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Check new SAG lists, get latest IC manual to prepare for 2018 surveys


March 1, 2018

This year promises to be even more challenging than last as surveyors add in new expectations on medication and pain management, ligature risk, emergency preparedness, ramped up infection control and other issues.

Here are some concerns to watch for and tips to survive survey in 2018:

New Survey Activity Guide
The Joint Commission (TJC) has a new Survey Activity Guide (SAG) out with the latest requirements for documentation and updates to tracer activities for all providers.

Patton Healthcare is encouraging hospitals to note the eight new requirements for documentation presented on the first day of survey, including new Emergency Management standards requiring a continuity of operations plan that also outlines leadership succession in the event a key emergency operations plan (EOP) player cannot fulfill the role.

Providers must also have, among other things, documentation of annual emergency preparedness training. “It is not really clear what they want here, but our assumption is this would be a description of what you have done, maybe some dates and summary statistics of training that has occurred, while individual employee files would contain the evidence that specific individuals have completed the training,” recommends Patton Healthcare in its January newsletter.

The SAG also includes revisions and clarifications to TJC’s “Life Safety and Environment of Care Document List and Review Tool.”

Infection control
Inadequate control of the risk of infection, particularly with the high-level disinfection and sterilization of medical devices, continues to be one of the top-scored deficiencies leading to a ruling of immediate threat to life (ITL) by TJC.

There is a new, updated edition of the ANSI/AAMI Standard 79 (ST79), “Comprehensive guide to steam sterilization and sterility assurance in health care facilities,” available from the Association for the Advancement of Medical Instrumentation (AAMI). Get a new copy now and study it, advises Jennifer Cowel, president of Patton Healthcare Consulting in Naperville, Ill.

Revised in the fall of 2017, “there are some detailed changes in that release that we are already seeing scored on hospital surveys,” warns Cowel. “For example, the new AAMI ST79 guides hospitals to review the manufacturer IFU [instructions for use] on the blue wrap they use for sterile packs to determine if you can stack sterile packs in sterile storage or not. This detail, like the many other changes, can trip you up on survey.”

Remember if a surveyor asks for a document or IFU, you must produce it at the time or get cited. You cannot produce it later to get rid of the RFI.

There are also revisions to the National Patient Safety Goal 7, effective Jan. 1, on reducing healthcare-associated infections (HAI) and TJC issued a warning issued in December that surveyors will start issuing RFIs for individual instances of poor hand hygiene.

Changes to NPSG.07.03.01 on multidrug-resistant organisms (MDRO) require licensed independent practitioners and other staff to be educated about MDROs upon hire, granting of initial privileges and periodically as determined by the hospital. Changes to NPSG.07.04.01 on central line-associated bloodstream infections (CLABSI) include the same revision on allowing organizations to determine training time frames, along with a specific mandate to use alcoholic chlorhexidine as an antiseptic for skin preparation unless other reasons prohibit its use.

More important is the warning from TJC in its December issue of Perspectives that in addition to surveying a hospital’s hand hygiene program under NPSG.07.01.01, it would begin citing individual failures to practice good hygiene under EP 2 of IC.02.01.01, calling for using standard precautions to reduce infections.

Medication and pain management
TJC surveyors will also be looking at both medication management and pain management in connection to revisions to standards announced last year and also effective January 1.

The MM chapter revisions include expanded requirements related to when and how drugs are administered, as well as new elements of performance requiring an emergency plan for dealing with a loss of power to drug dispensing machines and medication refrigerators.

The revisions to standards on pain assessment were more complicated, emphasizing leadership accountability for making “safe opioid prescribing” a priority and broadening the types of pain management that should be explored as an alternative to more addictive medications.

“The new pain assessment standards will probably also be challenging,” says Kurt Patton, a pharmacist who, after a tenure as TJC’s director of accreditation services, founded Patton Healthcare Consulting. Pain assessment and management of pain always has been on the radar of clinical surveyors and the new standards will be as well, he says. “TJC does not want to be perceived as part of the reason we have an opioid crisis in the U.S., so I am somewhat assuming these new standards will be a heavy focus.”

In addition to the pain management standards, expect surveyors to continue to ask questions about MM.09.01.01, the standard on antibiotic stewardship added in 2016 after CMS expressed concerns, says Sue Dill Calloway, president of Patient Safety and Healthcare Consulting and Education in Dublin, Ohio.

Self-harm and other clinical concerns
Calloway notes that CMS has proposed CoPs in recent years on antibiotic stewardship and discharge planning. Both could see renewed scrutiny from CMS surveyors this year along with opioid prescribing practices, she warns.

Calloway anticipates that CMS will finalize the proposed discharge planning CoPs, as well as increasing focus on ligature risk, as outlined in a new memo to state surveyors at the end of last year.

Ligature risk is next to infection control for deficiencies that lead to ITL by TJC surveyors or immediate jeopardy by CMS surveyors, say agency officials and accreditation experts.

The CMS memo and interim Interpretive Guidelines issued in December to regional CMS surveyors also emphasized that hospitals must improve screening of patients for risk of self-harm.

While the focus of the memo was on inpatient settings for behavioral health (BH) patients, hospitals should be prepared to provide a safe environment for any at-risk patient.

"Hospitals, especially those accredited by the Joint Commission, need to have safe rooms to prevent suicides,” says Calloway. “Hospitals need to consider providing a psychiatrist and other services when patients are boarded, waiting for a behavioral health bed.” She recommends exploring the use of telemedicine. “We need not only to keep these patients safe, but try and provide services to them.”

Review hospital policy with staff in emergency settings, including hospital emergency departments as well as off-site ambulatory or urgent care settings where CMS regulations regarding patients’ rights to care under the Emergency Medical Treatment & Active Labor Act (EMTALA) are often overlooked.

“CMS continues to issue deficiency reports and hospitals need to monitor EMTALA regulations since now the penalty has more than doubled, to almost $105,000 per violation for hospitals over 100 beds,” notes Calloway.

Civil fines for violations of under EMTALA regulations were increased at the end of 2016, and so have related deficiency reports. More than 3,600 incidents have been cited, she says. And CMS is not shy about the fines.

“Earlier this year, they settled with a hospital for $1.3 million,” says Calloway, noting that an incident with just one patient can result in more than one deficiency, each with its own fine.

“I also think the higher amount might drive the OIG [Office of Inspector General] to spend more time going after hospitals with deficiencies,” she says.

Emergency management
The CoP for emergency preparedness went into effect last November and will certainly be on the short list for surveyors. While hospitals that have been long-held to TJC’s EM standards are well set to meet the newest CoP, be sure to review the revisions and clarifications set out in the most recent update to the Comprehensive Accreditation Manual for Hospitals (CAMH) as well as the new SAG.

Among other things, hospitals are being expected to ensure that emergencies within the organization and community are part of the required hazard vulnerability analysis (HVA), that patient evacuation is included — and documented — in the staff list of roles and responsibilities in the event of a disaster, and that alternative emergency lighting is addressed in your EOP.

The CAMH also includes the newest EM standard, EM.04.01.01, outlining requirements for combined EOPs within an integrated health system.

Don’t assume that cybersecurity is not the job of the accreditation team.

Not only does it top the list of ECRI Institute’s technology hazards for 2018, it is considered a patient safety issue by CMS and has been cited in more than one CMS hospital survey.

For instance, a hospital in California hit by a malware attack in 2016 that shut down its electronic health records (EHR) system was cited under nursing services, care of patients, medical records and governing board CoPs. Among concerns were “the ‘gaps’ and the ‘mistakes’ on the transcription of the written physician orders,” and an admission by a member of the governing board that “the facility had young nurses that were not used to ‘paper’ forms,” according to the deficiency report.

In another case, medication transcription errors were found in patient records blamed on the lack of a computer system shut down by a cyberattack.

Already this year, at least one hospital has been hit in a ransomware attack so expect more attention from CMS and the HHS Office of Civil Rights, which oversees patient information privacy and HIPAA enforcement. Federal officials issued memos to surveyors and inspectors telling them to examine hospital precautions and several alerts were sent out by various organizations.

In addition, TJC expects cyber incidents to be included in HVAs and emergency preparedness planning, as noted in the new SAG.

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

The Joint Commission’s 2018 Survey Activity Guide: https://www.jointcommission.org/assets/1/18/2018_Organization_SAG_Issue_Date_Dec_2017.pdf

Patton Healthcare Consulting, January newsletter: https://pattonhc.com/patton-healthcare-consulting-newsletters/january-2018-phc-newsletter/

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