In recent weeks, we’ve learned that The Centers for Medicare & Medicaid Services (CMS) adopted the 2012 Life Safety Code® (LSC) and published an amendment effective July 5, 2016. The Joint Commission (TJC) in turn announced that they had also adopted the 2012 LSC.

Read more about these changes: CMS Proposes Updated Life Safety Code

However, the CMS K Tags (documents that guide the survey process) have not been updated yet, and TJC standards have to be revised within 60 days from the date the CMS rule was published in the Federal Register (August 8, 2016). Hospitals have a brief reprieve as they study the changes in the code and how the changes will impact their facilities when both CMS and TJC begin surveying to the 2012 LSC in November 2016.

For many hospitals, this will serve as welcome news. For others, the other shoe has dropped, as the changes mean it won’t be business as usual.

TJC Eliminates Plans for Improvement (PFIs)

TJC announced yesterday (July 12) that CMS has requested further changes in the TJC survey process related to the environment of care. Effective August 1, 2016, hospitals will no longer be able to submit their Plans for Improvement (PFIs) for consideration to TJC.

PFIs will not be a component of the organization’s final accreditation report. Instead, all deficiencies will be cited, and the organization will need to address them in their 60-day plan of correction submitted to TJC, unless the CMS central office has granted an extension.

What does this mean for healthcare facilities?

The American Society for Healthcare Engineering (ASHE) has compiled a quick summary of what the changes will mean to hospitals, critical access hospitals, ambulatory surgery centers, hospice, long-term care, intermediate care facilities for individuals with intellectual disabilities, and other special programs.

Some of the major changes for hospitals address how various entities under the hospital’s certification number must comply with the LSC. For example, corridors must contain positive latching hardware; alcohol-based hand rubs must be placed in areas that allow only appropriate access; when a fire watch and evacuation must occur if the sprinkler system is down for 10 or more hours; construction requirements for new buildings; and waivers.

Having only 60 days to address and correct all of the deficiencies in the LSC will be burdensome for some hospitals. For example, a deficiency related to dampers might be hard to correct within a couple of months, especially if it involves capital expenditures, ordering parts, remodeling, etc.

In Compass’ experience, we find that many of the deficiencies in the physical environment and life safety code occur due to new construction or renovation; as a result of ineffective management of contractors doing work in buildings; or lastly, due to an ineffective building management program. We anticipate that some hospitals are going to be struggling to get their hospital-based outpatient surgical departments in alignment with the provisions of the NFPA 101. Formerly, these departments fell under business occupancy if they had fewer than four patients who were rendered incapable of self-preservation, receiving anesthesia, or needing assistance for self- preservation. Under the amendment published by CMS, all new and existing hospital-based outpatient surgical departments are required to comply with the provisions of the NFPA 101 regardless of the number of patients served.

Facilities staff should begin now to look over any PFIs that they have on the books and accelerate the process for completing them. Additionally, facilities staff should begin a more aggressive preventive maintenance program to address as many potential failures as possible. Study the changes in the LSC and contact outside experts to help assess and manage the environment of care processes.

More Information

We’ll continue to alert you as new information becomes available. In the meantime, if you would like more information on assessing and managing your environment of care processes, contact us. We can provide assistance through CMS and TJC mock surveys and focused environment of care and life safety assessments. We’re also developing a webinar on this topic to help organizations respond to these changes.

Image credit: iStock / Thinkstock

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