••WHAT’S NEW:

• New SPHCC
  • New Website – Get ready! Although we have had to postpone the launch of our new website until August 2012, the new, improved site is steadily progressing through development. 
  • New Membership Options & Benefits – The new SPHCC will have 5 membership levels to choose from.  These will range from a no-cost entry level up to a new upper level with built in on-site consultation time and e-supports. For the first time, customized support pages for associates and other individuals will also be available.
  • Current Memberships – Rest assured. All of our current memberships will be extended until our new website is up and running.

• CMS-3244-F: Authentication of Verbal Orders – Proposed changes by CMS regarding authentication of verbal orders have now been finalized!  The 48-hour requirement has been eliminated (to be replaced by state law or hospital policy) and the temporary exception allowing ‘another practitioner’ to authenticate for the original ordering practitioner is now permanent.  The final ruling can be downloaded below.  A more detailed overview of these and additional changes in the COP reform, relevant to psychiatric programs is presented in a special expansion of the CMS Section below. [REF: MDx, RNx, P&T, Phrm]

• Prepublication Standard (HAP): Revision to WT.04.01.01  (RN)

• Prepublication Standard (BHC): New Requirements for Prevention and Wellness Promotion Services   (JCSC, PI, SW)

••REFS:

• PR: Clarifications and Expectations: Managing Barrier Integrity    [REF: EOC, LDR, SFT]
• EC: Clarifications and Expectations: Managing Door Maintenance    [REF: EOC, EM, LS]

••PEARLS:

• TS: Patient’s Assessment of Quality Scale [PEARL: PI, PtAd, RNx]

••DOWNLOADS:

• CMS-3244-F: Medicare and Medicaid Programs; Reform of Hospital and Critical Access Hospital Conditions of Participation [77 FR 29034]

• Risk Assessment for Infection Prevention and Control  FYI: IC

• Infection Prevention Risk Assessment: A How-to Exercise  FYI: IC

• OSHA Bloodborne Pathogens Standard  FYI: IC

• CMS Survey and Certification Letter 12-21-LSC (3/9/12)  Instructions Concerning Waivers of Specific Requirements of the 2012 Edition of the National Fire

• See also [Ftxt] and Full Text Articles below

Publication Color Key: Perspectives (PR), The Source (TS), and Environment of Care News (EC), Joint Commission Online (OL)

RTN Quick Jump••Top••RefRvw••TJC••Perspectives••Source••EC News••TJCOnline••CMS••Internet••New Adds••Abbreviations••Bottom

•PR: – Clarifications and Expectations: Managing Barrier Integrity    [REF: EOC, LDR, SFT] Perspectives June 2012, Pg 3, Vol 32, # 6

Clarifications and Expectations is a relatively new column featuring practical explications of Life Safety Code by George Mills, MBA, FASHE, CEM, CHFM, CHSP, Director, Department of Engineering, The Joint Commission. The focus for this month is fire and smoke barriers.  Hospitals are designed with wall-to-wall and floor-to-ceiling smoke and fire barriers that allow for containment of fires/smoke for critical periods of time and faster/more convenient lateral evacuation (when necessary) of patients (i.e., defending in place) instead of having to completely leave a building.  However, defending in place is critically dependent on properly protecting openings in those barriers such as doors (e.g., fire-barrier doors that must be self-closing and latching vs. fire-barrier doors that are similar, but do not have to be latching) and penetrations.  Last year TJC surveys frequently included citation of penetrations (especially above the ceiling) fire barriers (LS.02.01.10 52% of surveys) and in smoke barriers (LS.02.01.30 45% of surveys).  These same standards were cited in more than a third of SPHCC member surveys as well.  In addition to providing excellent definitions of the key terms and requirements, the article and Mr. Mills recommend a strategy of limiting access to fire/smoke barriers by implementing a Barrier Access Program.  The essence of the program is that anyone working above the ceiling must have a formally issued, time and date-limited, Barrier Access Permit prominently displayed on their ladder.  In addition, all staff are trained and encouraged to report (not challenge) any ladder observed without that permit to security.  The reporter is rewarded  through the paying of a bounty (e.g., gift card).  Other tips for better protection and management of barriers included conducting annual and random barrier/penetration inspections and using the same manufacturer of approved fire-stop rated products (vs. polyurethane expanding foam that is a good insulator, but burns rapidly and emits toxic smoke).  Note also that penetrations can be listed in batch mode as a single PFI on the SOC if they are accompanied by a specific list or drawing identifying specific penetration locations.

RTN Quick Jump••Top••RefRvw••TJC••Perspectives••Source••EC News••TJCOnline••CMS••Internet••New Adds••Abbreviations••Bottom

• TS: – Focus on Certification: Evaluating Participants’ Perception of Care  [PEARL: PI, PtAd, RNx] The Source June 2012, Pg13, Vol 10, # 6

This article specifically references disease-specific care programs, but the requirement for evaluating patient perception of care is core and relevant to hospitals (PI.01.01.01 #16). While digging into this article’s references, the following pearls were uncovered that could enhance your satisfaction survey process:
    •    Patients & Nurses Assessment of Quality Care Scales – These scales primarily evaluate nursing care from the perspective of the patient (PAQS) and the nurse (NAQS).
    •    The HCAHPS (Hospital Consumer Assessment of Healthcare Providers and Systems) Survey is the first national, standardized, publicly reported survey of patients’ perspectives of hospital care. It is a 27-item survey instrument and data collection methodology for measuring patients’ perceptions of their hospital experience. It was developed by CMS and AHRQ and endorsed by the National Quality Forum in 2005. 
A Pearl uncovered in this article is the Patient’s Assessment of Quality Scale—Acute Care Version (PAQS-ACV)

• EC: NEW! Clarifications and Expectations: Managing Door Maintenance   [REF: EOC, EM, LS] E C News June 2012, Pg 6, Vol 15, # 6

This is a reference quality article published last month in Perspectives under the same title.  See our review in the May Reading Tips Newsletter. 

[Index] [Blog] Perspectives [PR] – (June, Vol 32, # 6)

Pg03 – Clarifications and Expectations: Managing Barrier Integrity   [REF: EOC, LDR, SFT] 

Pg07 – Traditional Equivalencies: CMS Permits Use of Certain Sections of 2012 LSC   [FTX] FYI: EOC, LDR, SFT  The current edition of the NFPA Life SAfety Code (LSC) for survey purposes is the 101-2000.  This is related to the fact that TJC will not adopt a more current version until CMS does.  However, TJC has decided that if an organization has submitted a waiver request to CMS (as per the CMS 3/9/12 Survey and Certification Letter, S&C 12-21-LSC), that it will consider Traditional Equivalencies for certain 101-2012 sections to include the following:
    •    LSC section 18/19.2.3.4 Capacity of the Means of Egress
    •    LSC section 18/19.3.2.5.3 Cooking Facilities
    •    LSC section 18/19.5.2.3 Heating, Ventilating, and Air Conditioning
    •    LSC sections 18/19.7.5/5.6 Furnishings, Mattresses, and Decorations
Submission information is available in your e-SOC under the PFI menu item.  For a more in-depth review of equivalencies and related submission process, see  Requesting Life Safety Extensions and Equivalencies A Brief Outline of the Submission Process, EOC News, January, 2011, page 6.

[Index] [Blog] The Source [TS] (June Vol 9 # 6)

Pg02 – 5 Sure-Fire Methods: Complying with Standard IC.01.03.01   FYI: IC, JCSC, PI, This article focuses on IC.01.03.01 because this standard is a Top 10 deficiency for some programs like like Longterm and Ambulatory Care.  It does not reach that level of significance for TJC hospitals, SPHCC General Psychiatric Hospitals or SPHCC Forensic Hospitals.  Still, for the IC coordinator and JCSC, this article’s overview of assessing IC-related risks is worth briefly reviewing.   One of the keys to compliance mentioned is not to rely only on surveillance data for the establishment of risk priorities.  Look more broadly at sources such as sentinel event data or community trends.  Use a multidisciplinary committee or small group to help analyze collected information/data and identify risks using a defined methodology for assessment and prioritization of those risks.  The article alludes to JCR resources (e.g., Risk Assessment for Infection Prevention and Control) for such assessments but does not mention any specifically.  However, a great number of such tools can be found for no cost on the Internet by searching the term ‘Infection Control Risk Assessment Tools.  For example:

    •    APIC Infection Control Risk Assessment Tool (PDF) [HTML]
    •    IP Tools’ Infection Control Risk Assessment Tool (PDF) [HTML]

See also:  Infection Prevention Risk Assessment: A How-to Exercise

Pg06 – 101 Tracer Methodology: Medication Management Tracers in the Ambulatory Setting   FYI: BHC, MDx TJC has previously addressed Medication Management in its Tracer 101 Series. Two years ago it also addressed these tracers in the ambulatory setting (The Source, June 2010, Volume 8, Issue 6) .  This time the take home point is about the recent TJC determination that texting orders is unacceptable (because it does not permit verification of the senders identity or retain the original message as validation.   For a more useful review of the medication management tracer in the hospital setting, see:
    •    Tracer Methodology 101: Medication Management System Tracer, The Source, Oct 2009, Vol7#10 pg 8
    •    Tracer Methodology 101: The Medication Management System Tracer, The Source, February 2009,             Volume 7, Issue 2

Pg10 – CMS: Ensuring Proper Discharge Planning and Patient Transfers During Transitions in Care   FYI: PI, SW EPs 22-26 of Standard PC.04.01.01 has specific discharge-related requirements for hospitals using TJC for deemed status.  They primarily address the need for patient education and information support, particularly when home health or other post hospital extended care services are planned/anticipated.  The article suggests developing and using discharge templates to improve compliance and handoff communication.  It also suggests evaluating your discharge planning process by including questions related to this function as part of patient satisfaction surveys.

Pg13 – Focus on Certification: Evaluating Participants’ Perception of Care   [PEARL: PI, PtAd, RNx] 

[Index] [Blog] Environment of Care News [EC] (June Vol 15 #6)

Pg01 – NFPA codes, Joint Commission standards continue to reduce hospital fire risks   FYI: EOC, SFT, StEd This is the first in a series of fire safety articles created through a collaboration between Joint Commission Resources and the National Fire Protection Association (NFPA).   It provides some interesting history about the reduction of hospital fires and related patient deaths over the years, to include a sidebar on ‘Deadly Hospital Fires Over the Past Century.  It also traces the use of NFPA 99 (TJC currently uses 1999 edition) and 101 (TJC currently uses 2000 edition) by CMS and TJC.  StEd may find some useful tidbits for annual training and fire safety refreshers.

Pg06 – NEW! Clarifications and Expectations: Managing Door Maintenance   [REF: EOC, EM, LS] 

Pg08 – OSHA & Worker Safety: Sharp Focus How health care workers can prevent exposure to bloodborne pathogens   FYI: EOC, MDx, SFT, StEd, This article describes OSHA resources (e.g., 2-page 1991 Bloodborne Pathogens Standard) and recommendations for preventing exposure to bloodborne pathogens.  Although the primary focus is med-surg and few state hospitals have much involvement with OSHA, a number of the suggestions and principles are relevant to our nurses, physicians, housekeeping and maintenance staff who are among the occupational groups most highly exposed.  Consider ideas such as the establishment of an Exposure Control Plan as part of your strategy for compliance with TJC standard EC.01.01.01 that requires the minimization of EOC risks.  

Quarterly Provider Updates

• QPU April – June 2012
  • Issuances for April – June 2012 [PDF, 53KB]
    • R2418CP: April 2012 Update of the Hospital Outpatient Prospective Payment System (OPPS)
  • Regs-2Q12QPU [PDF, 18KB]
    • No new, state hospital-relevant activity/issues for this release

Mid-Quarter Instructions

• January 2012 Mid-Quarter Instructions [PDF, 37 KB]
  • Inpatient Psychiatric Facility (IPF) Pricer –Annual Update – FYI: F&B

Spotlight/What’s New

• CMS-3244-F: Medicare and Medicaid Programs; Reform of Hospital and Critical Access Hospital Conditions of Participation [77 FR 29034]    [REF: GB, IC,IM, JCSC, LDR, MDx, RNx]

The 5-year exception to CMS requirements for authentication of orders (including verbal orders) was scheduled to end on January 26, 2012.  However,  in response to provider concern, CMS re-evaluated their position and on October 24, 2011, published a proposed rule  (76 FR 65891 or CMS-3244-P) entitled “Reform of Hospital and Critical Access Hospital Conditions of Participation”.  On May 11, 2012, Survey and Certification Letter 12-29 announced finalization of that proposal with some revisions as 77 FR 29034 or CMS-3244-F that was published on May 16th and will become effective on July 16, 2012.  The provisions of CMS-3244-F extend significantly beyond the authentication of orders to involve at least 14 major provisions.  The accepted changes from CMS-3244-P (P) and/or revisions from CMS-3244-F (F) most relevant to psychiatric facilities include the following:

Re: Governing Body [(CMS_§482.12)/TJC_LD.01.03.01]
    •    P – Single governing body for multiple hospitals:  One governing body allowed to oversee multiple hospitals in a multi-hospital system and
    •    F –  Governing Body & Medical Staff: The governing body must include a member, or members, of the hospital’s medical staff.

Re: Patient Rights  [(§482.13(g)/PC.03.05.19]
    •    P – Reporting of Restraint-Related Deaths:  It is now only required to maintain an internal log (vs. make a report to CMS) of deaths that occurred while a patient was in soft, 2-point wrist restraint with no use of seclusion.

Re: Medical Staff  [§482.22(a)/MS.07.01.01]
    •    P– Role of other practitioners on the Medical Staff:  Concept of medical staff is broadened to include other practitioners (e.g., APRNs, PAs, pharmacists). 
    •    P – Medical staff leadership:  Podiatrists may now assume greater medical staff leadership roles as they are allowed to “be responsible” for the  organization and conduct.
    •    F – Medical Staff Eligibility:  The medical staff must include doctors of medicine or osteopathy, but may also include other categories of non-physician practitioners when determined as eligible for appointment by the governing body and in accordance with scope-of-practice and other relevant State law.  Any candidate who has been recommended by the medical staff and appointed by the governing body must be subject to all medical staff bylaws, rules, and regulations, in addition to the requirements contained in §482.22.

Re: Nursing Services [§482.23]
    •    P – Nursing care plan (§482.23(b)(4)/NR.02.03.01)):  Nursing care plans are no longer required to be stand-alone and may be integrated into the patient’s overall hospital interdisciplinary care plan.
    •    P – Orders by other practitioners (§482.23(c)/MM.06.01.01):  Drugs and biologicals may be ordered by a practitioner other than a doctor.  These orders may be documented and signed by such practitioners and are sufficient to permit preparation and administration of drugs and biologicals.
    •    F – Orders by other practitioners:  The provisions referenced above may be enacted only “if such practitioners are acting in accordance with State law, including scope- of- practice laws, hospital policies, and medical staff bylaws, rules, and regulations.”  
    •    P – Administration of medications (§482.23(c)(6))/MM.06.01.01):  With orders and assessment of patient capacity, hospitals may support medication (non-controlled drugs and biologicals) self-administration programs for patients and their caregivers/ support persons .
    •    F – Administration of medications:  To use the provision referenced above, a hospital must have policies and procedures in place to “address” the security of the medication(s) for each patient and to document the administration of each medication.
    •    P– Standing Orders (§482.23(c)(1)(ii)/MM.04.01.01):  Hospitals are allowed to use standing orders for the preparation and administration of drugs and biologicals on the orders contained within pre-printed and electronic standing orders, order sets, and protocols for patient orders.  Standing orders must be approved in writing by medical staff, nursing and pharmacy and based on nationally recognized and evidence-based guidelines and recommendations and medically necessary for the patient.

Re: Medical Record Services (§482.24/RC.02.03.07, EP#4)
    •    P – Verbal Orders: The requirement for authentication of verbal orders within 48 hours has been eliminated and the matter of such timeframes deferred to state law or hospital policy.
    •    P – Authentication of Orders:  The requirement has now been made permanent that all orders (including verbal) be dated, timed and authenticated by the ordering or another practitioner who is responsible for the patient’s care and authorized by the hospital to write orders (and if in accordance with state law).
    •    P – Authentication of Orders:  This provision requires that the practitioner is acting in accordance with State law, including scope-of-practice laws, hospital policies, and medical staff bylaws, rules, and regulations.”

Re: Infection Control (§482.42(a)(2/IC.01.01.01)
    •    P– Infection Control Log:  The requirement to maintain an infection control log has been eliminated.

Re: Outpatient Services (§482.54(b)(1)/LD.04.01.05)
    •    P – Outpatient Services Director:  The requirement for a single Director of Outpatient Services position has been eliminated.

    •    P – Outpatient professional staffing: Hospitals now have more flexibility in deciding what professional staff are appropriate to the scope and complexity of the outpatient services being provided.

Note: In all the above provisions, CMS makes it clear that they are applicable “only if … in accordance with State law, including scope-of-practice laws, hospital policies, and medical staff bylaws, rules, and regulations.”

INTERNET HIGHLIGHTS

Joint Commission Online(JCO) & Website

• TJC Topic Library
  • 06/11/2012: Audio/Visual files for the June 5, 2012 Webinar – Provider Roundtable: Emerging Trends in Behavioral Health (BHC)
  • 06/05/2012:  Prepublication Standard – Revision to WT.04.01.01  (RN)
  • 05/30/2012: Advancing Effective Communication, Cultural Competence, and Patient-and Family-Centered Care  (JCSC)
  • 05/21/2012:  New Requirements for Prevention and Wellness Promotion Services  (BHC)
  • 05/11/2012:  Audio/Visual files for May 8, 2012 Webinar – TJC Behavioral Health Accreditation On-Site Survey   (BHC)

SPHCC Library Additions & Full Text Articles

• 77 FR 29034: Medicare and Medicaid Programs; Reform of Hospital and Critical Access Hospital Conditions of Participation  CMS-3244-F (Txt), CMS-3244-F(PDF)
• Full Text Articles
  • Traditional Equivalencies for Certain Sections of the 2012 Edition of the Life Safety Code Will Be Considered (LS) (6/12)