• Revising the Statement of Conditions^TM (SOC): PFI rules, SPFI, Time-Limited Waivers, and the end of the 6-month grace period EOC News August 2016, Vol 19 , Number 8 Pg 8 – The influence of CMS on TJC requirements and survey process is again being felt.  Largely because Title 42 CFR §488.28(d) “prohibits a time frame of more than 60 days to complete corrective actions in the physical environment”, TJC is having to make significant changes in its Statement of Conditions and related survey processes.  The best explication of this is provided in this month’s Clarifications and Expectations column published in both Perspectives and EC News.  And, it has already gone into effect (i.e., August 1, 2016).  Given the complexities and implications of these changes, we have invited our Associate and Senior Regulatory Consultant with Healthcare Compliace Team, Barbara G. Pankoski, CHFM, CHSP-FSM  to review this article.  Your comments would also be greatly welcomed.
  
• Click here for our REVIEW(Mbr/Guest); the FULL TJC ARTICLE(Mbr); to share a COMMENT(Mbr/Guest).

**RECOMMENDED READING:

1. PR: Sentinel Event Statistics for First Half of 2016 (PDF)[REF: LDR, SC] 
2. TS: Tracer: Point-of-Care Testing and Laboratories (PDF)[REF:Lab]
3. TS: Psychiatric Advance Directives (PDF)[REF:BHC, RI]
4. EC: The Safe Environment: Making the case to leaders (PDF)[REF: EC, LDR]
5. EC: EC Toolbox: Fire drill matrix (PDF)[REF: EC]
6. EC: Revising the Statement of Conditions (PDF)[REF: AOM, EC, LDR, SC. ’16]
   

**USEFUL UPDATES, LINKS & DOWNLOADS:

• TJC: Project REFRESH: The implementation requirement contained in recently deleted EP 23 of PC.01.02.01 has not been lost, but rather, now incorporated into EP1.
• TJC: Quick Saftey Issue #9 – Preventing Delays in Treatment
• Bazelon Center: Psychiatric Advance Directive: Forms to Prepare an Advance Directive for Mental Health Decisionmaking
  
• CDC Study: 30% of Antibiotic prescriptions are unnecessary (see: Prevalence of Inappropriate Antibiotic Prescriptions Among US Ambulatory Care Visits, 2010-2011, JAMA, May 3, 2016, Vol 315, No. 17)
• Latest TJC Blogs: Physician Leader Monthly – Leadership Blog
  

**SupporTips

PR: Sentinel Event Statistics for First Half of 2016

The five most recently reported sentinel events (relevant to psychiatric hospitals) for the first half of this year included:

#2/5: Falls
• Key causal factors: Inadequate assessment, communication failures and failure to follow established protocols and safety practices
• See also: Sentinel Event Alert Issue 55: Preventing Falls and Fall-Related Injuries in Health Care Facilities
#4/5: Patient Suicide
• Key causal factor: Inadequate psychiatric assessment
• See also: Sentinel Event Alert Issue 56: Detecting and Treating Suicide Ideation in All Settings
#5/5: Delay in Treatment (see Comments for KeyDef)
• Key causal factors: Inadequate assessment, poor planning/scheduling systems, understaffing, misdiagnosis, communication failures and human factors (e.g., memory lapses, bias)
• See also: Quick Safety Issue 9: Preventing Delays in Treatment

Tip: Note the common theme of inadequate assessment in these three risk areas and with that in mind, proactively review the adequacy and effectiveness of your assessment processes for these issues.

*TS: Tracer Methodology 101: Point-of-Care Testing and Laboratories (PDF)[REF:Lab] The Source, August 2016, Vol 14, #8, Pg 7 JCs1608_B2

As background for this tracer the article reports a “growing number of inaccuracies in waived testing”.  In particular, the article’s discussants focus on the concern of having unqualified staff performing non waived tests.  This may be an increasing challenge because of the growing number of both tests and devices requiring greater attention to the qualifications and competencies of those who utilize/perform them.  As with all article in this series there is an included tracer scenario and sample questions.  Although the scenario took place in a med-surg hospital, the sample questions are still relevant to our psychiatric inpatient facilities.
Tip: If you still have lab services, prepare for increased surveyor attention to the qualifications and competency of staff who perform waived and non waived tests.  To that end, consider conducting an annual mock survey focused on this issue.

*TS: Psychiatric Advance Directives: Benefits and Strategies for Implementation (PDF)[REF:BHC, RI] The Source, August 2016, Vol 14, #8, Pg 7 JCs1608_B3

The Psychiatric Advanced Directive (PAD) is specifically required for BHC organizations under standard CTS.01.04.01. While that standard is not formally applicable to state psychiatric hospitals, the PAD is certainly relevant.  It should also be noted that attention to advanced directives is required of all hospitals under RI.0105.01 and there is no prohibition to support of a PAD.  Such a directive “documents the individual’s treatment preferences that should be implemented at a later time if the individual’s ability to make decisions becomes compromised “.  As such, an effective document would identify the individuals preferences regarding medications (acceptable, non-acceptable), alternatives to hospitalization, alternatives to highly restrictive or high risk procedures (e.g., restraint, seclusion, ECT), non treatment personal care, visitors, emergency contacts, surrogate determination, assistive devices and diet. Needless to say, PADs are best developed when a patient is well/stable/competent. However, whenever they are developed, it is suggested that a proxy be included so that new treatments arising after the PAD is written and/or activated can be discussed in a timely manner with someone who is competent.  Questions about the need for a proxy could be addressed by two assessment tools suggested in the article (i.e., Decisional Competence Assessment Tool for Psychiatric Advance Directives and the MacArthur Competence Assessment Tool for Treatment.) The article also suggest considering the use of online forms and/or software to help structure the process.  Search (outpatient) suggests many patients will be able to self-complete a PAD and few will call for refusal of all treatment.
Tip: Take advantage of the Bazelon Center’s publication, PSYCHIATRIC ADVANCE DIRECTIVE: Forms to Prepare an Advance Directive for Mental Health.

* EC: The Safe Environment: Making the case to leaders (PDF)[REF: EC, LDR] EC News, August 2016, Vol 19, #8, Pg ?? JCe1608_B4

As in all aspects of quality and safety throughout the hospital, TJC believes the informed and active involvement of leadership is critical.  This article more specifically makes the case for leadership involvement in issues related to compliance with EC. EM and LS standards.  Hospital leaders need to have a fundamental understanding of what standards require.  It also makes suggestions for how to do this such as regular leadership rounding/walk throughs or a semi-regular “Coffee with the Crew”.  With the latter strategy, the idea is to create a casual, informal, non-confrontational, trust-building, communication improving forum for sharing information and improving leader awareness. The authors also present a few persuasion tips to assist facility engineers/managers in making their case more effectively.  In addition to making clear, simple (i.e., with minimal technical detail/jargon), structured (e.g., consider use of notecards) presentations and finding ways to bring points home with the use of photos or other visuals.  Being able to make a sound business case to leadership that shows a cost savings or return on investment can also be helpful.
Tip: Hospital leaders should give serious consideration to the TJC recommended rounds and “Coffee with the Crew”.
See also:
• Coffee with the Crew: Helping CEOs Better Understand Facility Needs Perspectives (November, Vol 31 #11) pg4  [goto Comments for SPHCC article summary]
• Coffee with the Crew: Bringing Together Senior Leadership and Facility Management Staff to Discuss Facility Needs Environment of Care News (December Vol 15 #12), PG 4  [goto Comments for SPHCC article summary]
Ask about: The SPHCC Mini-WebNR Series, “EOC Essentials for Leaders”

* EC: EC Toolbox: Fire drill matrix (PDF)[REF: EC] EC News, August 2016, Vol 19, #8, Pg 5 JCe1608_B5

This installment of the EC Toolbox series offers a matrix that was developed to help TJC’s life safety code specialists survey the fire drill requirements of EC.02.03.03.  According to the article, one of the “biggest fire drill compliance problems” is the organization’s failure to build in the variation (i.e., 50% or more unannounced, and drills conducted at unexpected times under varying conditions)  that is required by standard to help make the drills truly effective.  The matrix is an uncomplicated spreadsheet that was specifically designed to collect and display key required data points that not only confirm the occurrence of drills and their level of compliance but also makes it easy to see the presence or absence of required variation.  As such, it is a useful survey preparation tool.  It should also be noted that the LSC surveyor may hand out this matrix for the facility to complete during survey.
Tip: Copy the ‘Sample of a Fire Drill Matrix’ on page 7 of this article; use it to document your fire drills on an ongoing basis and have the most current version available for sharing with the LSC surveyor as  needed.
Ask for: A copy of our mock up of the Fire Drill Matrix based on this article.

  Since 1995, healthcare facilities have utilized the Statement of Conditions as a management tool to identify Life Safety deficiencies that could not be immediately corrected.  However, recent publications in “The Joint Commission Perspectives” and the “The Joint Commission EC News” August 2016 editions reflect a total revamping of their Statement of Conditions (SOC) process.  These changes went into effect on August 1, 2016.
The Joint Commission (TJC) has made changes to the Statement of Conditions largely because the Centers for Medicare & Medicaid Services (CMS) Code of Federal Regulations §488.28 does not allow more than 60 days to complete corrective actions in the physical environment. Consequent changes include the following:
1.    Plans for improvement (PFIs) identified by the hospital will no longer be reviewed by the Joint Commission’s survey team or included as a part of the Joint Commission’s final report
2.    There will be no extensions offered for PFI’s from TJC (including the automatic 6-month extension)
3.    Life Safety deficiencies noted during TJC survey will be identified as “Requirements for Improvement (RFIs)” .  These identified RFIs will require a 60-day Evidence of Standards Compliance (ESC) by the Joint Commission. If a Life Safety deficiency identified during survey requires more than 60 days to correct, it will require a “Time-Limited Waiver” (TLW) process.
4.    The Joint commission will only review survey related equivalency requests and these will require approval by CMS.
5.    The Joint commission has added a new category “Survey-Related Plan for Improvement (SPFI) in order to manage a hospital’s corrective actions when resolving Life Safety deficiencies identified during survey.
6.    There is now a new Interim Life Safety Measures (ILSM) for both PFI and the SPFI .
Although a hospital has an option to continue to manage their self-identified Life Safety deficiencies through The Joint Commission’s PFI electronic software, many hospitals have chosen to manage through their own in-house Computerized Maintenance Management software and work order program.  The choice to utilize the existing electronic statement of conditions program for both the Basic Building Information (BBI) and the Plan for Improvement (PFI) is now optional.
As of August 1, 2016, life Safety deficiencies identified during an actual survey which will take more than 60 days to repair will become “SPFIs” and be entered into the electronic Statement of Conditions program. There will be an identified tab in the electronic Statement of Conditions for the SPFIs.  This tab for SPFIs can provide a list of all SPFIs open and the mandatory limit of 60 days is preset in the program. The hospital organization will be responsible for closing open SPFIs.
When survey identified Life Safety deficiencies will take longer than the 60-day time frame, the facility must go to the “time limited waiver” tab in the eSOC within 45 days from the end of their actual survey and follow the correct TLW request procedures. When a TLW is submitted by the healthcare organization, the facility will be notified that their request will be considered.
For organizations that use The Joint Commission for deemed status, TJC will forward Time Limited Waiver requests to the healthcare organization’s CMS regional office within the appropriate 60-day window.  Once the CMS regional office considers the submitted TLW, the Joint Commission will be notified.   If the waiver is accepted by the CMS Department of Engineering and CMS regional office, the Joint Commission will update the organization’s scheduled completion date (SCD) and approve the TLW.  If the CMS regional office does not grant a requested TLW, the hospital is expected to correct the deficiency within the original 60 day time frame.  Should a facility fail to correct an approved Time Limited Waiver deficiency within the approved time frame. it will “result in a decision of Accreditation with Follow-up Survey” .
These recent changes from CMS and the Joint Commission should renew the Healthcare organization’s goal to be “continuously compliant ready”.
Tip 1: Make sure leadership and  EOC managers are fully aware of the changes described in this article as their understanding and support will be crucial to effective compliance.
Tip 2: Facilities should take a no-nonsense approach to Life Safety features in order to stay continuously compliant and survey ready.  Be proactive by implementing more Life Safety building tours and create work orders ASAP to document corrective measures.

–by  Barbara G. Pankoski, CHFM, CHSP-FSM