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TheJointCommission:2018Update
WhoweareSurveyProcessandMethods
Standards
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KennethA.Monroe,PE,MBA,CHC,PMPDirector-Engineering
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LearningObjectives
z Attheconclusionofthispresentation,participantswillbeableto:q DiscussTheJointCommissionmission&deemedstatusq Understandthesurveyprocessq DescribetheSAFERMatrixq Understandwhichstandardsarescoredmostfrequentlyin2017q DiscusstheprocessofStandardscreationq UnderstandthenewandrevisedEP’sintheLSandECchapters
§ WeareNOTpresentingadetailedEPdiscussion
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Big Shoes to Fill!
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SIG-DepartmentofEngineering
V A C A N T Engineer
KennethA.Monroe,PE,MBA,CHC,PMPDirector
Herman McKenzie, MBA Engineer
V A C A N T ? Engineer
V A C A N T Engineer
Andrea Browne, PhD., DABR Medical Physicist
V A C A N T Engineer
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SIGENGINEERING–GoalsandAspirations
z Getfullystaffedz NewDirections
q What’snext?
§ InfectionControl
§ EmergencyManagement
§ Workplaceviolence
z EnhancementstoLSandECStandardsq DSSMFunction
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HAI’s–HospitalAcquiredInfections
z Approximately700,000casesperyearz Approximately60,000deathsperyearfromHAI’s
q Equivalenttoone747-400every2.5days
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Mission:
q Tocontinuouslyimprovehealthcare
q Byevaluatinghealthcareorganizations-meaningfulassessment
q Toprovidesafeandeffectivecare
q Inspiringthemtoexcel
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TheJointCommission:DeemedStatus
z 1965q Congress:SSAmendmentsq IFaccreditedbyJCAH,“deemed”tobeincompliancewithMedicareConditionsofParticipation(CoP’s)
z LossofDeemedStatus:q Approx.2/3to3/4ofrevenuefromCMSq Spigotturnedoff
z NotallHCO’sdeemedbyTJCq StateAHJ’sq Competitorsq Notdeemedatall
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TheJointCommission:DeemedStatus
z DeemedPrograms:q Hospitalsq BehaviorHospitalsq HomeCare,Hospiceq AmbulatoryHealthcare,includingSurgeryCenters
q CriticalAccessHospitalsq Labs
z Survey:Every3yearsq (Labs:every2years)
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TJC–StandardsandElementsofPerformance(EP’s)
§ Telluswhatyouaregoingtodo
§ Tellushowyoudidit.
§ Surveyto2012editionsof:§ NFPA101–LifeSafetyCode§ NFPA99–HealthcareFacilitiesCode
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ACO-DSSM-SIG–LiketheGovernment
DSSM–LegislativeKenMonroe
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LifeSafetyCodeSurveyors(LSCS)
• 78Full/PartTime/Intermittent(hiring)
• Manycurrentlyworkinhealthcarefacilitymanagement
• Minimumofbachelorsdegree,mosthavemultiplemasters&doctoratelevel
• Liveacrossthecountry,surveytheglobe• Highperformers,veryengaged,top1%
JimKendig,MS,CHSP,CHCM,HEM,LHRMFieldDirector,LSCS
TimMarkijohn,MBA\MHA,CHFM,CHEFieldDirector,LSCS
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ACOAccreditationandCertificationOperations
UnderstandingTheSurveyProcess
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SurveyTypes
• FullU(FullUnannounced\Triennial)
• MedDef(MedicareDeficiency)
• SSU/OQPS(SpecialSurveyUnit&OfficeofQualityandPatientSafety)
• ICM2or3(IntracycleMonitoring)
• ExtensionSurvey(Newbuilding/services)
• MedicareSurvey(CLDonInitial)
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LifeSafetyCodeSurveyorDays-2018Hospitals–EachPhysicalAddress=Min.2LSCSdays(new)
0–1,000,000 2LSCSDays1,000,000–1,500,000 3LSCSDays>1,500,000 LSCFDReview
AHC/ASC 1LSCSDayMedDef 1LSCSDaySSU/OQPS 1LSCSDay
NonHospitalLifeSafetyCodeSurveyorDays-2018GrossBuildingSquareFootage
GrossBuildingSquareFootage
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TheHospitalSurveyTeam
z TeamLeader
q PhysicianorNurse
z LifeSafetyCodeSurveyor(LSCS)
z Otherclinicalteammembers
z Basedonphysicalsizeoftheorganizationandtheamountandtypesofprograms(HAP,OME,AHC,BHC)
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LSCSPreSurveyReview
• SOC(BBI–Eapp)PFI’snotvisibletoLSCS
• PreviousreportandESC’s
• Publicwebsite
• SurveyorResources
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11requirementssurveyorswantyoutoknowabout
z Triennial4hoursgeneratorrunappliestoallHAP/AHC(EC.02.05.07EP’s9&10)
z Writtensurgicalfireriskassessmentandplan(EC.02.03.01EP-11)
z Exitsigntestingwithbatteries(EC.02.05.07EP-1)
z Elevatorfirefighteroperationsmonthlytest(EC.02.03.05EP-27)
z LIM’s(EC.02.05.05EP-7)
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11requirementssurveyorswantyoutoknowabout-page2
z Fireresponseplan,LIP,copyatoperatororsecurity(EC.02.03.01EP-9)
z Stairwellsignage(floorinformation)tactile(LS.02.01.20EP-10)
z KitchenHoodExtinguishing(FA/Energy/Fans)(EC.02.03.05EP-13)
z Successionplananddelegationofauthority(EM.02.01.01EP-12)
z GeneratorEPOremote/notonexteriorenclosures(EC.02.05.03EP-11)
z Corridor/SuitePerimeterDoors(LS.02.01.30EP-13)
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SurveyAgenda:LSCSArriveswithTeamDay1
0800-0900
FacilityOrientation
0900–0930
OpeningConference/IntroductionsOnly
0930–1045ish
DocumentReview
1045–1200
PressureRelationships(OR’s/SPD)
1200–1230
Lunch
1230–1600
BuildingTour(EndofdayFindings)
Day20800-0815
Day#1MorningBriefing
0815–1200
BuildingTourCont’d
1200–1230
Lunch
1230–1430
EC/EMSessions(Separate)
1430–1530
Enterday#2Findingsintoreport
1530–1600
InterimLSCSExit/TeamExit
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DayOnemorning:FacilityOrientation
MainFirePanel-Uponarrivalbythesurveyor,anescortwillbeneededtotakehim/hertothemainfirealarmpaneltoverifythatitis
functional-checkbreaker.!
Tipforsuccess:makesureyouknowlocationofelectricalpanelwiththedesignatedbreakerforthefirealarm.
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LifeSafetyPlans-Thesurveyorwillthenmeetwithanorganizationstaffmember(s)tobecomeorientedtothelayoutofthebuilding.
• AreasSprinklered(ifnot100%)• HazardousStorageRooms• FireBarriers• SmokeBarriers• Suites(bothtypes),includingsize• SmokeCompartments• Chutes/shafts• ApprovedEquivalenciesorWaivers
DayOnemorning:FacilityOrientation
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DayOnemorning:FacilityOrientationNewMay2017z Visitgenerators
q Obtainnameplateinfo,lookforEPO
z Visitfirepumproom
q Electricordiesel(Daytankatleast2/3Full)
q SpareSprinklerHeadsandTools
z Priortothestartofthebuildingtour–the3Q’s
Tipforsuccess:Knowthenumberandtypesofsprinklerssoyoucandeterminethenumberofsparesneeded.
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DayOnemorning:DocumentReview
z Paperorelectronic,90minutesisthegoal!z SamechecklisttheLifeSafetyCodeSurveyors(LSCS)/Hospitalusez ServesasHospitalspreptoolforsurvey–mockreviewz ChecklisthasStandard,EP,Timefrequencyz OpenbooktestTipforsuccess:
q Organizetestingdocumentbinderinsameorderaschecklistq Closeallopenissuesandplaceworkorderrightbehindreport
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• PoliciesandproceduresforInterimLifeSafetyMeasures(ILSMs)
• Writtenfireresponseplan
• Evaluationsoffiredrillsconductedforthepast12months–completefiredrillmatrix
• Maintenancerecordsforfireprotection&suppressionequipment
• Maintenancerecordsforemergencypowersystems
• MaintenancerecordsforpipedmedicalgasandvacuumsystemsTip for success: LSCS will use IOU if not readily available
DayOnemorning:DocumentReview
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DayOnemorning:DocumentList&ReviewTool
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DayOnemorning:DocumentationClarification
z Anydocumentnotavailableattimeofsurveycannotbeclarifiedpostsurvey
z Documentsreadilyavailable
z Reducethevolumeofpost-surveyclarifications
z Lesstimeandresourcesspentafterthesurvey
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DayOnemorning:FireDrillMatrix
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FireDrills-Tips
Tipforsuccess:
z Reminderonedrillpershiftperquarter+/-10days
z >1hourbetweendrills(BestPractice:Varydays)
z Numberonelocationforfiresinhealthcare?Kitchen!
z PlacecentralstationandFDCchecksonfiredrillform–savetimeandmoneyandeliminatemissedannualandquarterlyrequirements.
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DayOnemorning:PressureRelationships
z OR’s-Positivetoadjacent
z SPD-Decontam-Negativetoadjacent
z SPD-Prep/Pack,Sterilizing,Sterilestorage–Positivetoadjacent
z AIIR’s–Negativetocorridor,.01”W.C.
z SoiledUtility–NegativetoCorridor
Tipforsuccess:WhenyouannounceTJCinhouse–someoneshouldcheckthecriticalpressurerelationships
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DayOneafternoon:TheBuildingTour
z Startatthetop
q Roof–Labexhausts(NotAIIR’s)
q Walkstairenclosures
q MechanicalRooms,centralplant(exitsignsvisible)
q Lab,Pharmacy,Kitchen
q Patientsunits
q Radiology,ED,MedicalRecords
q Fire/smokeBarriers
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DayOneafternoon:TheBuildingTour
z FD’s(Label,Gap,Close,Latch,Plates)SD’s(Close,Gaps)
z Corridordoors,latchinghardware,nomore5lbexception
z AboveCeiling(Sprinklerpipes,Barriers,J-Boxes,MedPipe)
z EntirebuildingforEC,HospitalandAmbulatoryforLS
Tipforsuccess:Aboveceilingpermitsysteminplace?
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InterimLifeSafetyMeasures
z PolicyReviewedduringdocumentreview,ILSMReferenceguidegiven
z MostlyforLSfindings,eithercorrectedonsiteornot<8hours
z SurveyorrequiredtodocumentinreportwhatILSMisputinplaceuntilcorrected
Tipforsuccess:KnowyourILSMpolicy–educationcanbelimitedtospecificstaffsuchasplantopsandsecurity
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ILSMchangesonthereport
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ILSMchangesonthereport
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Perspective…
z Youarebeingevaluatedon(HAP)…§ 156EP’s–EC§ 193EP’s–LS§ 112EP’s–EM
z So…usingonlyECandLS–youarebeingevaluatedon349EP’s….!z Keepthingsin‘perspective!’
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SAFERMatrix
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Immediate Threat to Life (follows current ITL processes)
Like
lihoo
d to
Har
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Pa
tient
/Vis
itor/S
taff
HIGH
MODERATE
LOW
LIMITED PATTERN
Scope WIDESPREAD
SurveyAnalysisForEvaluatingRisk(SAFER)Matrix
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SAFERScoringExample:LSChapter
• STANDARD/EP: LS.02.01.30, EP2 • OBSERVATION: In the laboratory storage room G111 was greater than fifty square feet in size and it contained combustible materials. The door serving this store room was not equipped with a door closure device. During the survey engineers installed a door closure device on this door.
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Immediate Threat to Life Li
kelih
ood
to H
arm
a P
atie
nt/S
taff/
Visi
tor
HIGH
MODERATE
LOW
LIMITED PATTERN WIDESPREAD
Scope
Wheredoesthefindingbelong?
Basedontheoperationaldefinitions,pleaseplacethefindingintheareaoftheSAFERmatrixyoubelieveitgoes.
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Rationale
z Policiesrequireroomsstoringcombustiblematerialstohavesecureclosuredevice.Theroomcontainedpotentiallydangerousmaterialsthatcouldcauseharmdirectly,butwouldbemorelikelytocauseharmasacontributingfactorinthepresenceofothercircumstancesoradditionalfailures;therefore,“Moderate”likelihoodtoharm
z Thedoorclosuredevicefor1storageroomdidnotcomply.Thisappearstobeauniqueoccurrence,notrepresentativeofroutineorregularpracticethus“Limited”inscope
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Label Definition
WIDESPREADDeficiency is pervasive in the facility, or represents systemic failure, or has the potential to impact most/all patients, visitors, staff (5 or more)
PATTERNMultiple occurrences of the deficiency, or a single occurrence that has the potential to impact more than a limited number of patients, visitors, staff (3 or 4)
LIMITEDUnique occurrence that is not representative of routine/regular practice, and has the potential to impact only one or a very limited number of patients, visitors, staff (1 or 2)
Scope
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Label Definition
HIGH Harm could happen at any time
MODERATE Harm could happen occasionally
LOW Harm could happen, but would be rare
LikelihoodtoHarm
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Example:SAFERMatrixwithinReport
Immediate Threat to Life
Like
lihoo
d to
Har
m a
Pa
tient
/Vis
itor/S
taff
HIGH MM.03.01.01, EP8 MM.03.01.01, EP7
MODERATE
MS.01.01.01, EP5 PC.01.02.01, EP4 PC.01.02.03, EP6 PC.01.03.01, EP1 PC.01.03.01, EP5
IM.02.02.01, EP3 MS.08.01.01. EP1 MS.08.01.03, EP3
IC.02.01.01, EP2 IC.02.02.01, EP4
LOW
RC.01.01.01, EP19 RC.02.03.07, EP4
LIMITED PATTERN
Scope WIDESPREAD
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SurveyAnalysisforEvaluatingRisk(SAFER)Matrix™-AggregateHOSPITALResultsforEntire2017
Immediate Threat to Life All Standards 0.37%
EC 0.22% LS 0.00%
Like
lihoo
d to
Har
m a
Pat
ient
/Sta
ff/Vi
sito
r
HIGH All 1.54% EC 1.04% LS 0.21%
All 1.65% EC 1.57% LS 0.23%
All 1.56% EC 2.49% LS 0.13%
MODERATE All 16.53% EC 14.10% LS 7.87%
All 12.88% EC 12.32% LS 5.78%
All 4.37% EC 3.89% LS 1.10%
LOW
All 42.05% EC 40.94% LS 65.72%
All 15.17% EC 18.42% LS 16.83%
All 3.87% EC 5.00% LS 2.14%
LIMITED PATTERN WIDESPREAD
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SurveychangesduetoSAFER
z NomoreDirectandIndirectEPdesignationsq ConsolidatedESCintoone60-daytimeframe
z NomoreAorCcategoriesq NomoreOpportunitiesforImprovement(OFIs)q *NomoreMeasuresofSuccess(MOS)
z Seeit/CiteitSurveyMethodologyàMoreFindings
*Note:ThisdoesnotapplytoSentinelEventswhereaMOSisrequired.Atthistime,thesubmittalofaMOSforSentinelEventsisstillrequired.
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Top10Findings:MostChallengingStandardsEnvironmentofCare(EC)and
LifeSafety(LS)Chapters
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Standard 2017 2016 2015LS.02.01.35 86% 51% 46%EC.02.05.01 73% 57% 58%IC.02.02.01 72% 60% 59%LS.02.01.30 72% 50% 50%EC.02.06.01 70% 68% 62%LS.02.01.10 66% 48% 45%EC.02.02.01 63% 47% 39%EC.02.05.05 62% 18% 12%LS.02.01.20 62% 49% 51%EC.02.05.09 59% 29% 30%
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Standard 2017Rank
%Non-compliant EP Summary
LS.02.01.35TheHospitalprovidesequipment
forextinguishing
fires
1
59% 4Managesystemsforextinguishingfiresincludingtheintegrity(nothingsupportedbysprinklerpiping,missingescutcheons)
41% 5Sprinklerheadsarenotdamaged.Theyarefreeofcorrosion,foreignmaterials,paint,andhavenecessaryescutcheonplatesinstalled
34% 14Otherissues,including:blockedaccesstofireextinguishers(Wildcard)
MostCitedStandards,2017-#1
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LS.02.01.35–EP-4-Sprinklerpipingsupportsnothingelse.
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LS.02.01.35–EP-4-Sprinklerpipingsupportsnothingelse.
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LS.02.01.35–EP-4-Sprinklerpipingsupportsnothingelse.
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LS.02.01.35–EP-4-Sprinklerpipingsupportsnothingelse.
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Standard 2017Rank
%Non-compliant EP Summary
EC.02.05.01TheHospitalmanagesrisksassociated
withitsutilitysystems
2
45% 8 Labelsutilitysystemcontrolstofacilitatepartialorcompleteemergencyshutdowns
40% 15
IncriticalareastheorganizationmanagesriskassociatedwithUtilitySystems,includingPressurerelationships,Filtration,AirExchanges(ach),andTemperatureandHumidity
25% 16Innon-criticalareastheorganizationmanagesriskassociatedwithUtilitySystems,includingPressurerelationships,TemperatureandHumidity
MostCitedStandards-#2
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EC.02.05.01EP15CriticalPressureRelationships
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MostCitedStandards,2017-#4
Standard 2017Rank
%Non-compliant EP Summary
LS.02.01.30TheHospitalprovidesand
maintainsbuildingfeaturestoprotectindividualsfromthehazardsoffireand
smoke
4
38% 3 Buildingandfireprotectionfeatures:ExistingHazardousAreas
32% 18 SmokeBarrierintegrity
30% 11 Corridordoors
20% 19 Smokebarrierdoors
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LS.02.01.30
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Standard 2017Rank
%Non-compliant EP Summary
EC.02.06.01Thehospitalestablishesandmaintainsasafe
andfunctionalenvironment
566% 1
Safeenvironment,includingligaturerisks,stainedceilingtiles,mismanagedpullcords
13% 26 Furnitureandequipment
LS.02.01.10Buildingandfire
protectionfeaturesaredesignedand
maintainedtominimizetheeffectsoffire,smokeandheat.
6
39% 7 Buildingandfireprotectiongeneralrequirements:Fire-rateddoor
38% 10(now14)
Buildingandfireprotectiongeneralrequirements:BarrierPenetrations
MostCitedStandards,2017-#5
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EC.02.06.01–notconsidered‘art’
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LS.02.01.10–EP-14–BarrierPenetrations
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LS.02.01.10–EP-14–BarrierPenetrations
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LS.02.01.10–EP-14–BarrierPenetrations
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LS.02.01.10EP7,nowEP11RatedDoor
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LS.02.01.10EP7,nowEP11RatedDoorSelfClosing–Nowedges!
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LS.02.01.10EP7,nowEP11UndercutsRatedDoor:(<3/4”)
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Standard 2017Rank
%Non-compliant EP Summary
EC.02.02.01TheHospitalmanagesrisks
relatedtohazardousmaterialsandwaste
742% 5 Minimizeriskswithhazardouschemicals
26% 12 Hazardousmaterialsandwastelabeling
EC.02.05.05TheHospital
inspects,testsandmaintains(ITM)utilitysystems
8
52% 6 ITMofnon-highriskutilityequipment
12% 5 ITMofinfectioncontrolutilityequipment
MostCitedStandards,2017-#7
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Standard 2017Rank
%Non-compliant EP Summary
LS.02.01.20TheHospitalmaintainsthe
integrityofthemeansofegress
932% 11 Meansofegressclearandunobstructed
18% 1 Lockingarrangements
EC.02.05.09TheHospitalinspects,testsandmaintainsmedicalgasandvacuumsystems.
10
37% 6 Medicalgascylindermanagement
25% 5 Medicalgasshutoffvalveslabeledandaccessible
MostCitedStandards,2017-#9

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LS.02.01.20EP11CorridorClutter
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LS.02.01.20EP-11-StairwellStorage
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EC.02.05.09-MedGasStorage
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CMSTop10z Top10DisparateLSCCategoriesforallProgramTypesandAO’s
q Fire/SmokeBarriersq Sprinklersq HazardousAreasq Electricalq Doorsq FirePlanq EmergencyLightsq Constructionq FireDrillq HVAC
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EmergencyManagementUpdate(EM)
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EM:ConclusionsfromEmergencies
z MajorIssuesBegantoSurface:q ProblemswithCommunication
q Inadequateemergencygeneratorbackup
q FaultyIncidentCommandSystems
q LackofInvolvementwithEmergencyOperationsCenter(EOC)
q Theextentofanorganization’splanningisdictatedbytheimpactoftheirworstrecentdisaster
z TJCcreatesEMChapter
z CMScreatesFinalRule,2016
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EmergencyManagement
EmergencyProgramEM.01
Planning&Leadership
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ChapterOutline
z FoundationfortheEmergencyOperationsPlan[EM.01.01.01]
z TheEmergencyOperationsPlan(EOP)q GeneralRequirements[EM.02.01.01]q SpecificRequirementsq SixCriticalAreas[EM.02.02.01-EM.02.02.11]q DisasterVolunteers[EM.02.02.13-EM.02.02.15]
z Evaluationq Evaluatingtheplanningactivities[EM.03.01.01]q EvaluatingtheEmergencyOperationsPlanthroughexercises[EM.03.03.03]
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EM.01.01.01
z Hazardvulnerabilityanalysis(HVA)q Documented
z Identifypotentialemergenciesq Withintheorganizationandcommunity
q Affectondemandforservices
q Abilitytoprovideservices
q Likelihoodofoccurring
q Consequences
q Sitespecific:oneormany
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EM.01.01.01-HVA
z HazardVulnerabilityAnalysis(HVA)q Documentedinventoryofresources&assets,notlimitedtothefollowing:
§ Fuel
§ PersonalProtectiveEquipment(PPE)
§ Water
§ Medical/surgicalsupplies
§ Medication
§ Other
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EM.01.01.01-CommunityEngagementz DeterminewhichcommunitypartnersarecriticaltohelpingdefineprioritiesinitsHVAq Communitypartnersmayinclude
§ Otherhealthcareorganizations§ Thepublichealthdepartment§ Vendors§ Communityorganizations§ Publicsafetyofficials§ Publicworksofficials§ Representativesoflocalmunicipalities§ Othergovernmentagencies
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EM.02.01.01
z Thehospital’sEmergencyOperationsPlan(EOP)isdesignedtocoordinatesixfunctionalareasduringanemergency
z SeeStandardsEM.02.02.01-EM.02.02.11:q Communications
q Resourcesandassets
q Safetyandsecurity
q Staffresponsibilities
q Utilities
q Patientclinicalandsupportactivities
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EM.03-PlanningEvaluation
z Conductannualreviewsq Hazardvulnerabilityanalysis(HVA)
q ObjectivesandscopeoftheEOP
q Inventoryofresourcesandassets
q Eachdocumented
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EM.03-Exercises
z Foreachsitethatoffersemergencyservicesorisacommunitydesignateddisasterreceivingstationq Atleastoneofthetwoincludesaninfluxofsimulatedpatients
q Tabletopsnotpermitted
q Canbeconductedwithescalatingeventsandcommunity-wideexercises
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New–EM.04.01.01
z Deemedstatuspurposesonly
z Optionalforallsettings
z Appliestoorganizationsthatchoosetobemembersoftheirsystems’integratedEMprogram.
z Newstandardwith3EPs
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JanuaryandMarch,2018ElementsofPerformanceRevisionsand
Modifications
AlignmentwithCMSK-tagsBasedonNFPA101-2012andNFPA99-2012
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Standards and EP Production for CMS LS / EC - K-Tags!
Standards Production, K-Tags: DSSM Sept. 02, 16 – March 29, 2017
CMS Review Process!March 31, 2017 – February, 2018
Field notification, non-deemed programs !July, 06, 2017–Dec. 20, 2017
K-Tags, etc. PUBS - schedule, Pt. 2 July 24, 2017–Dec. 22, 2017
Final EP’s Release Date!
March, 2018
Finish!March, 2018
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HowManyEPsweretouched
Chapter NEW MOVED REVISED REVISED & MOVED DELETED
EC 29 31 22 8 0 LS 49 86 15 39 4 TOTALS 78 117 37 47 4
TOTAL EP's Touched 283
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LS.02.01.30EP-12(wasEP-11)
z Innewbuildings,allcorridordoorsareconstructedtoresistthepassageofsmoke,….
z Positivelatchinghardwareisrequired.Rollerlatchesareprohibited.
z NFPA101-2012:18.3.6.3.1;18.3.6.3.5;18.3.6.4;18.3.6.5;18.3.6.3.10;18.3.6.3.11)
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LS.02.01.30EP-13(wasEP-12)r–March,2018z Inexistingbuildings,allcorridordoorsareconstructedtoresistthepassageofsmokeand….(NoChange)z Note:Forexistingdoors,itisacceptabletouseadevicethatkeepsthedoorclosedwhenaforceoffivepoundsisappliedtotheedgeofthedoor.
z Poweredcorridordoorsareequippedwithpositivelatchinghardwareunlesstheorganizationcanverifythatthisequipmentisnotanoptionprovidedbythedoormanufacturer.Ininstanceswherepositivelatchinghardwareisnotanavailableoptionprovidedbythemanufacturer,thedeviceusedmustbecapableofkeepingthedoorfullyclosedwhenaforceof5poundsisappliedatthelatchedgeandinanydirectiontoaslidingorfoldingdoor,whetherornotpowerisappliedinaccordancewithNFPA101-2012:19.3.6.3.7.
z (continued…)
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LS.02.01.30EP-13(wasEP-12)r–March,2018page2
z Note2:ForhospitalsthatuseJointCommissionaccreditationfordeemedstatuspurposes:Doorstotoiletrooms,bathrooms,showerrooms,sinkclosets,andsimilarauxiliaryspaces(exceptpantries)thatdonotcontainflammableorcombustiblematerialsarenotrequiredtohaveadevicecapableofkeepingthedoorfullyclosedifaforceof5poundsisappliedatthelatchedge.Inthesecases,rollerlatchesonthesedoorsthatkeepadoorclosedwhenaforceof5poundsisappliedarepermissible.
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PhysicalEnvironmentasaPriority
z Theneedsoftheorganizationcannotbemetifthephysicalenvironmentfails
z Facilitiesstaffmustunderstandthecurrentphysicalenvironmentrequirements,whichmaybedifficulttoachievewiththecurrentbuildingtechnologies
z FacilitiesmustpartnerwithLeadershipinmanagingtheinfrastructure
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Legionella–quickly….
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Legionella
z Ref:S&C17-30-Hospitals/CAHs/NHs
z June02,2017
z Training:September22,2017
z ArticleinECNews–Sept2017–startingonpage6
z EC.02.05.01
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LIGATUREUPDATE
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LigatureUpdate
z ScoredatEC.02.06.01–EP-1z StartwithRiskAssessment
q Riskassessment=CLD,maybeq NoRiskAssessment=ITL
§ Minoritemsnotscoredifappropriateriskassessment(suchastoiletseat,showercurtain)
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LigatureUpdate
z Assureriskassessmentconducted
z Actiontoimplementplan
z Citeallligaturerisksz Guidancedocuments….
z Seealso2014FGIGuidelines
§ ReferencedatEC.02.06.05EP1
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LigatureRisks–OtherReading
z CMSS&Cletter18-06,December08,2017z TheJointCommissionPerspectives
q FromtheExpertPanelMeetings:
q November,2017
q January,2018
q February,2018
q March,2018
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LigatureFacilityExtensionRequest(LEFR)z Ligature/Self-HarmRisksthatresultwithaConditionLevelfor
DeemedStatusorganizationswillreceiveaMedicareDeficiencyFollow-upSurvey(CLD01–MedDef)
z IfnotclearedattimeofMedDefaSecondaryMedDefwillbescheduled(AFS08)
§ Removed(permanentsolution)
§ Replaced
§ RiskAssessedandMitigated–wherepermittedonly
z Non-deemedmayresultinaAccreditationwithFollow-upSurvey(AFS)
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LigatureFacilityExtensionRequest-Introducing
PHASE 2 – COMING LATER 2018!Phase 2 will be used for Deemed and Non-Deemed Organizations!
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LigatureFacilityExtensionRequest-LFER
z SubmittedtoSIG-ClinicalandEngineeringforreviewandapproval
z Ifrejected,aconferencecallwillbecoordinatedtodetermineanacceptablePlanofCorrection/Mitigation
z EvidenceofStandardsCompliance(ESC)willbeacceptedbasedonaJointCommission“RecommendedforApproval”LFERforDeemedandaJointCommissionAcceptedSPFI/TLWforNon-Deemed.
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LigatureFacilityExtensionRequestz Deemed:Approximately1weekpriortotheSecondaryMedDefthe
AccountExecutivewillcontacttheHCOtodetermineisallligature/self-harmdeficiencieswillberesolved.§ Yes–SecondaryMedDefwilloccur
• Ifadditionalfindingsordeficienciesarenotcleared,MedDefprocesswillstartover(CLD01)
§ No–SecondaryMedDefPostponed(ValidationSurvey)
• AccountExecutivewillprovidetheHCO:• AttestationLetter:acknowledgingthattheyneedadditionaltimetoresolveligature/self-harmdeficiencies• Dueimmediately
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z StatementofConditions-Update
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StatementofConditions-Terms§ BBI:BasicBuildingInformation
§ SitesarepopulatedbyeApp(electronicapplication)
§ PFI:PlanForImprovement
§ Extensions
§ SPFI:Survey-RelatedPlanForImprovement
§ TLW:TimeLimitedWaiver
§ Equivalency:
§ TraditionalorFSES(FireSafetyEvaluationSystem)
§ LigatureFacilityExtensionRequest(LFER)
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StatementofConditions
z AllRFIswillhavea60dayESCfromthelastdayofsurvey.
z IfaNationalFireProtectionAssociation(NFPA)Code,physicalenvironmentdeficiencythatisscoredunderECorLScannotberesolvedwithinthe60dayESC,nolaterthan30daysfromthelastdayofsurveytheorganizationmustsubmitforaSPFIandaTLW.§ IftheorganizationisplanningonsubmittinganEquivalency,theSPFIandTLWmaybe
submittedpriortothesubmissionoftheEquivalency.Theorganization’sSPFIandTLWrequestshouldconsiderthetimetodevelopandapproveanequivalency.
§ OncetheJointCommissionapprovesanequivalencyitwillbedocumentedintheorganization’sHistory/AuditTrailandthensenttoCMSforapproval(ifapplicable).
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StatementofConditions
z TheorganizationdoesnotneedtohaveanapprovedSPFIorTLWfortheESCsubmission.Theyjustneedtobesubmitted.
z Follow-upsurveysneedtoeithershow:
q TheRFIhasbeencorrected
q AsubmittedSPFIandTLW
z TLWsandEquivalenciesareonlysenttoCMSfordeemedstatusHCOs
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TimeLimitedWaiver(TLW)
z ATimeLimitedWaiverisaprocesstoprovideadditionaltimetocompleteLifeSafetyChaptercorrectiveactions
z OrganizationsthatuseJointCommissionaccreditationfordeemedstatuspurposesaretofollowthisprocess:
§ CreateaSurvey-relatedPlanForImprovement(SPFI)
§ EntertherequesteddateintheScheduledCompletionDatefield
§ Whenprompted,completetheTimeLimitedWaiverform
§ SubmittotheJointCommission
z TheJointCommissionwillreviewandforwardtherequesttotheRegionalOfficeforfinaldecision
z Non-deemedorganizations:processsame,stopsatTJC
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CMS&Equivalencies
z OrganizationsthatuseJointCommissionaccreditationfordeemedstatuspurposes:Survey-relatedequivalencieswillcontinuetobesubmittedtoouroffices
§ TheEngineeringstaffwillworkwiththeorganizationsuntiltherequestisacceptablebybothTJCandCMSRO
§ CMSrequiresthatanexistingequivalencyberecitedandresubmittedatthetriennialsurvey.
August2016Perspectives
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Tools&Resources
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JointCommissionPhysicalEnvironmentPortal
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www.jointcommission.org/safer
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ReviewandConclusion
I T L
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Questions?
Kenneth A. Monroe, PE, MBA, CHC, PMP Director - Engineering
[email protected] (630) 792-5758
Tim Markijohn, MBA\MHA, CHFM, CHE Field Director
[email protected] (630) 792-5148
Jim Kendig, MS, CHSP, CHCM, HEM, LHRM Field Director
[email protected] (630) 792-5819
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TheJointCommissionDisclaimer
z Theseslidesarecurrentasof05/11/2018.TheJointCommissionandtheoriginalpresentersreservetherighttochangethecontentoftheinformation,asappropriate.
z Thesewillonlybeavailableuntil05/11/2019.AtthatpointTheJointCommissionreservestherighttoreviewandretirecontentthatisnotcurrent,hasbeenmaderedundant,orhastechnicalissues.
z Theseslidesareonlymeanttobecuepoints,whichwereexpoundeduponverballybytheoriginalpresenterandarenotmeanttobecomprehensivestatementsofstandardsinterpretationorrepresentallthecontentofthepresentation.Thus,careshouldbeexercisedininterpretingJointCommissionrequirementsbasedsolelyonthecontentoftheseslides.
z Theseslidesarecopyrightedandmaynotbefurtherused,sharedordistributedwithoutpermissionoftheoriginalpresenterandTheJointCommission.
