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Recent Changes in Healthcare Governing Codes and Requirements Impact Joint Commission Accreditation
Recent Changes in Healthcare Governing Codes and Requirements Impact Joint Commission Accreditation

The State of Illinois, as well as a number of other state governments, recognize The Joint Commission (TJC) accreditation as a condition of licensure and the receipt of Medicare and Medicaid service reimbursements for healthcare organizations. With the population aging, these organizations are relying more and more on these reimbursements. However, keeping a facility continuously accredited by TJC can be a challenge for healthcare providers, especially with recent changes to governing codes, requirements and procedures.

Effective July 1, 2014, The Joint Commission announced changes to their survey decision reports for organizations under the authority of CMS. TJC is aligning its survey process with the requirements of the Centers for Medicare & Medicaid Services (CMS) in order to renew accreditation with CMS. Previously, healthcare organizations could self-report Life Safety Code deficiencies on the Plan for Improvement (PFI) list; however, there is no longer an advantage in doing so. The PFI section of the Statement of Conditions still exists, but the protection of findings is no longer there. Changes were also made to the reporting process for the Requirement for Improvement (RFI) and Opportunity for Improvement (OFI) sections of the report.

In addition, CMS is currently proposing the adoption of the National Fire Protection Association’s (NFPA) Life Safety Code, 2012 Edition. The proposed rule “Medicare and Medicaid Programs; Fire Safety Requirements for Certain Health Care Facilities” was published in the Federal Register on April 16, 2014. The rule will also adopt NFPA 99 Health Care Facilities Code, 2012 Edition. Both Codes will be adopted with some exceptions and revisions. The most noticeable changes in the 2012 Life Safety Code to the current 2000 Edition are provisions regarding:

  • Corridor projections
  • Suite size
  • Sprinklers in high rise buildings
  • Door locking
  • Roller latches
  • Extinguishment requirements
  • Alcohol Based Hand Rubs (ABHRs)
  • Storage of medical equipment and placement of fixed furniture in corridors
  • Fireplaces and cooking facilities

The new approach to facility risk assessment is the most fundamental change in the NFPA 99 Health Care Facilities Code. Chapter four provides guidance on how to apply NFPA 99 to healthcare facilities based upon “four risk categories” determined utilizing a risk-based methodology, as outlined below. The assessment shall be conducted by each facility based on treatment and services provided.

  • Category 1: “Facility systems in which failure of such equipment or system is likely to cause major injury or death of patients or caregivers…” Examples of major injuries can include amputation or a burn to the eye.
  • Category 2: “Facility systems in which failure of such equipment is likely to cause minor injury to patients or caregivers…” A minor injury is one that is not serious or life threatening.
  • Category 3: “Facility systems in which failure of such equipment is not likely to cause injury to patients or caregivers, but can cause patient discomfort…”
  • Category 4: “Facility systems in which failure of such equipment would have no impact on patient care…”

Each health care or ambulatory occupancy will need to define and implement its risk assessment methodology and document the results. CMS would not require the use of any particular risk assessment procedure. Results of the risk assessment can drastically impact the Life Safety requirements in different areas of a facility, such as in operating rooms or intensive care units. Life Safety experts can help the facility in evaluating risk factors to classify portions of the facility based on NFPA 99 defined risk categories.

Additionally, more legislative changes are coming to hospitals located in Illinois. As reported by Crain’s Chicago Business, a new hospital licensing fee will be introduced by the State Senate to create a healthcare reporting system and enhance hospital inspections. Recently, Illinois Governor Pat Quinn signed the legislation establishing a fee of $55 per patient bed, which will raise an additional estimated $1.7 million per year. The focus is now shifting to patient safety and quality of delivered health care. More than half of the money collected from the new fee will be dedicated to the hospital reporting system. An additional 30 percent will be earmarked for developing new quality and safety measures, and the remaining 20 percent will be used to address patient complaints. The legislation “will allow the state to fund and implement a wide range of safety and quality improvement initiatives which will help ensure that patients continue to receive the highest quality of care in Illinois,” said Tabrina Davis, system leader of corporate communications and public relations for Presence Health. “Creating a mechanism that funded safety and quality initiatives is critical at a time of significant changes in the healthcare industry.” Hospitals will be required to pay the fee annually when their license is renewed. Small rural hospitals and so-called safety net hospitals that treat a large proportion of poor and uninsured patients are exempt from the fee. This new legislature also means more frequent and thorough inspections, requiring from existing facilities better preparedness.

Regular Life Safety Code assessments by a Life Safety expert team are becoming more critical in this constantly changing regulatory environment. It is important to get a life safety expert involved who can assist in facility assessments to determine compliance with key areas of evaluation. As design professionals specializing in the field of building construction and Life Safety assessments, Primera has a team of experts skilled in evaluating and advising on possible procedures for remediating deficiencies associated with JCA Environment of Care (EC) and Life Safety (LS) sets of standards. Life Safety experts, such as Primera, can guide healthcare organizations through the accreditation by creating Life Safety Code equivalency requests, working with the Authority Having Jurisdiction (AHJ), conducting Fire Safety evaluations compliant with NFPA-101A Fire safety evaluation System (FSES), and creating a PFI and building maintenance program. Awareness and continuous preparation are truly the keys to success in this fast-changing and highly competitive arena.

For additional information on Primera’s Life Safety services, please contact Rosa Lazebnik.

Recent Changes in Healthcare Governing Codes and Requirements Impact Joint Commission Accreditation

One of the challenges facing healthcare facilities today is maintaining accreditation by The Joint Commission. Recent changes in codes and requirements can impact your next TJC inspection.