On April 10, 2017, the American Society for Healthcare Engineering (ASHE) has issued a memo to hospital and health system executives explaining recent changes that may result in more life safety observations during survey.

According to ASHE, the Centers for Medicare & Medicaid Services (CMS) has asked that accrediting organizations make changes to the survey processes.  This means the Joint Commission will no longer be able to consider hospital plans for improvement (PFIs) for life safety compliance.  Previously, PFIs allowed hospitals time to fix issues without being cited. WIth the CMS changes, even routine deficiencies will be noted during survey.  This means you are likely to see an increase in life safety observations.

This change is sure to have a major impact on the survey report in comparison to previous years.  Many of the new observations may be routine in nature and it is very possible they are being appropriately managed by staff.  Previously, the Joint Commission allowed facilities to self-manage these corrections.  Now they require an official observation, attaching a 60 day window for correction of the deficiency.  If additional time is necessary, CMS has an extension process.

A likely change that will be noticed is with doors.  As we all know, doors in healthcare facilities take a lot of abuse and often need repair.  Wood doors will fluctuate with environmental changes, affecting the door’s ability to function properly. Routine adjustments have become common practice as part of door management.  Going forward, any non-compliant door will be cited regardless of a door management program.

See how Compliance One can assist with annual door inspections and a door management program HERE.

ASHE members can view the memo HERE.