EC & LS for Clinical Managers
Top Scored & Other Hot Spots
Jennifer Cowel, RN MHSA
Speaker
Jennifer Cowel, RN MHSA
TJC Experience: Former TJC Hospital
Surveyor and former Director of Service
Operations in Accreditation in Central Office
 Accreditation and regulatory compliance
consultant
Vice President and Principal Patton
Healthcare Consulting
630-664-8401
JenCowel@PattonHC.com
Learning Objectives
• Why EC & LS are now top scored
• Explain how the length of survey changed for LSC
• Discuss three ways EC or LS can lead to an
Immediate Threat during survey
• Describe a short-cut to an adverse decision in LS
or EC
• Define the e-BBI, PFIs and ILSM
• Describe the top scored EC & LS standards
• Explain how clinical staff can help prepare
Balance of Power Shift
• In 1965 TJC was written into legislation and
granted “deemed” status
• In 2008 TJC was written out
• In 2009 TJC applied for and was awarded
deemed status by CMS, awarded for 3 years
– TJC cross-walked all CoPs to standards
– TJC added new requirements to meet
Why CMS Drives the Bus
Disparity Rate May
Findings
• Particularly with
–Life Safety Code
• An extra LSC day added to each
survey starting in 2011!
–Leadership (governing body)
–Double ding is back!
Scoring in 2010
• 4 of the top 5 scored standards were in EC or
LS in 2010
• In 2009 EC was the most scored chapter
• EC has 42 direct impact EPs
• LS has 37 direct impact EPs
LS Chapter Cheat Sheet
• Based on NFPA 101-2000 LSC
• Chapter Outline
– Administrative (LS.01.01.01)
– Interim Life Safety Measures (LS.01.02.01)
• Three types of occupancy
– Healthcare (LS.02.xx.xx)
– Ambulatory (LS.03.xx.xx)
– Residential (LS.04.xx.xx)
Definition of Occupancy
• CMS Changed the definition in 12/10
• No public notice from TJC about this yet
•
CMS definition is:
– If patients receiving medical treatment or services could potentially be incapable of selfpreservation during an emergency, and are provided with sleeping accommodations or
treatment and services on a 24-hour basis, the facility must be classified as a Health
Care Occupancy.␣
– If patients receiving medical treatment or services could potentially be incapable of selfpreservation during an emergency or receive anesthesia services, but are not provided
with sleeping accommodations or treatment and services on a 24- hour basis, the
component facility must be classified as a Ambulatory Health Care Occupancy.
CHANGES TO THE SURVEY IN 2011
Increase LSC Days
Perspectives, Nov. 2010
• Beginning in Jan.1, 2011
• Depending on hospital size 1 to 3 days will be
added
– >750,000 sq feet
– > 1.5 mil sq feet
– More than one inpt site= add a day
• Most likely, if you had a one day LSC last
survey, will get a two day LSC next
Increase LSC Days
Perspectives, Nov. 2010
• LSC surveyor to conduct the EOC system tracer
• More time for LSC review
• More time for education
Survey Process Preparation
• Before your next survey prepare for and/or
practice the following:
–
–
–
–
–
Day one documents – surveyor planning session
Environment of Care system tracer
Document Review session *
Emergency Management system tracer
LSC building tour *
Day 1 Documents
Documents needed day 1:
• Environment of Care (EOC) meeting minutes
past 12 months
• Six EOC management plans
• Annual evaluations for each plan
• Safety Committee minutes
• Performance Indicators (EC.04.01.01)
Day 1 Documents (cont)
• Statement of Condition documents (eSOC) including
any Plans for Improvement (PFI)
• Map of Organization (need compartment
drawings for the tour)
• Emergency Operating Plan, annual evaluation
and HVA
EOC System Tracer
•
•
•
•
Was conducted by clinical surveyor
Now conducted by LSS surveyor
Focus: discussion oriented
Discussion topic areas: chemical spills, medical
waste, infant security, medical equipment, OR
fire safety, Utility failures
Document Review Session
• “C” Element of Performance
– Show me the documentation
– Generally, they are looking back 12 months, but for EP’s that require
less frequent testing/maintenance, they can go back three years or
more
• If the documentation isn’t found quickly – you are scored
Time Frames Defined
• Intro to EC Chapter:
– Daily, weekly, monthly and quarterly are calendar
references
– Semi-annual is 6 months from the last occurrence
+/- 20 days
– Annual is 12 months +/- 30 days
Now That You Know…
fix it
• Options for managing self identified deficiencies in LS.02.xx.xx
– LS.04.xx.xx
– Correct it immediately
– Fix in 45 days in corrective maintenance – document it.
– If it takes >45 days, create a Plan for Improvement (PFI) in
your e-SOC
– Consider equivalency request to TJC
What is the SOC?
• The Statement of Condition (SOC) is required
•
by TJC, parts done on Joint Commission site,
includes:
• Basic Building Information – eBBI
• Plan for Improvement – PFI
• There are other parts!
What is the BBI?
• The Basic Building Information eBBI:
• Done online – part I of SOC
• Required for each healthcare and ambulatory facilities
on your eAPP
• Update is needed when you add new sites to your eAPP
• Look at it, part is pre-populated, other parts need your
input!
• Drives the length of your LSC survey
What is the PFI?
• The Plan for Improvement:
• Done online, part IV of the SOC
• Document PFIs on a regular basis when the deficiency
cannot be fixed within 45 days
• Includes start and end dates
• Failure to meet end date plus 6 months leads to
adverse decision
Short Cut to Trouble
• Immediate Threat to Life
• Situational Decision Rule
Immediate Threat to Life
Immediate
Threat
2
“Situational”
Decision Rules
3
Direct Impact
Indirect Impact
•It is the Joint Commission equivalent of
the “go directly to jail” card!
•Joint Commission believes there is
substantial noncompliance issues that have
caused or could cause harm/death to
patients or staff.
•ITL called, your accreditation status
changes to Preliminary Denial of
Accreditation (PDA) overnight!
Immediate Threat to Life
Immediat
e
Threat
2
3
“Situational”
Decision
Rules
Direct
Impact
Indirect
Impact
•EC & LS examples from Perspectives,
conferences, other communications:
– One single issue or a
combination of observations:
– Inoperable fire alarm system
– Inoperable or unreliable fire
pump
– Inoperable Medical Gas System
or alarms
– Negative pressure rooms not
working
– Generator tests failed, not fixed
Immediate Threat to Life
Immediat
e
Threat
2
3
“Situational”
Decision
Rules
Direct
Impact
Indirect
Impact
•EC & LS examples cont:
– Utility system: main circuit
breaker not tested or
maintained
– Raw sewage leaking from pipes
in basement
– No way to transmit fire alarm
signal to local fire department
– No emergency exit and no ILSM
to compensate
Situational Decision Rule for LS
Immediate
Threat
2
“Situational”
Decision Rules
3
Direct Impact
Indirect Impact
• Short cut to AFS or PDA
• AFS13 Defined:
o
The hospital did not complete
corrective action identified in
your PFI in a timely fashion or
failed to implement ILSM
In plain English:
o
Busted plan - Failure to
implement corrective action in
e-SOC review PFI
o
Failed ILSM
Busted Plan Defined
• If you do completed a PFI, you did not request
and extension and you are more than 6
months past the due date, and the surveyor
has “accepted” your eSOC: this is a “busted
plan”
• Results in adverse outcome, identified day one
of survey!!!
• Review your own PFIs regularly!
ILSM in Brief
(LS.01.02.01)
• Interim Life Safety Measures (ILSM): The hospital
protects occupants when LSC is not being met &
during construction
– Applies to LSC deficiencies
– Applies to both construction and other nonconstruction repairs.
– Applies to issues identified on your PFI. Ask to
see these!
– Many ITL could be avoided if ILSM was
implemented
ILSM in Brief
(LS.01.02.01)
• Interim Life Safety Measures (ILSM):
– Hospital needs an ILSM policy
– The policy must have criteria
– The criteria are used to assess deficiencies and
identify the need for ILSM
– Ask for your criteria, ask to see the paper work
showing ILSM was evaluated for construction and
for PFIs
Top Scored EC & LS Standards
• Surveyors see these everywhere, low hanging fruit
• These are seen by both the LSC surveyor and the
clinical surveyors
• Prevent them from seeing these at your organization
and create an impression on day 1
Exits and Cluttered Corridors
(LS.02.01.20 -50% in ‘10)
Hospital maintains means of egress:
• Blocked or locked egress doors
• Corridor clutter, storage in hallways
• Cart on Wheels can be plugged in but not
parked for >30 minutes
• Crash carts are considered “in use”
• Isolation carts outside occupied room also
considered “in use”
34
Exits and Cluttered Corridors, cont
• LS code requires 2 exits per story
• If exit is blocked, you need ILSM and an
alternative exit for staff
• Exit discharges to outside uneven surface
or obstructed (EP8)
• Exit signs – burned out, enough, proper
location
• “No Exit” signs posted
35
Fire Protection Features
(LS.02.01.10 - 44% in ‘10)
Building & fire protection features minimize the
effects of fire,
smoke and heat.
– Fire and smoke doors labeled, correct type, close,
label visible, under cut, door gaps
– Penetrations are sealed with correct material – IT
cables biggest offender. Consider a “bounty”
system!
36
Fire Doors, cont
• Inspect and maintain fire doors
– Appropriate fire rating on doors
and frame
– Door positively latches
– Door had a closure
– No gaps > 1/8 inch, or
undercut
>3/4 inch
– Resulted in ITL if multiple problems
Rated Doors (cont.)
• Must have legible labels on the door and
jambs. Options available:
– Scrap off the paint!
– Have third party testing agency re- label doors
– Implement ILSM, or
– Request equivalency from TJC
Penetrations –
Seal with Fire Stop
• If there are cracks or gaps then it is to be
removed and repaired using current
technologies
• TJC does not accept the expanding foam used
for insulation in any fire or smoke barrier – not
UL rated & toxic
Fire Protection Equipment
(EC.02.03.05 – 38% in ‘10)
Hospital inspects, tests & maintains fire safety
equipment.
 Has resulted in ITL!
 Includes inspection, testing and maintenance of: fire
alarms boxes, smoke detectors, sprinklers, portable
extinguishers, magnetic release devices, tamper
switches & water flow devices.
 If outsourced to a vendor keep the report, read the
report and act on problems!
 Make sure reports are tied to an inventory of devices
40
Fire Extinguisher Dating
(EC.02.03.05 EP 15)
 Month, day, year and initials of inspector
required per NFPA 10-1998
 They will review the tag
 If bar coded, they will review documentation
 Required monthly
41
LS -Maintain Building Features
(LS.02.01.30 – 37% in ‘10)
Building features are provided and
maintained to protect individuals from fire
and smoke
– Label all Hazardous Areas (such as boiler rooms, laboratories, O2
tank supply rooms)
– Limit access to hazardous areas
– Education to staff with access
– Smoke dampers
– Corridor doors that do not latch properly
– Smoke doors with gaps > 1/8 inch, >3/4 inch undercut
42
Provide/Maintain Fire Systems and Equip
(LS.02.01.35 EP6)
Sprinklers
• 18 inch rule
• Sprinkler pipes can not support other items
like cables or wires
• Sprinkler head clean and free of obstruction,
collar flush
Defibrillators: FAQ
(EC.02.04.03)
Q. Are defibrillators considered life support
equipment?
A. Yes. examples include: ventilators, heartlung bypass machines, defibrillators, AED.
①
②
③
Must be on your inventory of medical equipment
Maintenance per manufacturer instructions
You are scored per your policy
44
Emergency Power
(EC.02.05.07 – 26%)
Inspect, test, and maintain emergency power
systems… battery powered lights, generators,
automatic transfer switches
• Has resulted in ITL decision
Emergency Power, cont.
• Make sure generator testing done per
standard
• Retest after a fix to ensure is passes eg the 4
hour generator test
• Inspect, test, maintain transfer switches
• If testing is outsourced to vendor keep, read
and act on reports!! Leaders need to be
notified when there are problems.
Safe, Functional Environment
(EC.02.06.01 – 20%)
• Areas scored here: furnishing and equipment are in good
repair, the environment meets needs of patient.
• Ripped mattresses, cracked ceiling tile, mold, broken
wheel chair
• In behavioral health units do environmental risk
assessment for suicide risks. Either fix or implement
other safety interventions such as increase monitoring.
Document and keep your risk assessment. ( or scored at
EC.01.01.01)
Medical Gas
(EC.02.05.09 – 20%)
• Test & inspect & maintain medical gas
and vacuum per policy
• Get vendor reports, fix problems
noted
• Gas shut off valves must be labeled
with rooms they shut off. Staff must
know who can shut these off and
when.
• Alarms must be working. Has led to
ITL
Safety and Security
(EC.02.01.01 – 15%)
Hospital manages safety and security risks
• Complete risk assessments on areas of potential risk
• Scored in sensitive areas such as Labor and Delivery,
Pediatrics
• Trace your own policies, do staff stop you or surveyor
when they enter area?
• See unsecured O2 scored here JKC
Strategies for Success
Preparing Clinical Areas
• Rollout the Clinical Area Checklists
– Email them out, assign, implement, collect them
back, analyze compliance
•
•
•
•
Involve/educate clinical & frontline staff
Everyone knows who to call to get fixed
Identify areas to improve, fix it, then reassess
Make LS an every day expectation!
Strategies for Success
Do Mock Surveys
• Conduct mock tracers in clinical areas
• Do EOC System Tracer during your Mock
survey
– Use the documentation checklist
– “show me where this is documented”
– Look for missing dates, think medication
refrigerators when doing this!
Strategies for Success
Mock Surveys cont.
• Validate:
– Inventory of fire alarms, strobes exists for each test
– Generator testing documentation
•
•
•
•
Tests every 20 – 40 days
Checks of each transfer switch
Monthly test done and documents full 30 min
What was the percentage load of the generator capacity on each
test
– Documentation of safety inspection for each patient care
unit 2x/year?
Strategies for Success
• Review your eSOC quarterly for updates,
completion of projects
• Validate that ILSM evaluations exist on paper
for each PFI on the eSOC
• Work with facilities staff and learn the
language
Strategies for Success
• Make use of the PPR to document compliance
– Record the name and location of each report that
documents compliance
– Helps during on-site survey!
• When in doubt, get clarity from SIG
QUESTIONS?
JenCowel@PattonHC.com
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