Regulatory Changes: 3 Frequent Survey Findings
As regulations change, one way to help ensure a successful survey is paying attention to findings at other facilities — particularly those in your region. If other hospitals are getting “dinged” for a particular deficiency, it’s only smart to preemptively address those same issues in your own hospital before a surveyor walks through your doors.
Of course, uncovering those findings isn’t so simple — at least not before survey outcomes become public
, as the CMS proposes. Having helped your peers through nearly 50 surveys in the past few months, we’ve noted survey patterns you should know about.
First, it’s worth noting there’s been a sharp jump in the number of findings in the last 12-18 months, in both clinical and physical environments, simply because the deficiency scoring is no more. Before, when surveyors found an issue and gave it a score, you could have up to two hits and still be compliant. That cushion is now gone. A hit is a deficiency, period. And surveyors are going as far as they need to uncover a finding.
Onto specific, frequent findings:
>> Air Pressurization and Air Exchange Rates
In 2016, air pressurization and exchange rates were huge. In a sense, they were automatic conditional deficiencies for CMS’ Conditions of Participation (CoPs), which are newly revised requirements for reimbursements. We’re talking simple misses like people pushing carts in front of med gas valves or electrical panels.
These things are easy to fix, but people forget surveyors are at the facility for three days, so you’ll have a tracer coming the first day. Everyone and everything is perfect, corridors are clear and pristine. Your staff thinks, “survey’s done in my area.” But guess what? Two days later, another surveyor has to walk through your department to get to another department and, as they do, someone’s moved a cart in front of an electrical panel, fire extinguisher, or med gas valve — those are three different elements of performance. And, remember, if they see just one issue, that’s enough for a finding.
These things are very simple but carry tremendous weight in your survey outcomes.
This year, ligature is the heavy hitter of regulatory surveys. Back in March, The Joint Commission came out with a focus on ligature as a way to reduce risks to patients who might harm themselves or others. To be clear, ligature refers to a hanging or choking point.
Earlier this year, we watched a surveyor take a piece of dental floss, hang it over a door hinge and say, “That’s a ligature point.” Every hospital across the country should be focusing on ligature risk assessments right now to reduce risks for strangulation.
>> ASHRAE 188
ASHRAE 188, which covers risk management for water systems, was developed primarily to counter the threat of legionnaires’ disease — a type of pneumonia caused by bacteria that lives in water. ASHRAE 188 has been another common weakness in recent surveys.
“It’s vitally important all buildings incorporate good design, operations and maintenance procedures that prevent growth and spread of Legionella,” said Michael Patton, member of the ASHRAE committee that developed the standard
. This, too, should be part of your facilities health assessment.
In addition to addressing these frequent findings, ensure your documentation is clear, organized, and easy to navigate when surveyors arrive. That alone will prevent surveyors from growing suspicious and investigating deeper when answers aren’t readily available. (We’ve written more on how documentation can help ensure a positive surveyor first impression here
More importantly, you can rest easier knowing patients are safe and have a positive experience under your care.
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