Joint Commission makes major changes to Plans for Improvement

Joint Commission makes major changes to Plans for Improvement

The Joint Commission will no longer consider hospital Plans for Improvement (PFIs) for its Life Safety chapter requirements starting August 1. Instead, all life safety deficiencies will need to be corrected within 60 days, although a time-limited waiver process will be available through Centers for Medicare and Medicaid Services regional offices. 

The changes were announced earlier this week at the American Society for Healthcare Engineering’s 53rd Annual Conference and Technical Exhibition. The changes affect the Joint Commission’s Statement of Conditions (SOC) requirements.

The Joint Commission created the SOC program in 1995 as a means for hospitals to correct deficiencies they self-identified within a justifiable time frame based on budgeting and scheduling needs, with Interim Life Safety Measures to ensure patient safety. Initially, these self-identified actions were not documented during survey because the SOC already documented the deficiency. It also became the method for hospitals to submit PFIs, giving them additional time to make the corrective action, many of which fell within an automatic six-month extension.

The Centers for Medicare & Medicaid Services (CMS) recently adopted the Joint Commission’s Life Safety chapter requirements, and has asked the Joint Commission to adopt the following changes for its SOC:

• No longer allowing the SOC to document self-identified deficiencies, instead, taking the self-identified deficiencies and converting those to Requirements For Improvement by the surveyor
• No longer allowing more than 60 days for corrective actions unless approved by the CMS regional office
• The surveyor citing all deficiencies replacing the extension request component with a Time Limited Waiver process, using the Survey-related Plan For Improvement process that will be managed and tracked by the CMS regional office
• Managing the survey-related equivalency process, as defined by CMS, using Salesforce and the SOC to manage and track the CMS regional office action  
• Removing the six-month automatic extension
• No longer granting requested extensions

“Joint Commission leadership, after reviewing the restrictions being placed on the SOC, has determined that the Basic Building Information and PFI components of the SOC no longer fit the quality assessment program it was originally designed as, and will become an optional management program and will not be a part of the survey process,” the organization states. “Post survey, the CMS Time Limited Waiver and equivalency components of the SOC will be used to manage survey-related deficiencies. All questions should go to The Joint Commission Department of Engineering at 630-792-5900.”

Hospital reduces MRSA rates by 42 percent with electronic hand-hygiene measurement

A new study published in the American Journal of Infection Control shows a direct correlation between using an electronic hand-hygiene compliance system to improve adherence to the World Health Organization’s Five Moment hand-hygiene recommendations and significantly reduced hospital-onset methicillin-resistant Staphylococcus aureus (MRSA) infections.

The study, “Electronic Hand Hygiene Monitoring as a Tool for Reducing Healthcare-Associated Methicillin-resistant Staphylococcus aureus Infection,” was conducted at Greenville Health System (GHS) in Greenville, S.C. Researchers used hand-hygiene compliance data from the DebMed System to measure the impact hand hygiene has on the incidence of health care-associated infections (HAIs).

Researchers report that the health system’s hand-hygiene compliance rates increased by 25.5 percent during the course of the study. During the same time, hospital-onset MRSA rates decreased by 42 percent. The team estimates that the decrease resulted in approximately $434,000 of additional care costs avoided.

ASHE recognizes hospitals for cutting energy consumption

The American Society for Healthcare Engineering (ASHE) named Spaulding Rehabilitation Hospital Boston its 2016 Energy Champion for demonstrating strong leadership in becoming a more energy efficient facility and using saved resources to support patient care. In addition, 29 hospitals have earned an Energy to Care Award for slashing energy use.

ASHE, a professional membership group of the American Hospital Association, recognized the hospitals’ efforts at its 53rd Annual Conference and Technical Exhibition held earlier this week. Facilities that reduce energy by 10 percent or more over the previous year, as well as previous Energy to Care winners who go on to reduce consumption by an additional 5 percent are eligible to win an Energy to Care Award.

NFPA hosts free webinar on changes to 2017 NFPA 70, National Electrical Code

The National Fire Protection Association (NFPA) will host a free webinar on July 20 to cover changes in the 2017 edition of NFPA 70 National Electrical Code (NEC), including new articles on large scale power generation, energy storage and direct current distribution.

The webinar, “Proposed Changes to the 2017 Edition of the National Electrical Code,” is aimed at electricians, installers, contractors, designers, engineers, code enforcers, authorities having jurisdiction and policymakers. Jeff Sargent, NFPA’s regional electrical code specialist, will discuss the 2017 revision.

The NEC has been adopted in all 50 states and sets the standard for safe electrical installation and inspection to protect people and property from fire and electrical hazards. It is one of the most widely used codes for the built environment in the world.

Joint Commission, ASHE add fire safety resource to joint portal

The Joint Commission and the American Society for Healthcare Engineering (ASHE) have added new resources to help health care organizations comply with Joint Commission Life Safety Chapter requirements.

The resources can be accessed on ASHE’s Focus on Compliance site, and at the Joint Commission’s Physical Environment Portal.

OSHA delays effective date for enforcing employees' rights to report workplace injuries, illnesses

The Occupational Safety and Health Administration is delaying enforcement of the anti-retaliation provisions in its new injury and illness-tracking rule to conduct additional outreach and provide educational materials and guidance for employers. Originally scheduled to begin Aug. 10, enforcement will now begin Nov. 1.

Under the rule, employers are required to inform workers of their right to report work-related injuries and illnesses without fear of retaliation; implement procedures for reporting injuries and illnesses that are reasonable and do not deter workers from reporting; and incorporate the existing statutory prohibition on retaliating against workers for reporting injuries and illnesses.

Guidance clarifies when ransomware should trigger breach notice obligations

A new factsheet on ransomware prevention and response from the Department of Health and Human Services’ Office for Civil Rights reminds health care providers and others covered by the Health Insurance Portability and Accountability Act (HIPAA) that breach notification obligations may be triggered when a ransomware attack occurs.

“Whether or not the presence of ransomware would be a breach under the HIPAA Rules is a fact-specific determination,” the factsheet notes. Unless the covered entity or business associate can demonstrate “a low probability” that protected health information has been compromised, a breach of this information is presumed and the entity must comply with the applicable breach notification provisions, the guidance states.