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TJC: Revised Survey Process and Tougher Job for LSC Surveyors

Analysis  |  By A.J. Plunkett  
   November 18, 2020

With CMS approval, surveys for initial accreditation to participate in Medicare resumed in May, as they could be done virtually—offering the greatest protection against COVID-19, and less pressure and interference for organizations already in the throes of patient surge.

This article was originally published November 18, 2020 on PSQH

Expect The Joint Commission (TJC) to get tougher on water management and infection control, preconstruction risk assessments, workplace violence protections, and kitchen safety.

Don’t be surprised if TJC Life Safety Code®(LSC) surveyors go into places you may not have seen them venture into in years past. The same goes for clinical surveyors, who literally may be getting up in your kitchen—and possibly in the kitchens of any on-site commercial food service if it serves patients or residents.

During one of the ever-popular sessions at the American Society for Health Care Engineering (ASHE) annual conference, top TJC executives reviewed problems and solutions, and offered a rundown of what facility and compliance managers can look forward to during upcoming surveys.

That will include a new water management standard, potential new workplace violence standards, and perhaps revisions to emergency management requirements. In addition, the Environment of Care orientation session is being eliminated, with elements moved to other areas of the process.

Originally scheduled for September, the live ASHE conference was canceled and moved to an all-virtual platform held October 5–7 due to the coronavirus pandemic, which also put a hold on surveys in mid-March.

With CMS approval, surveys for initial accreditation to participate in Medicare resumed in May, as they could be done virtually—offering the greatest protection against COVID-19, and less pressure and interference for organizations already in the throes of patient surge.

Survey visits increasing

TJC started slowly, doing only 38 virtual surveys in May. Then as patient surge came under control in some areas, they conducted 96 more on-site surveys. Finally by September, the number of on-site visits was up to 386, said Tim Markijohn, MBA/MHA, CHFM, CHE, field director for LSC surveyors.

The first week of October alone, TJC had already done 152 surveys on-site and 130 virtually, said Markijohn, and they were expecting to ramp up even more in November and December.

As TJC has indicated in the last few months, they are using several factors to determine whether to conduct an on-site visit, he said. That includes when a facility is due for triennial survey, whether the organization is actively caring for a surge of COVID-19 patients, and whether it is safe to send surveyors into that region.

TJC developed an online dashboard, available to the public, to determine the most recent infection rates in a county or city and evaluate who is ready for survey, Markijohn said. That tool, dubbed the COVID Community Prevalence Dashboard, crunches information from a variety of sources to show a community’s infection rate within two weeks.

The tool can be found under the Resources tab on the top right of TJC’s main page, then clicking on the Research link on the left, then clicking on Operations Support Research, and finally scrolling down to the COVID dashboard link. The dashboard will give you some of the same information that TJC is using to determine if it will show up for survey, which will still be largely unannounced as required by CMS.

However, TJC won’t share what thresholds they use to determine when infection rates are too high, Markijohn said—in part because the thresholds keep changing as COVID-19 surge continues to fluctuate across the country.

Before anyone arrives, your TJC account executive should be reaching out to discuss the state of your organization’s response to the public health emergency (PHE), if you have your Emergency Operations Plan (EOP) activated, and how many COVID-19 patients you are currently treating. TJC has also encouraged hospitals and other organizations due for survey to contact their account executive if they are experiencing a patient surge.

When surveyors do arrive, expect a discussion about your hospital’s response to the PHE to be among the first items on the agenda. That will include whether your organization has activated its EOP and, if so, whether you’ve accepted or implemented any of the CMS 1135 waivers that provide flexibility on several Life Safety and Environment of Care requirements.

The 1135 waivers, which are available only during the COVID-19-related PHE, allow hospitals to delay such things as regular fire drills, inspection, testing and maintenance (ITM) on some non-critical systems, more alcohol-based hand rub dispensers needed to ensure infection control, and certain requirements in temporary care locations.

ITM of critical systems such as emergency generators, portable fire extinguishers, and fire suppression and response systems is not included in the waivers.

First declared retroactive to March 1, the PHE has been extended for 90-day periods, most recently through January 21, 2021.

“We want to know what impact COVID has had on your organization, so that we know whether or not the waivers are appropriate for your organization, and if so, have you accepted those,” said Markijohn.

TJC and others have warned that once the PHE is lifted, the waivers will no longer be allowed and hospitals will be responsible for catching up to the needed ITM and documenting its completion.

Markijohn stopped short of encouraging hospitals to continue with ITM of noncritical systems, but he noted that, based on information gathered in the field, “most organizations have continued to do the inspection, testing and maintenance that they did before the public health emergency.”

Be prepared to show when your EOP was activated, what waivers you chose to take advantage of, and your plan for catching up to ITM not done during the PHE.

Where will you see LSC surveyors, and for how long?

While much of your on-site survey will look like pre-pandemic surveys, there are changes.

For instance, TJC has expanded the role of the LSC surveyor. Previously, clinical surveyors visiting off-site emergency departments or hospital-based ambulatory surgical sites also checked for LSC problems. Now, to allow the clinical surveyors to focus on quality of care, the LSC surveyors will also visit those sites. And that could mean the LSC surveyor will be around an extra day for each freestanding emergency department or ambulatory surgical center.

The number of days the LSC surveyor is on-site is already dependent on the square footage to be surveyed. Be aware that the square footage the facility manager or a consultant may come up with could be different from the determination of the surveyor, warned Jim Kendig, MS, CHSP, HEM, CHCM, LHRM, field director for LSC surveyors.

“Any space that serves a patient or resident—‘resident’ is typically a nursing home resident—any space that serves a patient or resident needs to be surveyed by the Life Safety Code surveyor,” said Kendig.

That could include a building that houses a service for patients, but not the patients themselves.

“In your POB (your physician office building) or in your MOB (your medical office building), if you have your lab, your laundry, your kitchen, or anything along those lines, we’re going to go in and survey that space because it serves a patient or resident,” Kendig said.

“Similarly, if you have a McDonald’s or Subway in the main lobby as part of your healthcare occupancy, if we see patients or residents receiving services from that, we will survey that space.”

Once on-site, an LSC surveyor will calculate the square footage of all the healthcare occupancies and any of the business occupancies that serve patients. The LSC survey will be two days if that calculation remains under 1 million square feet, but anything over that adds a day, said Kendig. That is in addition to the time added for LSC surveys at the freestanding emergency departments or ambulatory surgical centers.

What else will surveyors be looking for?

That kitchen in the business occupancy or lobby won’t be the only kitchen to get increased scrutiny.

There is a new kitchen tracer checklist that has been expanded from two to three pages—two pages for the clinical surveyor to check and another page for the LSC surveyor, said Kendig.

He suggested using the checklist to review your facility’s compliance, adding that you can reach out to him or Markijohn for a copy.

Also get a copy of NFPA 96-2011, Standard for Ventilation Control and Fire Protection of Commercial Cooking Operations. Kendig noted two areas in the kitchen that LSC surveyors said continue to confound compliance managers.

One is a requirement that deep fat fryers be installed with at least 16 inches of space between the fryer and any nearby surface flames from adjacent equipment.

Kendig reminded facility managers that the only exception to that is when there is at least an 8-inch high steel or tempered glass baffle between the fryer and the surface flames.

Also, anytime staff move cooking equipment, they should be careful to return it to its appropriate place under the overhead fire suppression nozzle, according to the location design, warned Kendig.

NFPA 96-2011, section 12.1.2.3.1 requires there to be an “approved method” to returning the equipment to the exact spot, noted Kendig, illustrating the point with a photo of permanent wheel chocks to indicate where the equipment rests.

However, wheel chocks are not required specifically. Kendig, who has experience in hospital facility management, said he would use an “L” marked on the floor to indicate equipment positioning.

Other survey changes upcoming

TJC is also revising other parts of the survey process for Life Safety (LS), Environment of Care (EC), and Emergency Management (EM) standards:

  • Look for a new pre-construction risk assessment checklist, which is currently being developed along with Sylvia Garcia-Houchins, MSN, RN, CIC, director of infection prevention and control.

That means TJC will be focusing more than ever on infection control in the environment of care.

Remember that TJC surveyors will want to go to the construction and renovation sites on day one, as soon as possible, said Kendig.

Among other things, they will be looking for the appropriate pressure relationships to maintain infection control and whether the means of egress are clear, he said.

  • The questions for the Basic Building Information (BBI) component of the electronic Statement of Conditions have been updated, but are awaiting upload by TJC’s information technology department, said Kendig.

The BBI was revised with the help of the LSC surveyors who were asked what questions to include. Those changes will be available, hopefully, in 2021, said Kendig.

Under element of performance (EP) 7 of LS.01.01.01, under which hospitals are required to manage the physical environment to comply with the LSC, hospitals are also required to keep their BBI up to date.

  • As of January 2021, there will be no formal opening EC session, said Kendig. Instead, elements of that session will be folded into three other parts of the survey process.

First, the LSC document checklist has now been expanded to include some EC elements, said Kendig. That is likely to lengthen the LS document review session, he noted.

Second, some elements of EC have been added to the LS building tour. They will be part of the document review checklist.

And finally, on the advice of some of the clinical surveyors, the EC elements in radiology and CT areas will be handed over to the physician or nurse surveyors on the team. The clinical tracers are being updated to include those EC elements, said Kendig.

Look for those updates to be included in the January 2021 Survey Activity Guide, he said.

  • TJC is also looking at revising the EM session as well as instituting some interim EM standards for the duration of the PHE. There is also a review overall of the EM standards and EPs, said Kendig.

He did not review what those changes might be, but said the hope was to have the revisions in proposal stage by July 2021 with a goal of implementation in 2022.

The changes will likely increase the EM session from 60 minutes to 90 minutes, he said.

  • As previously announced, deficiencies related to ligature risk and patient self-harm will longer be scored under EC.02.06.01, the catch-all standard that requires a “safe and functional environment.”

Instead, problems will be scored under National Patient Safety Goal 15.01.01.

  • TJC is concerned about escalating problems with workplace violence in healthcare and is exploring a new standard specifically about ensuring workplace safety against violence.
  • And finally, TJC is in the final review stages of a new standard on water management focusing on mitigating risk of the spread of infectious diseases such as Legionnaires’ disease.

That could be implemented as soon as July 2021.

A.J. Plunkett is editor of Inside Accreditation & Quality, a Simplify Compliance publication.

A.J. Plunkett is editor of Inside Accreditation & Quality, a Simplify Compliance publication.


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