laundry chute and shelving unit doors in a corridor were measured upon opening and found to protrude beyond acceptable limits into the means of egress.

At still another hospital, the citation was for not providing a non-slip egress to a public way.

Sprinklers—In several instances, hospitals were cited for not having compliant tamper alarms on sprinkler systems in storage or hazardous areas. Sprinkler heads covered in dust or lint were cited for not being maintained properly.

In another area, surveyors examined maintenance documentation of a facility’s sprinkler system and found that repairs listed as needed had not been marked cor-rected; they also found sprinkler gauges without test dates listed and out-of-date service reports.

Fire and smoke barriers—Failures to provide adequate construction or to provide proper or fully sealed penetrations accounted for many deficiencies found with fire and smoke barriers. Facilities were also cited for smoke doors that did not close properly and were not “smoke tight.” One hospital was cited for having several holes in a single one-hour rated wall.

Hazardous areas—Hospitals were cited for failing to have hazardous areas sprinklered or for not having self-closing doors. Facilities were also cited for not having the proper fire-rated construction for hazardous areas and for not maintaining the proper separation for those areas.

Doors—Hospitals in FY 2015 were cited for numerous reasons concerning fire doors, including hold-open devices that weren’t tested properly in conjunction with smoke detectors, doors that did not have positive latching, doors that had prohibited roller latches, inspections that were done improperly or not at all, and doors incorrectly rated for their position in the barrier between fire, smoke, and patient safety. Hospitals were also cited for not having the correct signs on doors to indicate use of a delayed-egress lock.

Electrical—CMS referenced standards in NFPA 70 National Electrical and NFPA 72 National Fire Alarm and Signaling codes when citing hospitals for fire alarm systems that were not maintained and tested appropriately, for missing documentation, and for not testing door hold-open devices. Transfer switches and life safety panels were the subject of scrutiny, and one hospital was cited for NFPA 70 in general for deficiencies that “affected the entire facility.”

Fire alarms—One hospital was cited in FY 2015 because the staff of one unit did not know the location of manual fire alarm pull stations, while another was cited for not maintaining the fire alarm system properly after a surveyor heard a constant buzzing noise coming from the alarm speaker. Other hospitals were cited for maintenance and testing irregularities.

Generators—Poor or incomplete generator maintenance and testing was behind most citations, including one deficiency cited after a surveyor found that a hospital had not acted on the recommendations of a certified inspector. That inspector had informed the facility that the generator was not in good shape and warned there was a fire risk if it was used. The hospital administrator was informed that the find-ing rose to an immediate jeopardy–level citation, which threatens a hospital’s ability to bill for Medicare and even to stay open. “A prompt abatement plan was requested and received,” said the deficiency report.

CMS cited one hospital for a heating, ventilation and air conditioning (HVAC) system that failed to shut down once the smoke detectors were activated. Other hospitals were cited for HVAC systems that were not installed or maintained as required by the manufacturer’s recommendations.

Fire extinguishers—
Problems with fire extinguishers accounted for the fewest disparities between AO surveys and CMS follow-up surveys. Citations included, among other things, failures to ensure that portable fire extinguishers were installed in accordance with the requirements found in NFPA 10, Standard for Portable Fire Extinguishers.


CMS survey-and-certification letter on the FY 2015 report to Congress on AOs’ per-formance: http://tinyurl.com/FY2015-AO-report-to-Congress


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