SURVEYOR Volume 2024 | No. 2 Quality Review Edition
Volume 2024 | No. 2
SURVEYOR
TABLE OF CONTENTS
BOARD OF COMMISSIONERS Brock Slabach, MPH, FACHE I Chair CHIEF OPERATIONS OFFICER, NATIONAL RURAL HEALTH ASSOCIATION Maria (Sallie) Poepsel, PhD, MSN, CRNA, APRN Vice Chair OWNER AND CHIEF EXECUTIVE OFFICER, MSMP ANESTHESIA SERVICES, LLC Mark S. Defrancesco, MD, MBA, FACOG I Secretary PAST PRESIDENT, AMERICAN COLLEGE OF OBSTETRICIANS AND GYNECOLOGISTS Leonard S. Holman, Jr., RPh I Treasurer HEALTHCARE EXECUTIVE AND CONSULTANT Roy G. Chew, PhD I Immediate Past Chair PAST PRESIDENT, KETTERING HEALTH NETWORK John Barrett, MBA I Board Member-at-Large SENIOR CONSULTANT, QUALITY SYSTEMS ENGINEERING Gregory Bentley, Esq. PRINCIPAL, THE BENTLEY WASHINGTON LAW FIRM Jennifer Burch, PharmD PHARMACIST/OWNER, CENTRAL PHARMACY, CENTRAL COMPOUNDING CENTERS José Domingos PRESIDENT AND CHIEF EXECUTIVE OFFICER, ACCREDITATION COMMISSION FOR HEALTH CARE Richard A. Feifer, MD, MPH, FACP CHIEF MEDICAL OFFICER, INNOVAGE Denise Leard, Esq. ATTORNEY, BROWN & FORTUNATO Marshelle Thobaben, RN, MS, PHN, APNP, FNP PROFESSOR, HUMBOLDT STATE UNIVERSITY
03 CORNER VIEW
04 FROM THE PROGRAM DIRECTOR
06 FREQUENT DEFICIENCIES IN CLINICAL AND ADMINISTRATIVE STANDARDS IN ACUTE CARE HOSPITALS 20 FREQUENT DEFICIENCIES IN PHYSICAL ENVIRONMENT AND LIFE SAFETY IN ACUTE CARE HOSPITALS 28 FREQUENT DEFICIENCIES IN CLINICAL AND ADMINISTRATIVE STANDARDS IN CRITICAL ACCESS HOSPITALS 38 FREQUENT DEFICIENCIES IN PHYSICAL ENVIRONMENT AND LIFE SAFETY IN CRITICAL ACCESS HOSPITALS
LEADERSHIP TEAM
José Domingos PRESIDENT AND CHIEF EXECUTIVE OFFICER Patrick Horine, MHHA VICE PRESIDENT, ACUTE CARE SERVICES Matt Hughes VICE PRESIDENT, CORPORATE STRATEGY Barbara Sylvester, RN, BBA, MSOLQ DIRECTOR, REGULATORY AFFAIRS AND QUALITY
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Volume 2024 | No. 2
SURVEYOR
Welcome to the 2024 Surveyor Quality Review. Each year, program-focused editions of this CORNER VIEW publication analyze compliance with ACHC standards over 12 months of surveys. This year’s data span initial and renewal surveys conducted between June 1, 2023, and May 31, 2024. ACHC-accredited organizations use the data to benchmark their performance by comparing these frequently-cited standards against their own survey report. There is value for non-accredited organizations, too. Because ACHC standards are closely aligned with CMS requirements, the information is relevant regardless of how your organization achieves its Medicare certification. For programs outside the Medicare regulations, the value remains. ACHC standards represent an important risk management/quality improvement framework. Reviewing the kinds of issues that arise in your peer organizations is an opportunity to act preemptively to manage your own risks. This is a critical business function in all healthcare settings. We know that some standards consistently present more compliance challenges than others. Frankly, if we offered only a list of frequent deficiencies, this publication wouldn’t vary much from year to year. Instead, Surveyor Quality Review gives insight into trends by quoting findings and offering practical tips to avoid citations. Some standards appear almost annually because of a large number of required elements. Perhaps a policy needs clarification, or staff members were not fully trained on a revision that impacts their work. Perhaps new or contract employees were not adequately oriented to a requirement for documentation, or employees made a change in their workspace that compromises fire safety. For a complex standard, any of these examples represents a potential deficiency and a risk to the organization, its staff, or its patients.
By sharing the observations of ACHC Surveyors, we offer an expert’s perspective on the most current issues impacting organizations. Trends by Program Internally, we use these data to guide the development of educational resources. Organizations seeking to renew their ACHC accreditation in 2024 were also surveyed in 2021. This year, our leaders are including comparative comments as they introduce their program findings. When we experience a large uptick in the number of initial surveys, as we have for several programs in this period, those difficult standards are likely to be prominent as new organizations confront them for the first time. However, we hope to see at least incremental improvement in standards that appeared as frequent deficiencies for this cohort of organizations three years ago. If we don’t see triennial improvements for some of the most frequently cited standards, it means we need to give more educational focus to these in the resources (webinars, workshops, tools) we offer. It is never ACHC’s intention to leave clients wondering about what is expected. To the contrary, our goal is to provide a range of resources that engage and enrich the experience of continuous quality improvement in the healthcare markets we serve. In this year’s first issue of Surveyor , I wrote about team collaboration and handoffs. Remember that ACHC serves as an extension of your team, ready to confer and coach. With Surveyor Quality Review , we are passing an evidence-based guidance tool to you. I hope you grasp it firmly and run with it!
MISSION STATEMENT
Accreditation Commission for Health Care (ACHC) is dedicated to delivering the best possible experience and to partnering with organizations and healthcare professionals that seek accreditation and related services.
José Domingos President & CEO
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FROM THE PROGRAM DIRECTOR
In nutritional services, standard 24.01.09 Lighting, ventilation, and temperature control also ticked upward from three years ago, moving from a deficiency rate of 23% to 35%. The intent here is to mitigate the risk of food-borne illness through effective management of food preparation and storage areas. Noncompliance with this standard closely correlates with deficiency citations for 07.02.01. If your organization was cited for 24.01.09, it is highly likely that you also will be cited for the broader infection prevention standard. The third of these regrettable “upwardly mobile” standards is 25.01.03 Security of medications . Here the increase was from 30% in 2021 to 51% in 2024. This was the largest change in the wrong direction. Surveyor comments focused on inadequately secured drugs and ineffective disposal of unused medications, both situations creating opportunities for diversion. I also want to call special attention to standard 15.01.08 which was numbered 15.01.17 in 2021. The frequency of citation then and now was within one percentage point, but the importance of recognizing patients at risk of harm to self or others and implementing effective mitigation measures is of critical importance as we see more workplace violence occurring in hospitals across the country. Four additional standards ( 10.01.16, 15.02.08, 15.02.17,
Standard 06.03.08 Policy requirements: Food preparation and storage in patient care areas focuses on coordination between nutritional services and the unit-based staff through effective policies. This standard was also noted as a deficiency in many acute care hospitals. In both settings, Surveyors observed a failure to segregate patient-assigned food, to label and remove expired items, and to consistently monitor storage temperatures for refrigerated or frozen items. Standard 18.02.01 Risk mitigation measures for infection prevention , dominated last year’s chart at 100% and, like its equivalent for acute care hospitals, (07.02.01), it is again most prominent in this year’s results. The expansiveness of its scope, which encompasses all areas of the CAH, makes it especially challenging. The last of the top three (an undesirable distinction) is 17.01.06 Evacuation . This standard ties to the emergency operations plan and specifically to identifying how the needs of varying patient populations will be managed, including a strategy for those who may refuse evacuation. We know that many facilities are still recovering from operational challenges brought on by the pandemic, but ACHC’s hospital team is invested in supporting your success. Take advantage of our monthly Coffee Chats, the growing list of free webinars, new master classes, and other resources through ACHCU. And don’t forget about ACHCU Academy! It will be in Dallas, in March 2025 and offers a fantastic opportunity to learn face-to-face with our team and with your peers from other hospitals. I hope to see you there.
The 2020 merger of ACHC and HFAP included significant efforts to provide a smooth transition for continuing customers and a warm welcome to new and transitioning organizations. This year’s Surveyor represents a milestone for the Acute Care Hospital and Critical Access Hospital Quality Review Edition . The data now span a period that allows comparison with survey results reported in 2021. This comparison is relevant as a progress check for the cohort of hospitals that were surveyed as HFAP became part of ACHC. Physical Environment and Life Safety Results You’ll find the most frequent deficiencies in these areas in separate charts on page 20 for acute care hospitals and page 38 for critical access hospitals. Acute Care Hospital Clinical and Administrative Results In 2021, 12 standards were identified as not compliant on at least 20% of the surveys analyzed. Those 12 divided neatly in thirds, with eight (2/3) showing improved performance in 2024 data. This is commendable for the cohort of renewing hospitals. Four topics (staff competency assessment, product recall management, QAPI Program scope, and emergency preparedness in nutritional services) improved such that they fell below the threshold for inclusion in this year’s Quality Review . The four others ( 07.05.04, 08.00.03, 18,00.08, 24.01.08 ) remain above 20% and are covered on the following pages. My comments here will focus on the remaining three that saw declining compliance and one standard with an essentially unchanged percentage. Standard 07.02.01 remains the most often cited deficiency and unfortunately, the frequency of this finding increased from 2021 to 2024 (60% to 65%). The data demonstrate consistency in Surveyor evaluation because the percentages are quite consistent for this overlapping group of hospitals. By contrast, last year almost 90% of the acute care hospitals surveyed were cited for this standard. To improve, hospitals must seek commitment from every individual in every department to find, report, and correct issues related to cleanliness and maintenance of the facility.
15.03.02 ) are new to the report this year. Critical Access Hospital Clinical and Administrative Results
For CAHs, we are taking a close look at 14 clinical and administrative standards that were cited on at least 30% of the surveys performed. In 2021, only five standards rose to that level, but another nine were noncompliant on 27% of the surveys analyzed that year for a similar overall count. Comparing years, however, only three standards appear on both lists (05.05.03, 06.03.08, 18.05.04), and each was more frequently cited in 2024 than in 2021. Of the three standards that received the highest number of deficiencies, only one is a carry-over from 2021.
Deanna Scatena, RN Associate Program Director
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CHAPTER 07: INFECTION PREVENTION & CONTROL AND ANTIBIOTIC STEWARDSHIP 07.02.01 Risk mitigation measures for infection prevention Overview of the requirement:
The hospital has identified and implements mitigation strategies to minimize transmission of infectious disease within and from the facility to other settings. Compliance is evaluated through observation, interviews, and document review. The broad scope of the standard contributes to the frequency with which it is noted as a deficiency. Required elements address staff immunization, aseptic technique, isolation precautions, hand hygiene, use of PPE, and other specifics, but most deficiencies identified issues with disinfection and sterilization of instruments, and environmental cleanliness and maintenance issues.
Comment on deficiencies:
ACUTE CARE HOSPITAL ACCREDITATION
Frequency of citation:
65%
Examples of surveyor findings:
n Instruments in sterile peel packs had broken or peeling surgical tape on Metz scissors, knife handle, hemostatic clamps, Allis clamps, and Baron suction tubes. n GI scopes were stored touching one another. n Rust was observed in OR suites on microscope bases, medical gas tanks, IV poles, stool casters, surgery table bases, and on code carts. n Significant dust accumulation was noted on plastic supply bins, at ceiling air vents, on storage shelving, within and on door seals of medication refrigerators, on high equipment throughout the laboratory, on lamps, cupboards, and ledges in patient rooms, on top of medication dispensing machines, and in clean linen storage areas. n Surgical mattresses were torn. n Encourage all staff to own facility cleanliness. Housekeeping/environmental services should be alerted to problem areas where static dust buildup, dirt, and debris are frequently noted. n Train environmental services/housekeeping to observe for and report rusted equipment, and damaged floors, walls, and doors when cleaning rooms. n Make sanitary condition rounding a team activity that includes department staff, environmental services, and infection preventionists. n Address variance from approved policies and procedures for housekeeping services, linen service, and environmental maintenance. n Create infection control quality goals related to a sanitary environment by collecting and trending data from environmental rounds. Develop action plans for high-frequency issues. n Conduct periodic training for cleaning, sterilization and storage of equipment.
100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% 07.02.01 08.00.03 10.01.16 15.01.08 15.02.08 15.02.17 15.03.02 16.01.02 18.00.08 24.01.03 24.01.08 24.01.09 25.01.03 30.03.03 FREQUENT DEFICIENCIES IN CLINICAL AND ADMINISTRATIVE STANDARDS IN ACUTE CARE HOSPITALS
Tips for complianc e:
Nursing Services
Anesthesia Services
Pharmacy Services/ Medication Use
Medical Records
Infection Prevention & Control and Antibiotic Stewardship
Patient Rights and Safety
Nutritional Services
Conduct periodic audits of instruments in sterile peel packs looking for surgical tape, closed ratchets, and other issues to promote accountability.
Materials Management
Surgical Services
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CHAPTER 08: MATERIALS MANAGEMENT 08.00.03 Safe storage of supplies Overview of the requirement:
Items are stored in a manner appropriate to their use and protected from damage or loss. Compliance is assessed through observation. Deficiencies noted missing solid surface barriers on low shelving and unregulated storage of medications and supplies.
Comment on deficiencies:
Frequency of citation:
35%
Examples of surveyor findings:
n Storage shelves in Materials Management did not have solid barriers on the lowest shelves and the shelves were not 6” above the ground. Fourteen of seventeen shelves located in the surgery storage area did not have solid barriers on the lowest shelves. n Items appear to have fallen from the shelves in the main store room. Tape rolls and 4X4s were observed under the shelves, directly on the floor. n In Same Day Surgery, syringes, needles, and supplies are stored in unlocked cabinets in a medication room without a door. The ED medication room containing IV solutions, needles, syringes, and other supplies in bins and unlocked cabinets had one unlocked door. n Three of three supply room doors that opened into hallways leading to patient rooms were unlocked and accessible to anyone within the hallway. n Add expectations for storage in various locations to the environmental rounding audit tool. n Ensure all shelving units have a minimum six-inch floor clearance for non- sterile supplies and food item s, eight-inch floor clearance for sterile supplies, and a solid surface for bottom shelves. Don’t let convenience overtake safety. Supplies, like medications, must be secured to ensure access is limited to authorized personnel. Open doors and unlocked cabinets create risk.
CHAPTER 10: MEDICAL RECORDS 10.01.16 Informed consent Overview of the requirement:
Medical staff policies identify the procedures and treatments that require informed consent and the process for obtaining it. Medical records document the patient’s informed consent including, at least, the required elements. Compliance is assessed primarily through document review. Most deficiencies noted the failure to use patient-centered language; simple to understand but adequate to communicate the exact procedure.
Tips for compliance:
Comment on deficiencies:
Frequency of citation:
33%
Examples of surveyor findings:
n Consent forms were not written using language easily understood by a person without medical training, for example, OB consents used abbreviations CLE and C/S for continuous lumbar epidural and cesarian section. n Consents intended to be “simple language” lacked specificity as to the procedure, using “foot surgery” for a toe amputation. n Consents for procedures requiring anesthesia did not include the type of anesthesia to be used.
n Train relevant staff on the results of risk assessments for the presence of corrugated cardboard.
Tips for compliance:
n Educate all relevant staff on the informed consent policy at regular intervals.
Review forms for their use of simple language understandable by the individual providing consent.
n Train all staff that confirming comprehension is the goal, and it is achieved through a consistent, defined process.
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CHAPTER 15: PATIENT RIGHTS AND SAFETY 15.01.08 Privacy and safety: Safe setting Overview of the requirement:
Tips for compliance:
n Ensure that your policies for assessing patient risk of harm include all departments into which a patient may be admitted. n Train staff on policy and procedure for patients assessed to be at risk of harm to self or others. Ligature points and other environmental risks can arise over time. Conduct regular assessments focused on environmental changes (broken fixtures, items with looping or tying potential, etc.). Act immediately to mitigate identified risks.
Hospitals protect the physical and emotional health and safety of patients through effective risk management. Compliance is evaluated through observation, interview and document review. Most deficiencies focused on unaddressed safety concerns, including lapses in mitigating action for patients assessed at risk of harm to self or for environmental concerns. Similar observations were noted at standards 15.03.01 Identifying patients at risk and 15.03.02 Environmental safety risks although as distinct standards, neither of these reached the threshold of 20% for inclusion in this report.
Comment on deficiencies:
15.02.08 Orders for restraint or seclusion Overview of the requirement:
Hospitals have policies and procedures that identify the categories of licensed practitioners authorized to order restraint or seclusion. All use of restraints (chemical or physical) require documentation in the form of an order prior to application. In an emergent situation, documentation is expected immediately after the restraint has been applied. Compliance is evaluated through policy and medical record review. Deficiencies identified timeliness of documentation as a particular issue, along with gaps between hospital policies and actual practice.
Frequency of citation:
25%
Examples of surveyor findings:
n During observation of a medication pass, the surveyor was informed by the patient that she is blind. There was no disclosure by the nursing staff that the patient had a visual deficit. There were no postings in the patient’s private room of the condition. There was no notice on the main page of the medical record. The only documentation appeared in the admission assessment. This created a safety concern for the patient. n During the tour of the surgical services department (pre-op, surgery, post- anesthesia care, sterile processing), more than 50 unsecured needles and syringes were observed that could be accessed by unlicensed staff n A patient with a chief complaint of suicidal ideation presented in the emergency department. The medical record lacked evidence of a documented screening to identify risk of harm to self or others using a risk assessment tool. The patient was placed in the hallway for ‘close observation,’ but based on surveyor observation, there was no one-on-one monitor in place. n Within the behavioral health unit, five of eight beds have wheeled, height- adjustable overbed tables with drawers typically used in medical patient rooms. The overbed tables pose multiple ligature risk points and the drawers have a potential for hiding contraband. n One of six behavioral health (BH) patient rooms had a shredded window shade. Strings from the shade present a risk of self-harm or harm others. One of six BH patient rooms had broken plastic framing around the window that was sharp and could be used for self-harm or harm others.
Comment on deficiencies:
Frequency of citation:
29%
Examples of surveyor findings:
n A patient was given medications as a chemical restraint. This was noted in the provider’s ED progress note but there was no order completed in the EMR per the hospital’s restraint order process for chemical restraint. n Three of nine medical records for restrained patients lacked documentation of written orders from the physician. n One of three records lacked a timely physician order for restraint after initial application. Based on the interview and nursing note documentation, a verbal order was received on [date], but not documented in the medical record until 12 days later. n Orders did not indicate if the restraints were non-violent or violent. The EMR physician order set did not have an option for identifying violent or non-violent restraints. n Thirteen of twenty-nine restraint orders were placed by an RN as protocol. The timing between orders and the application of restraints showed late entries between four and seven hours after the restraint start time and early entries between eight and ten hours before the application of restraints. n Numerous orders entered by the RN were either not signed by the LIP or physician or had significant delays in order signatures. n Two of seven behavioral health patients under violent restraints had records that included initial orders for lesser restrictive measures, but failed to include the progressive order for violent restraint.
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15.03.02 Environmental safety risks Overview of the requirement:
Tips for compliance:
n Review policies to ensure restraints can only be ordered per hospital policy in compliance with state law and within scope of practice. n Ensure timely and complete order entries by training staff on restraint policies and procedures. n Conduct daily restraint chart audits.
Hospitals adopt an environment risk assessment tool with documented mitigation procedures when an at-risk patient is placed in an environment that includes potential ligature points. The required elements were revised in June 2023 to add clarity to the expectations. Whenever an errata is issued mid-year, it is safe to assume that those changes will receive special focus. Compliance is evaluated through observation and document review. Surveyors noted missing risk assessments, missing mitigation plans, or failure to implement mitigation as needed.
Comment on deficiencies:
15.02.17 Monitoring of the patient Overview of the requirement:
When restraint of seclusion are used during patient care, intervals for monitoring and reassessment must be defined and performed by qualified staff. Compliance is assessed through record review and interview. Surveyors noted incomplete policies, or monitoring documentation that deviated from the policy, usually for the type of monitoring required or the timing of reassessment.
Frequency of citation:
22%
Examples of surveyor findings:
n The hospital was unable to recall when the last environmental ligature risk assessment was conducted in patient care areas. n Neither of the most recent annual risk assessments identified locations of ligature points within the departments, nor did they include appropriate, effective mitigation strategies for patients at risk of harm. In the ED seclusion room, the hinges for the door present three potential ligature points. These ligature points are noted on the environmental risk assessment without a mitigation strategy. The ED nurse manager could verbalize that suicidal patients placed in that room have one staff member assigned to continuously monitor through the glass window, but the process for monitoring of patients in the room is not documented in written policy or procedure. n Risk assessment instructions state, “Areas are free of items that could be used to harm self or others. Areas that do not have sharps or potential contraband issues have been identified for risk of hanging and/or barricading.” The assessment makes no mention of the non-bolted, non-weighted chairs, overbed tables, or regular reclining chair that were in the patient rooms, does not identify the ligature points or potentials for barricading, and failed to note the loose air vent on the fan coil unit. n Risk assessment instructions state, “There is no use of wired bed/chair/ personal alarms – use cordless. If you must use bed cords, they are located close to an outlet and plugged directly into the outlet; cords are shortened to reduce looping around the neck and securing to an anchor point for hanging.” The mitigation states “Maintenance to position the cords closely to an outlet and they are plugged directly into the outlet. Cords are shortened to reduce looping potential and secured.” However, the cords have not been shortened and the zip ties used to reduce the length of the cords have left cords approximately three feet long. This does not appropriately mitigate risk for ligature use. n Environmental ligature risk assessments noted mitigation of ceiling vents as ligature points by covered them with plexiglass within the patient bathrooms. Three rooms lacked plexi covers.
Comment on deficiencies:
Frequency of citation:
22%
Examples of surveyor findings:
n Based on review of the “Restraint/Seclusion” policy, the policy does not address monitoring of a patient who is violent or in seclusion. n Records lacked documentation of patient monitoring every 15 minutes for the following assessment elements required hospital administration policy, “Restraints:” Vital signs, skin integrity, warmth and privacy, readiness for restraint release. n Four of six violent restraint episodes did not have every 15-minute monitoring of the patient as required by facility policy. n Seven of nine medical records reflecting use of restraints did not contain all elements for re-assessment and/or were missing re-assessments completed every 15-minute per policy. n Based on interview with emergency department leadership, patients are placed in the seclusion room with a staff member assigned to continuously monitor the patient through the large seclusion room window facing the nurse’s station in the ED. The organization’s restraint and seclusion policy is silent on the monitoring process for patients placed in the seclusion room.
Tips for compliance:
Restraints must be discontinued at the earliest possible time. This requires monitoring at consistent intervals.
n Review policies for required elements. n Define staff roles that may perform monitoring and/or assessment. n Ensure staff assigned to monitor/assess patients in restraint or seclusion are trained and have demonstrated competency to perform these tasks.
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CHAPTER 18: ANESTHESIA SERVICES 18.00.08 Equipment safety Overview of the requirement:
Tips for compliance:
n Schedule and document annual environmental risk assessment through review of all patient care areas. n Ensure risks identified include corresponding mitigation plans. One-on-one monitoring for patients identified as “at-risk” is an acceptable solution for areas that are not ligature resistant.
Anesthesia equipment is subject to regular preventive maintenance and individual medical records identify the machine used. Compliance is assessed through maintenance logs and medical record review. All deficiencies noted that some or all procedural patient records did not identify the anesthesia machine that had been used.
Comment on deficiencies:
Audit conditions in each department between risk assessments to ensure mitigation remains in place.
Frequency of citation:
22%
Examples of surveyor findings:
n Patient records lacked documentation of the anesthesia machine number.
CHAPTER 16: NURSING SERVICES 16.01.02 Pain assessment and reassessment Overview of the requirement:
n Add a required field for anesthesia machine number to surgical EMR records.
Tips for compliance:
CHAPTER 24: NUTRITIONAL SERVICES 24.01.03 Policy requirements: Food preparation and storage in patient care areas Overview of the requirement:
Patient pain is managed through assessment, intervention, and reassessment. Policies and procedures identify standardized tools (pain scales) and define the means and frequency of monitoring. This was a new standard as of March 2023. Compliance with this standard is assessed through observation, interview, and document review. Most findings noted a lack of reassessment, even when the hospital’s policy mandated a timeframe.
Comment on deficiencies:
Food storage and preparation in patient care areas is subject to written policies including defined elements. Compliance is assessed through observation and document review. Expired items, cleanliness, and temperature monitoring topped surveyor comments.
Frequency of citation:
28%
Comment on deficiencies:
Examples of surveyor findings:
n The policy “Pain Management,” lacked defined timeframes for pain reassessment after oral, intravenous, or intramuscular medication administration. n Three of nine records lacked a pain reassessment after the administration of pain medication as required by the facility’s policy, “Quality and Patient Safety: Pain Assessment and Management.” n The organization’s policy, “Pain,” instructs nurses to use the critical care pain observation tool (CPOT) to evaluate pain in nonverbal patients. In interviews with two med-surg unit RNs, they could not speak to methods used to evaluate pain in nonverbal patients. n Review policies for inclusion of all required elements. n Train staff to use the appropriate pain scales at the defined frequency. n Conduct chart audits to assess for compliance.
Frequency of citation:
22%
Examples of surveyor findings:
n Nutritional refrigerators were observed to be dirty with spills and food debris in the transitional care unit, cardiac medical unit, and cardiovascular intensive care unit. n Temperature logs for refrigerators and freezers located on nursing units were not checked daily as required by the standard. n Four milk cartons were observed in a patient refrigerator with a past “sell by” date. Patient assigned food was in the refrigerator two days after the patient had been discharged. Nutrition centers on all inpatient clinical units were observed to have food debris, dust, crumbs, and hair in the drawers and cabinets where patient food and food supplies are stored. n Minor cooking is done in the rehabilitation unit to allow patients to practice activities of daily living (ADL) skills. Supplies are currently procured by unit personnel from the local grocery store, not from the nutrition department. There is no collaboration relative to ADL cooking between the rehabilitation unit and food services as required by the standard. n Based on observation, the facility lacks a consistent process that demonstrates labeling of food product expiration/discard dates. n The employee food refrigerator was being used to store patient medications, such as insulin, that may be brought from home by patients to the sleep lab.
Tips for compliance:
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24.01.09 Lighting, ventilation, and temperature control Overview of the requirement:
Tips for compliance:
Just as unit-based medication remains the responsibility of the pharmacy, unit based food products are the responsibility of nutrition services.
Ventilation, airflow, and temperature where food products are stored and prepared must meet relevant guidelines. Light sources provide adequate illumination and are protected. Compliance with this standard is assessed through observation and interview. Most citations noted temperatures outside of acceptable range monitoring issues.
n Assign responsibility for daily temperature logging of unit-based refrigerators and freezers, identify acceptable range and train on what to do when a temperature falls out of range. n Avoid comingling patient-assigned food, staff food, and medications.
Comment on deficiencies:
Frequency of citation:
35%
24.01.08 Physical Environment Overview of the requirement:
Examples of surveyor findings:
n Three grab-and-go open-front coolers holding dairy, deli meat sandwiches, salads with protein, and sushi, and a sandwich station holding eggs, cheese, and deli meat that is prepped the evening before for next-day service, are not monitored for temperature every four hours as required by the state’s Food Code when the area is closed overnight. n The main kitchen freezer temperature log for [date] noted for the freezer “+25°” and maintenance was called. There was no documentation of how the food was handled while out of range and there was no documentation of a temperature recheck. Per policy, temperature should be followed-up within one hour when the device falls out of range. n The main kitchen refrigerator temperature log for [six dates in one month] noted a temperature of 41°F with no recheck documented. Per policy any temperature greater than 40° F requires action and a recheck in one hour. n During the tour of the dish room, it was noted that the temperature conversion tapes were marked “Must exceed 160°.” The dish machine is a heat sterilization unit. ANSI standards require final rinse of 180°. Based on temperature log review, the final rinse was meeting the 180° requirement. n During the tour of the cafeteria, a significant build-up of grease was found on the exhaust hood and fire suppression system over the short order grill. n A significant buildup of grease, dust, and lint was observed on the fire suppression pipes in the exhaust hood over the cooking area. The primary drain under the large dish machine was observed to be partially occluded by debris and in need of cleaning. Several locations in the main kitchen and the dry storage room had fluorescent light lenses that were “rippled” and not resting on the ceiling grid. n Record temperatures of all refrigerators and freezers used for food products, and dish machines, and document corrective action when they fall out of range. n Add observation of vent hoods to environmental rounding and schedule regular cleaning and maintenance. n Routinely inspect food preparation areas for cleanliness. n Educate staff to observe and report grease buildup on exhaust hoods and pipes.
Food services maintains a sanitary environment that minimizes infection risks and risk of product contamination. Compliance with this standard is assessed through observation and document review. Most deficiencies cited equipment cleanliness and maintenance issues.
Comment on deficiencies:
Frequency of citation:
27%
Examples of surveyor findings:
n Condensation was observed below the window in the door of the walk-in freezer. Gaskets were in good repair, but the plastic curtains designed to maintain temperature were broken, allowing cold air to make the door cold enough to cause ambient humidity to condense. n The patient refrigerators were unusable, needed defrosting. n The door gasket on the cook’s walk-in freezer was noted to be damaged. It was not attached at the bottom of the door and appeared to be covered with mold. n Employee food and personal items were observed in areas designated for patient food. n Refrigerators in patient nutrition rooms on several units contained individual- use condiments with no use-by dates. n Labeled food past its expiration date was found in refrigerators (pastas). Opened, but unlabeled items were noted in refrigerators and freezers (chicken stock, waffle fries, hash browns). n Include kitchen areas in environmental rounding for assessment of cleanliness and properly working equipment. n Assess refrigerators located outside the nutrition department for cleanliness and state of repair. n Educate staff to report equipment maintenance issues. n Label food items to capture “opened/prepared on” and “use by/discard on” dates. n Conduct periodic surveillance to identify and remove expired food items. n Audit food inventory and discard expired items.
Tips for compliance:
Tips for compliance:
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SURVEYOR
ACUTE CARE HOSPITAL
CHAPTER 30: SURGICAL SERVICES 30.03.03 Post-procedure follow-up call Overview of the requirement:
CHAPTER 25: PHARMACY SERVICES/MEDICATION USE 25.01.03 Security of medications Overview of the requirement: Medication is secured to prevent unauthorized assess. Comment on deficiencies:
Outpatient surgical patients receive follow-up calls 24 to 72 hours after discharge. Compliance is assessed through interview and document review. When documentation was not present in individual patient records, Surveyors noted that policy often failed to identify which patients should receive calls. Data from calls was not advanced to the QAPI Program for analysis and trending.
The standard is evaluated through observation, interviews, and document review. Most deficiencies noted the presence and easy accessibility of frequently diverted drugs.
Comment on deficiencies:
Frequency of citation:
51%
Examples of surveyor findings:
n Unsecured medications (vials and filled syringes) were found in clear plastic medication boxes located on the top of the anesthesia machines. n Multiple partially filled syringes of propofol were found in open container disposal boxes in each cardiac catheterization lab. n Unlocked, unsecured, clear, plastic pharmacy medication bins were observed next to the pyxis machines in inpatient medical units’ medication rooms. These bins were used to return medications to the pharmacy. Loose medications were observed in each of the bins. Based on interview, EVS, materials management, and unlicensed nursing staff have badge access to the medication rooms, leaving opportunity for those staff to retrieve medication from the bins. The medications in the return bins had been in the bins for up to ten days, so it is unclear how pharmacy is monitoring medication delivery and administration practices on the inpatient units. n An anesthesia cart was located in an unlocked storage room accessible to patients, visitors, and unauthorized staff. The anesthesia cart held a small waste bin which contained partially filled vials medications. Hospital policy states “Unused and non-empty containers with no pyxis alert and partial vials should be discarded in the non-hazardous Rx waste container.” n A shared nourishment/medication room is used to store non-narcotic medications, syringes, and needles. Based on interview, a risk mitigation plan in place requires an RN to accompany all unauthorized staff when they access the room to obtain nourishments for the patients, however, no written mitigation plan was available, and leaders stated it was a verbal plan. n Review how access to medication storage is managed, especially when drugs are stored with other items that require broad access. n Add observation of medication carts, cabinets, and other storage and disposal boxes to environmental surveillance rounding. n Policies should delineate the proper disposal of medications by medication type and disposal container type. n Train staff and providers on proper disposal of unused drugs and conduct audits to promote accountability. n Minimize the risk of diversion of unused portions of drawn up medications.
Frequency of citation:
22%
Examples of surveyor findings:
n Hospital policy required post-operative calls within 96 hours which is not compliant with the standard. n Information obtained during post-procedure follow-up calls is not tracked and reported to the QAPI Program. n The hospital’s policy is to call all outpatient surgical patients, but patient records had no documentation that this was being completed. n The hospital’s policy did not define which patients were to receive follow-up calls, nor did it identify that this applied to all surgical outpatients. n Audit hospital policy to ensure that it defines criteria for who receives a follow- up call, the time frame for the call, the information to be collected, and the action(s) taken with the documented results.
Tips for compliance:
Follow-up phone calls promote continuity of care, minimize returns to the ED, and support patient satisfaction.
Tips for compliance:
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Volume 2024 | No. 2
SURVEYOR
ACUTE CARE HOSPITAL NOTES FOR THE FACILITIES DIRECTOR
CHAPTER 11: PHYSICAL ENVIRONMENT 11.01.10 Eyewash stations and emergency showers Overview of the requirement:
The physical environment is the hospital’s largest and most critical piece of medical equipment, playing a vital role in patient care. Comparing results from 2021 standards to 2024 shows a mixed bag. In 2021, two physical environment standards ( 11.00.01 and 11.07.03 ) were cited on 47% of acute care hospital surveys. In 2024, 11.00.01 dropped to a remarkable 8%, well below the threshold for inclusion in this year’s report, but 11.07.03 rose to a frequency of 61%. For life safety standards, five were reported in the 2021 Surveyor Quality Review , appearing on between 44 and 58% of surveys conducted. Those five are repeated this year, but in every case, the frequency of citation declined, establishing a new range from 37 to 45%. This is encouraging data, but there is still work to be done. Physical environment and life safety standards always produce a significant number of deficiencies. Combining regular environmental rounding in collaboration with department leaders on the clinical and
Approved eyewash stations must be provided in every area where a person may be exposed to hazardous corrosive materials. Compliance is assessed through observation and document review. Citations mentioned a wide range of hospital locations where bleach or other corrosive chemicals are stored and used that lack eyewash stations. Many noted missing inspection logs for weekly or annual inspections.
Comment on deficiencies:
administrative side of the hospital’s operations will be helpful in identifying problems early. Communicating how your team looks at each space and construction element can help you find champions among your clinical colleagues. One goal is to extend your team’s effectiveness by having keen-eyed partners in every department who will catch and report environmental issues as soon as they arise.
Frequency of citation:
47%
Examples of surveyor findings:
n There is no eyewash station in the generator room where specific gravity testing is being conducted for the generator battery. This condition requires a plumbed eyewash station within 55 feet or 10 seconds access. n The hospital’s policy requires weekly eyewash station inspections. In the eye center, there was no documentation that the station had been checked in the past seven weeks. n There is no eyewash station in the dialysis unit where bleach is used to clean machines. This requires a plumbed eyewash station. n Eyewash stations in the dialysis unit, kitchen, and equipment decontamination rooms did not have mixing valves and were fed from only cold water. n Hazardous corrosive chemicals were observed in use in the main kitchen and chiller rooms. Neither space has an eyewash station. n Risk assess each department or area to identify whether there are caustic or corrosive chemicals to determine where an eyewash station is required. n Eyewash stations often require a mixing valve to maintain tepid water temperature of 60-100⁰F. n Every eyewash station requires a documented weekly inspection and an annual test and inspection.
Richard L. Parker, MBA, CHFM Associate Director, Life Safety & Physical Environment
FREQUENT DEFICIENCIES IN PHYSICAL ENVIRONMENT AND LIFE SAFETY STANDARDS
Tips for complianc e:
100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0%
Maintain inspection logs and document corrective actions. Audit logs to ensure consistent performance.
11.01.10
11.07.03
13.02.01
13.02.02
13.03.01
13.04.01
13.04.07
13.04.09
13.05.09
Physical Environment
Life Safety
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Volume 2024 | No. 2
SURVEYOR
PHYSICAL ENVIRONMENT AND LIFE SAFETY
CHAPTER 13: LIFE SAFETY 13.02.01 Fire alarm system – Installation and maintenance 13.02.02 Fire alarm system - Testing
11.07.03 Ventilation, Light, and Temperature Controls Overview of the requirement:
The hospital must meet guidelines for temperature, humidity, ventilation and air pressure relationships based on the function of the space. Compliance is evaluated through observation, interview, and document review. Most deficiencies were due to incorrect air pressure relationships. Also noted were the lack of policies on temperature and humidity in key areas and the adoption of low humidity levels without regard to the effect on equipment and supplies.
Comment on deficiencies:
Overview of the requirement:
Fire alarm systems are installed, tested, and maintained per NFPA 101 Life Safety Code (2012 edition and NFPA 72 National Fire Alarm Code (2010 edition). All basic and secondary components are included in the testing protocol. Compliance is assessed through observation and document review. Surveyors noted that smoke detectors were often installed too close to components of the HVAC system. Other installed features were made inaccessible by moveable objects providing obstruction. Testing frequency and corrective action for failed components were compliance issues for 13.02.02.
Comment on deficiencies:
Frequency of citation:
61%
Examples of surveyor findings:
n The surgery safety policy did not address processes to follow during periods when temperature and humidity are out of range. n Air pressure in the sterile processing department was negative to the adjacent supply room. Temperature and humidity were not monitored. n The infection prevention policy for temperature, humidity and pressurization identified the humidity range of 20-60%. The hospital facilities department has been maintaining a range of 30-60%. If the organization chooses to allow for the 20-60% range, it must conduct a risk assessment of all equipment and supplies manufacturer’s instructions for use. If the organization chooses to adhere to 30-60% humidity, it must revise the policy. n The OB soiled utility room pressure was observed to be positive pressure to the corridor and should be negative pressure. The morgue was observed to have a positive pressure relationship to the corridor and should be negative pressure. OR decontamination was observed to be neutral pressure to the corridor and should be negative pressure. Sterile processing air pressure was observed to be neutral pressure to the corridor and should be positive pressure. The preop surgery soiled utility room pressure was observed neutral pressure to the corridor and should be negative pressure. n Review policies to ensure that these conditions are addressed for function- specific spaces. n Conduct a risk assessment for equipment and supplies used when considering adopting the CMS waiver for a relative humidity range of 20 to 60%. n Take action as soon as readings indicate the environment does not meet required conditions.
Frequency of citation:
13.02.01: 37%; 13.02.02: 45%
Examples of surveyor findings:
n The ground floor fire alarm panel did not have a smoke detector within the required distance per NFPA 72 10.15. n Access to pull stations was blocked in various units (by furniture, trashcans, and signage). n Smoke detectors were installed too close to air supply diffusers (within 36 inches). n Two on-call sleeping rooms lacked fire alarm notification devices. n The annual fire alarm testing report did not include a list of the audible and visual devices tested. n Annual testing of waterflow switches was documented but semi-annual testing is required. n The most recent annual fire alarm system test report indicated that 20% of the notification devices (audible/visual) failed during the test. The Life Safety Specialist indicated that the failure was largely construction related and had been corrected. The hospital could not show documentation of correction and retesting of the failed devices. n Air handler shut-down interface relays for 39 devices were recorded as failed on the testing log from September 2023 and had not been corrected to date. The hospital did not conduct an ALSM Risk Assessment to determine what measures to implement to compensate for the life safety code deficiency. n Recognize that any deficiency with the fire alarm system that cannot be corrected in the same day must prompt an ALSM assessment. n Review smoke detector locations relative to other features to ensure compliant placement. n Develop a testing calendar including requirements as defined by NFPA. Develop logs to demonstrate that testing was performed and include follow- up actions for testing failures.
Tips for compliance:
Many reversed air pressure relationships are corrected at the time of survey. Implement more frequent monitoring and immediate correction to avoid citations.
Tips for compliance:
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