Quality Assurance Division Certification Bureau 1 FALL 2017 MHA Plan for Today 2 Certification Bureau Update NEW S&Cs From CMS Abuse Reporting New LTC Regulations and Impact Top 10 Health Tags Break Life Safety Code Update Emergency Preparedness Questions Certification Bureau Team Commitments Public Protection Communication Consistency Accurate Surveys Continuous Education 3 Fall 2017 Presentation 1
Survey and Certification Team 4 15 Surveyors Health & LSC 9 Openings 8 Surveyors 1 Training/Education Staff Member DPHHS Department Wide Hiring Freeze (February 2017) CLIA Surveyor 2 Certification Specialists 3 Supervisors- LTC, NLTC, & CLIA/LSC AREAS WE HAVE BEEN WORKING ON 5 Newsletter mtssad@mt.gov Abuse Reporting Pamphlet Compliance Readiness Bulletins (CRB) New Survey Process Internal Checklists for Processes CMS Survey & Certification (S&C) Policies/Memos FFY 2017 6 17-25 NH Electronic Staffing Submission Payroll-Based Journal Update 17-26 NH 17-27 NH 17-29 ALL 17-30 Hospitals/CA Hs/NH Notice of Proposed Regulation Changes to Requirements Related to Survey Team Composition and Investigation of Complaints Implementation Issues, Long-Term Care Regulatory Changes: Substandard Quality of Care (SQC) and Clarification of Notice before Transfer or Discharge Requirements Advanced Copy- Appendix Z, Emergency Preparedness Final Rule Interpretive Guidelines and Survey Procedures Requirement to Reduce Legionella Risk in Healthcare Facility Water Systems to Prevent Cases and Outbreaks of Legionnaires Disease (LD) 17-34 Hospice Hospice Survey Webinar Fall 2017 Presentation 2
CMS Survey & Certification (S&C) Policies/Memos FFY 2017 (continued) 17-35 ALL 17-36 NH 17-37 NH 17-38 LSC 17-41 NH 17-42 ALL 17-43 ALL 17-44 All Hospitals Reasonable Assurance Will Apply to Providers and Suppliers Who Voluntarily Terminate and Seek New Certification If a Termination Action by the State Agency Had Been Initiated Revision to State Operations Manual (SOM) Appendix PP for Phase 2, F-Tag Revisions, and Related Issues Revision of Civil Money Penalty (CMP) Policies and CMP Analytic Tool Fire and Smoke Door Annual Testing Requirements in Health Care Occupancies Notification of Final Rule Published Survey Team Composition and Investigation of Complaints Termination Notices Available via the Survey & Certification Website Quality and Certification Oversight Reports (QCOR) Website Launch Advanced Copy- Revisions to State Operations Manual (SOM) Hospital Appendix A 7 ABUSE REPORTING 483.12 - F225 Abuse and Neglect 483.12(c)(1) Ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, are reported immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury, to the administrator of the facility and to other officials (including to the State Survey Agency and adult protective services where state law provides for jurisdiction in long-term care facilities) in accordance with State law through established procedures. 8 ABUSE REPORTING ADULT PROTECTIVE SERVICES Adult protective Services (APS) are provided through Senior and Long Term Care; a Division of the Montana Department of Public Health and Human Services. Certification Bureau and Adult Protective Services, are two separate agencies who partner together for those we serve, but investigations are separate, as are the services provided. APS Reporting Toll free number 1 844 277 9300 9 Fall 2017 Presentation 3
ABUSE REPORTING TRIFOLD 10 Editing to Reflect New Regulations Policy of Reporting by Facility Complaints - Result in Lack of Reporting Elder Advocacy 11 The Adult Protective Services Act establishes a program designed to meet the needs of vulnerable adults who have been abused, neglected, or exploited. It places authority and responsibility for investigations and interventions in situations of abuse, neglect, and exploitation of vulnerable adults with Adult Protective Services. Elder Advocacy - Continued 12 During fiscal year 2016, APS provided some form of assistance to 6,925 persons across Montana, including court ordered guardianship services for 173 Montanans. Adult Protective Services are mandated under Montana Law. Fall 2017 Presentation 4
Elder Advocacy - Continued 13 There are 42 FTE adult protective services professionals located across the state who have the duty to investigate allegations of abuse, neglect and exploitation of vulnerable adults. The number of vulnerable adults living in Montana communities has grown rapidly over the past few years increasing the demand for the services provided by APS workers. Elder Advocacy - Continued 14 Investigations of allegations of abuse, neglect and exploitation have increased from 6,079 in 2011, to 6,925 in 2016. Of the 6,925 allegations received and investigated, roughly 37% were related to neglect, 18% to exploitation, 13% to abuse concerns, and 29% were requests for assistance for vulnerable adults. Elder Advocacy Support Services 15 Receiving, investigating, and intervening, when reports of abuse, neglect or exploitation occur Coordinating activities among state and county agencies which provide human services and working with law enforcement if there is evidence of suspected criminal activity Developing a safety plan in cooperation with the vulnerable adult Monitoring services and periodic re-evaluation of potential risk factors Fall 2017 Presentation 5
Support Services - Continued 16 Educating professionals and the public regarding the prevention abuse, neglect and exploitation Assuming the role of court-ordered guardian as agency of last resort, for vulnerable adults who are unable to do so themselves Assisting and consulting in the development of prevention programs and entities to provide necessary guardianship to individuals in the least restrictive environment available Providing temporary, emergency assistance, purchased through contingency funds authorized by the legislature, to vulnerable adults in need Elder Advocacy APS - Statistics 17 APS - Statistics 18 Once a report is received and APS investigates they conclude whether the report is: Confirmed Inconclusive Unfounded Undetermined Number of Reports Allegations Received 10 Abandonment 29 Domestic Violence 37 Exploitation 444 Financial Exploitation 30 Isolation 27 Medication abuse 254 Neglect 89 Physical Abuse 51 Property Exploitation 231 Psychological/Mental Abuse 738 Self Neglect 11 Sexual Abuse Fall 2017 Presentation 6
APS - Statistics Continued 19 From the current APS electronic system, from Feb 6, 2016 to -July 18, 2016, 740 reports were received, with 160 confirmed (substantiated) cases Unfortunately, data was not collected on substantiated reports prior to this time Females age 60 and older are at higher risk No trends have been identified in the reports, or outcomes APS - Statistics Continued 20 APS Work Type SFY-2011 SFY-2012 SFY-2013 SFY-2014 SFY-2015 SFY-2016 Abuse Allegations 861 14% 901 13% 850 12% 843 12% 765 11% 908 13% Neglect Allegations 3129 51% 3518 51% 3562 52% 3309 47% 2600 38% 2592 37% Exploitation Allegations Information and Referrals 1019 17% 1145 17% 1045 15% 1084 15% 1100 16% 1234 18% 741 12% 956 14% 1001 15% 1576 22% 2046 30% 2030 29% Protective Cases 88 1% 83 1% 190 3% 70 1% 106 2% 161 2% Guardianships 241 4% 242 4% 232 3% 214 3% 191 3% 173 2% Total APS Workload 6079 100% 6845 100% 6880 100% 7096 100% 6808 100% 6925 100% Information So Far 21 Questions Fall 2017 Presentation 7
Long Term Care Changes and Updates 22 Presented By Tina Frenick, LTC Supervisor Interwoven Paths of LTC The New Survey Process Key Areas 23 National Consistency in Surveys Need for Uniform Surveyor Training Recertification Survey Sample Selection Software Supported Process Experience, Knowledge Sharing Rationale Consistency 24 Allows states to benefit from improvements in the process Improvements achieved benefit all states simultaneously Fall 2017 Presentation 8
Rationale Training One simplified process One unified process means surveyors can attend any available BLTCC (Basic Long Term Care Course) More subject matter experts previously two different processes Surveyors are currently in the office training, which is web based, with an alternate training to occur in October for those who could not attend All surveyors must be trained prior to implementation of the new process The training will be available for surveyors to review up to the implementation of the new survey process 25 Rationale Sample Selection 26 Acknowledges professional expertise of surveyors 70% of the sample selected from MDS data 30% of sample selected onsite by surveyors, based on condition of resident at the time of the survey Rationale Software 27 Readily available to help identify appropriate regulation to assess compliance Available to ALL states Provides flexibility and organization in assessing resident well-being by allowing easy navigation between components of the survey process Fall 2017 Presentation 9
Rationale Experience 28 Allows CMS and states to have a shared process and tool set Increases collaboration and expertise within CMS workforce Survey agencies will have easier access to CMS resources and training Survey Process Innovations 29 A. Offsite Prep B. Facility Entrance C. Initial Pool D. Sample Selection E. Investigation F. Ongoing and Other Survey Activities G. Potential Citations Survey/Process Similarities Team meetings Investigation process Surveyors identify deficiencies and make severity determinations Team decides on final citations, severity and scope of deficient practices 30 Fall 2017 Presentation 10
Survey Process Innovations - Improvements 31 Software Floor Time Systems Regulations Workflow, Care Areas, Efficiency, Probes/Prompts Increased Observations and Resident Interviews Improved Consistency, Accuracy of Problem Identification, Increased Reporting Accuracy Surveyors Able to Observe Wider Range of Issues Survey Process Software Features Links surveyors to probes/questions as guidance Directly links to Long Term Care regulations Guides the workflows for Care Areas investigated Survey task completion reminders Assist surveyors in identifying MDS inaccuracies Allows surveyors to embed date and time automatically into the record 32 Process Elements 33 Fall 2017 Presentation 11
Offsite Preparation 34 Offsite prep data review now completed independently by surveyors Team Coordinator: Create survey shell Complete offsite prep Assign units Make mandatory facility task assignments Independent review Subtasks Document gathering, review facility history, assign mandatory tasks Sample 35 70% of the sample is pre-selected based on key care needs Residents who had at least one MDS within 180 days prior to the survey shell creation Any MDS assessment, except only Discharge assessments or only entry (not Admission) Includes resident names for closed record reviews Entrance The Entrance Conference Worksheet, and the facility Matrix, with instructions, will be reviewed with the facility administrator or designee, to ensure required information is received timely. Specific information is required from the facility, to include: Immediately, within 4 hours, and within 24 hours. Each surveyor will need access to EHRs accessed on tablets Most commonly accessed on the unit or nursing station 36 Fall 2017 Presentation 12
Initial Pool and Investigations Pool Two goals Identify residents for onsite, and determine if offsite selected residents should be included for the sample. Investigations 37 Investigation process inherently the same Observations and Interviews Document findings Determine compliance Select Severity for areas of noncompliance Task Changes Personal Funds and Environment * These will only be investigated if problems are identified Regulatory Overview 38 KEY Implemented in Phase I Implemented Phase II Implemented Phase III *New Regulatory Section Resident Rights Resident Assessment Freedom from Abuse, Neglect and Exploitation* Comprehensive Care Planning* Admission, Transfer, Discharge Quality of Life Quality of Care Physician Services Nursing Services Behavioral Health* Pharmacy Services Laboratory, Radiology, Dental Services Food and Nutrition Diagnostic services* and Specialized Rehabilitation Administration Compliance and Ethics Quality Assurance and Performance Improvement* Physical Environment Infection Control Training Requirements* Ongoing Survey Activities 39 A Significant Change includes the QAA/QAPI pathway being updated and explained to reflect new guidance. This includes brand new task sufficient and competent nurse staffing Complete closed record reviews Complete mandatory facility and triggered task assignments End of day meetings for surveyors Fall 2017 Presentation 13
Mandatory and Triggered Tasks 40 Updated Pathways for the following mandatory tasks: Dining Infection Control SNF Beneficiary Notification Kitchen Medication Administration Medication Storage Resident Council Sufficient and Competent Nurse Staffing QAA/QAPI Triggered Tasks, to only be investigated if concerns are identified: Personal Concerns Environment Potential Citations 41 Share completed investigation data with Team Coordinator Deficiency determination with the survey team includes severity and scope determinations Conduct an exit conference with facility to convey recommended areas of noncompliance Information So Far 42 Questions Fall 2017 Presentation 14
43 TOP 10 HEALTH RELATED DEFICIENCIES FFY2017 (October 1, 2016 to September 2017) Quality Certification & Oversight Report 44 Active Providers = 65 Total Number of Surveys = 117 Category # Citations % Providers Cited % Surveys Cited Infection Control 36 46.2 30.8 Professional Standards Accidents and Hazards 33 47.7 28.2 32 40.0 27.4 Category # Citations % Providers % Surveys Cited 45 Care Plan Update 31 40.0 26.5 Care Plan Development 21 30.8 17.9 Housekeeping and 19 27.7 16.2 Maintenance Maintaining Highest Well 19 26.2 16.2 Being Food - 18 26.2 15.4 Store/Prepare/Distribute Assessment Accuracy 17 24.6 14.5 Drug Storage, Records, Labeling 16 24.6 13.7 Fall 2017 Presentation 15
Deficiency Trending 46 Approximately 8.5 % of facilities cited for abuse/neglect/policies related to abuse F314 Pressure Ulcers, included 22 out of 25 of the top ten deficiencies, which is an improvement over last years statistics Pharmacy and Medication related citations consisted of 1/5 of the top ten Four of the top 25 deficiencies included Dietary and Nutritional concerns TOP 10 HEALTH RELATED DEFICIENCIES #1 F441 Infection Control Storage and cleaning of blood testers between residents [IJ (K)] Failure to identify the spread of a gastrointestinal virus [IJ (K)] Failure to identify the spread of a gastrointestinal virus and lice [IJ (L)] Oxygen equipment (e. g. nasal cannula, nebulizers, filters) not being maintained 47 TOP 10 HEALTH RELATED DEFICIENCIES #1 (continued) F441 Infection Control Handwashing Hygiene/Glove Changes - medication pass, transfers, food delivery, injections, between dirty and clean procedure, ADLs Cleaning of lifts Separation between clean and dirty linen Catheter tubing dragging on the floor Tube feeding materials left in shared bathroom 48 Fall 2017 Presentation 16
TOP 10 HEALTH RELATED DEFICIENCIES #2 49 F281 Service Providers Meet Professional Standards Failure to Obtain/Follow Physician Orders Treatment of Pressure Ulcers Unusual Dosage Which Became a Medication Error Therapeutic Diets Notification of Physicians when Exceeded Sliding Scale Mittens for Resident to Eliminate PEG Tube Removal Resident Required to Wear Sling not In Plan of Care Oral Care TOP 10 HEALTH RELATED DEFICIENCIES #2 (continued) 50 F281 Service Providers Meet Professional Standards Tube Feeding Process Not Followed Neurological Checks for Residents with Falls Nursing Professional Standards & Rights of Medication Administration PRN & Documentation of Efficacy G Tube Process for Medication Delivery Bowel Protocol Use of Multidose Vial of Insulin Past Expiration Date Failure to Label Prepoured Medication Cups TOP 10 HEALTH RELATED DEFICIENCIES #3 51 F323 Free of Accident Hazards/Supervision/Devices Storage of Hazardous Chemicals Resident with severe cognitive deficits and protection from falls Evaluation of Staff Using Assistance Devices Properly Maintenance of Wheel Chair and Oxygen Cylinder Protection Complications Related to Feeding Tube Usage Fall 2017 Presentation 17
TOP 10 HEALTH RELATED DEFICIENCIES #3 (continued) 52 F323 Free of Accident Hazards/Supervision/Devices Falls Monitoring and Interventions Sharp Edges on Handrails Gait Belts Not Used Failure to Repair a Call Light Transportation (Van) for Residents Not Being Maintained No Supervision in Rehab Dining Hall During Meal Time TOP 10 HEALTH RELATED DEFICIENCIES #4 through #10 53 4. F280 Right to Participate Planning Care Revise Care Plan 5. F279 Develop Comprehensive Care Plans 6. F253 Housekeeping & Maintenance Services 7. F309 Provide Care/Services for Highest Well Being 8. F371 Food Procurement, Store/Prepare/Serve Sanitary 9. F278 Assessment Accuracy/Coordination/Certified 10. F431 Drugs Records, Label/Store Drugs & Biologicals Information So Far 54 Questions Fall 2017 Presentation 18
Completing a Plan of Correction - EPOC 55 POC - Success The 1 st Time 56 The entity needs to have awareness of what needs corrected, abilities of staff, and what the facility is capable of. Ask, do you have enough information to know what needs corrected? If not, ask surveyors questions Determine a baseline Where do you begin, and where should you begin? POC - Prepare for Revisit Survey 57 The SA goal continues to be to improve consistency among surveyors when epocs are reviewed, approved, and denied. This change occurred, in part, due to provider comments, and to improve consistency within the State Agency and for the providers. Fall 2017 Presentation 19
POC - Sustaining Corrections 58 Identify the extent How were others affected How will corrections be made What systems will be changed, improved, or developed to carry out the corrections How will monitoring occur Look at realistic timelines, and a system that will catch, and address a problem quickly. POC - Recites 59 Lack of staff awareness of the true deficient practice Lack of staff awareness of the extent of corrections needed Staff accountability for corrections Facility designees assigned to carry out corrections, were not adequately skilled, or complete the task(s) necessary. Example: Social Services auditing medication errors POC - Recites 60 Timelines were not realistic (applies to any portion of POC) Monitoring did not capture the actual deficient practice, therefore, it continued to occur The facility did not validate the corrections were made, that education was understood, or that the system was completely in place to make the corrections Fall 2017 Presentation 20
POC - Date of Compliance 61 X5 Date All corrections should be finalized by this date, therefore, a facility should plan accordingly for the necessary corrections documented on the POC POC Review Criteria 62 5 Criteria CMS Requires 63 1. Address/Correct for those residents affected 2. Address how the facility will identify other residents/locations having the potential to be affected by the same practice 3. Address what measure(s) will be put into place or systemic changes made to ensure the deficient practice will not recur Fall 2017 Presentation 21
5 Criteria CMS Requires 64 4. Indicate how the facility plans to monitor its performance to make sure that solutions will be sustained 5. Completion Date: This is your X5 date, which you input into the epoc system. This is the date the facility has stated compliance for areas of deficient practice. Criteria One 65 Address each resident/location individually by sample number Include details of what was corrected for each resident, location, or the deficient practice Include titles (not names) of the responsible parties completing the tasks, or for those who educate others, to ensure they have knowledge base to complete the assignment Criteria One 66 Include dates for actions, or completion To determine if corrective actions are sufficient, surveyors have been educated to review each paragraph in the 2567, identify if a deficient practice was documented, and then validate if the facility addressed failure. Fall 2017 Presentation 22
Criteria Two 67 Steps for how the facility identified other residents/locations should be reflected in the plan To say "All residents/locations are affected" will not be applicable for a majority of situations, but if it is, the facility should show how they determined this Do not forget the titles of assigned parties, and dates of completion, and what will be done for those residents Criteria Three 68 For this step, the facility should address system issues, which may have been identified within the content of the deficiency, or the deficient steps leading to the root cause of the deficient practice Criteria Four 69 Monitoring of the deficient practice, and if needed, the identification of ongoing issues. A plan may not be accepted unless it shows how the facility will sustain the compliance Random audits - Now require specific detail, frequency, number, and who, what, and why the audit is occurring QAPI This should include steps, actions, and a plan, for how the deficient practice will be sustained Fall 2017 Presentation 23
Criteria Four Consider the resident(s) outcome when determining whether or not the timeline for monitoring is adequate. CMS has developed the QAPI oversight program and does not agree that it is acceptable to review a deficient concern only on a quarterly basis, but rather the QAPI oversight should be ongoing. Validate compliance through QA review, prior to the date of compliance. This may include an adhoc meeting, to show the areas of deficient practice, are corrected prior to the X5 date. Achieve and maintain the alleged compliance throughout the next survey cycle, and address failure timely for needed corrections. 70 Criteria Five 71 (X5 date) in ASPEN Central Office database Date of Compliance May be different for each deficiency All corrective actions taken by the facility must have occurred prior to the date of compliance for each individual deficiency Criteria Five 72 The X5 dates must be accepted by the State Agency, and as a policy of the Certification Bureau, not greater than 45 days from the date of exit Compliance dates cannot be the same date as the date survey completed (upper right corner of 2567) Fall 2017 Presentation 24
73 EPOC Process Successful Surveys http://dphhs.mt.gov/qad/certification.aspx Traditional Revisit (Follow-Up) 74 This is to confirm that the facility is in compliance, and has the ability to remain in compliance. The revisit survey is to re-evaluate the specific care and services that were cited. Facility uses 5 elements of the POC. The QAPI program should monitor and identify the performance of the corrected deficient practice, to ensure the practice does not recur, or if there are continued issues, they can be corrected timely. On-site vs Revisit by Mail? 75 The nature of the non-compliance dictates the scope of the revisit Conduct necessary tasks to determine compliance has occurred Surveyors gather documentation related to any area of non-compliance during the revisit Nothing precludes the Bureau from doing an onsite revisit for any deficiency, but certain circumstances require an onsite revisit survey Fall 2017 Presentation 25
Revisit Surveyor 76 Focus on residents who have conditions/needs/problems cited in the original survey Enforcement actions may have already been initiated by CMS, but: If compliance is not achieved, and the surveyor finds deficient practices continue to occur, enforcement action will be initiated Revisit - Compliance Date 77 The date of compliance will changed to the earliest date compliance is validated The earlier you achieve compliance, the better it is for the residents If a facility feels they have achieved compliance earlier than the X5 date, notify the surveyor right away If compliance is not achieved by the X5 date, the date will reflect the non compliance If compliance does not occur by the revisit survey, the facility will be deemed to Not be in Compliance and the enforcement track will continue Information So Far 78 Questions Fall 2017 Presentation 26
LSC Update 79 Presented By Tony Sanfilippo, CLIA & LSC Supervisor Life Safety Code Update 80 NFPA 80 Fire Door Inspections Legionella Top 10 Life Safety Code Deficiencies Emergency Preparedness NFPA 80 FIRE DOORS & DAMPERS 81 Chapter 5 Care & Maintenance Operability Doors shutters & windows shall be operable at all times Must contact testing Laboratory prior to initiating any field modifications Any assembly replacement shall meet all requirements as original designed & tested Fall 2017 Presentation 27
NFPA 80 FIRE DOORS & DAMPERS 82 Inspections & Functional Testing Fire door assemblies shall be inspected & tested not less than annually Prior to testing a visual inspection shall be performed to identify damaged or missing parts Visually inspect assemblies from both sides to assess the overall assembly condition NFPA 80 Fire Doors & Dampers 83 Minimum items to be documented & verified No open holes or breaks exist in any surfaces All light frames or vision panels are securely in place Frames, Hinges, Hardware & thresholds are securely in place & aligned No parts are missing or broken All Door clearances are maintained Self closing devices are operable NFPA 80 FIRE DOORS & DAMPERS 84 Minimum items to be documented & verified Verify door coordinator operation Verify latching hardware secures door when closed Verify auxiliary hardware items will not prohibit operation No field modifications have been performed that mat void tested & labeled assembly Visualize all gasketing & edge seals to verify integrity Fall 2017 Presentation 28
NFPA 80 FIRE DOORS & DAMPERS 85 Testing Upon door installation confirm operation of closing device & full closure of the door Resetting automatic closing devices shall be in accordance with manufacturers instructions Written Records shall be maintained & available to the AHJ NFPA 80 FIRE DOORS & DAMPERS 86 Fire Dampers Periodic Inspection & Testing Each damper shall be inspected & tested 1 year after installation Inspection Frequency shall be every 4 years, Hospitals shall be every 6 years All Testing shall be documented indicating type of damper, Fire/ Smoke, the location & date of inspection, the Inspectors name, & any noted deficiencies Document any corrective actions or repairs All documentation shall be maintained & made available to the AHJ CMS S&C 17-30 Legionella Risk 87 Factors to spread Legionella Water filters Showerheads & hoses Centrally installed misters, atomizers, air washers, & humidifiers Ice machines Hot tubs/saunas Decorative fountains Medical devices (such as CPAP machines hydrotherapy equipment, bronchoscopes, heatercooler units) Fall 2017 Presentation 29
CMS S&C 17-30 Legionella Risk Expectations for Healthcare Facilities Conduct a facility risk assessment to identify where Legionella could grow & spread in the facility water system Implement a water management system Utilize ASHRAE industry standard & the CDC toolkit which includes, temperature control, visual inspections & environmental testing for pathogens Specify testing protocols & document the results of testing & any corrective actions taken Healthcare facilities are expected to comply & demonstrate measures to minimize Legionella risk, as a condition of participation for CMS 88 Top 10 LSC Deficiencies 89 1. Sprinkler System - Maintenance and Testing 2. Electrical Equipment - Power Cords and Extension Cords 3. Corridor - Doors 4. Portable Fire Extinguishers 5. Egress Doors 6. Exit Signage 7. Hazardous Areas - Enclosure 8. Discharge from Exits 9. Sprinkler System - Installation 10. Fire Alarm System - Testing and Maintenance Top 10 LSC Deficiencies: #1 50% Sprinkler System - Maintenance and Testing K 353 Escutcheon Rings, Ceiling Membrane, AHJ Contact Number, State Agency 406-444-4170, if system is out of service over 10 hours, a Fire Watch Shall be conducted Over 4 Foot Obstructions Obstruction Testing 5 years Information Signage Gauges 5 years Calibrate or Replace Duct Work over 4 feet Coverage Above & Below 90 Fall 2017 Presentation 30
Top 10 LSC Deficiencies: #2 35% 91 Electrical Equipment Power Cords & Extension Cords K 920 Shall Be Rated for Appliance Draw Shall Not Be Utilized as a Substitute for Fixed Wiring N.F.P.A. 99, 2012 Edition Top 10 LSC Deficiencies: #3 31% 92 Corridor Doors K 363 Positive Latching Hold Open Devices Shall Release when the door is pushed or pulled Maintain All Door Components & Frames N.F.P.A. 101, 2012 Edition Top 10 LSC Deficiencies: #4 23% 93 Portable Fire Extinguishers K 355 Location Every 75 Feet, along normal paths of travel Height of Mounting not exceeding 40 lbs. 5 feet to top of Extinguisher Extinguisher over 40 lbs. 3.5 feet to top of Extinguisher Visually inspect pressure gauge, hose for signs of discharge, document on tag, pin securely attached, remove & shake contents N.F.P.A. 10, 2010 Edition Fall 2017 Presentation 31
Top 10 LSC Deficiencies: #5 24% 94 Egress Doors K 222 Shall not be locked Patient Needs Locking, Permitted with Exceptions & AHJ Approval N.F.P.A. 101, 2012 Edition Top 10 LSC Deficiencies: #6 19% 95 Exit Signage K 293 Document Testing & Maintenance, not to exceed 30 Days Letter Size, New Signs 6 Inches, Existing Sign 4 Inches N.F.P.A. 101, 2012 Edition Top 10 LSC Deficiencies: #7 21% 96 Hazardous Areas, 1 hour Fire Resistive Rating & Fire Suppression, K 321 Examples, Bulk Laundries over 100 square feet, Rooms over 50 square feet storing combustibles Paint Shops, Repair Shops, Soiled Linen or Trash in excess of 64 Gallons N.F.P.A. 101, 2012 Edition Fall 2017 Presentation 32
Top 10 LSC Deficiencies: #8 21% 97 Discharge from Exits K 271 Means of Egress, shall be free of all obstructions or impediments to full instant use in the case of fire or other emergency Snow & Ice, Furnishings, Decorations, Mirrors Changes in elevation of walking surfaces shall not exceed ¼ inches Exit discharge travel shall be clearly marked to the public way N.F.P.A. 101,2012 Edition Top 10 LSC Deficiencies: #9 19% 98 Sprinkler System Installation K 351 Canopies, Sprinklers Shall be Installed, Unless Non Combustible or Limited Combustible Remodeling, Sprinklers shall be maintained operable along with any other rated assemblies, after 10 hours a Fire Watch Shall be established Maintain all documentation & acceptance approvals Closets in patient sleeping rooms not over 6 square feet do not require sprinkler coverage, as long as the closet footprint has coverage Never cover or paint sprinkler heads N.F.P.A. 13, 2010 Edition Top 10 LSC Deficiencies: #10 17% Fire Alarm System Testing & Maintenance K 345 Table 14.4.5 Testing Frequencies, Batteries, Sensitivity for Smoke Alarms Fire Watch shall be established if system is out of service for more than 4 hours in a 24 hour period, also the AHJ shall be notified, State Agency Contact Number 406-444-4170 Fire Drills Shall be conducted quarterly for each shift utilizing the Fire Alarm system, Documentation of all drills shall be maintained for review by the AHJ N.F. P.A. 72, 2010 Edition & N.F.P.A. 101, 2012 99 Fall 2017 Presentation 33
EMERGENCY PREPAREDNESS 100 How long can you maintain the building without power? What does the generator support if you have one? What kind of natural or manmade disasters could your facility face? Do you have a transfer plan for residents? Do you expect all staff to make it to the facility in a disaster? How many more issues should be considered????? EMERGENCY PREPARDNESS 101 Emergency Preparedness Program FOUR (4) Provisions for All Providers Types 1. Risk Assessment and Planning 2. Policies and Procedures 3. Communication Plan 4. Training and Testing POLICIES AND PROCEDURES Based on Emergency Plan and Risk Assessment Must Address a Range of Issues Subsistence Needs Evacuation Plans Procedures for Sheltering in Place Tracking Residents/Patients/Clients and Staff During an Emergency Update Policies and Procedures at Least Annually 102 Fall 2017 Presentation 34
COMMUNICATION PLAN Must Comply with State and Federal Laws Coordinate Patient Care Within the Facility Across Health Care Providers State and Local Health Departments Emergency Management Systems Review and Update Annually 103 TRAINING AND TESTING PROGRAM 104 Maintain Training and Testing Programs Initial Training Included Staff Demonstrate Knowledge and Retrained at Least Annually Drills and Exercises to Test Emergency Plan TRAINING AND TESTING COMPLETION 105 Complete by 11/15/17 Conduct One of the Following Exercises: 1. Participation in full-scale exercise that is community based or 2. If no community based exercise available; an individual, facility based exercise Conduct an Additional Exercise: 1. A second full scale exercise that is individual, facility based 2. A table top exercise 3. Other? Fall 2017 Presentation 35
LONG TERM CARE CONSIDERATIONS 106 Must Share Information from the Emergency Plan with the Residents and Family Members or Representatives Subsistence Needs Temperature Controls Emergency Power and Stand-by Systems LONG TERM CARE CONSIDERATIONS 107 Must Share Information from the Emergency Plan with the Residents and Family Members or Representatives Subsistence Needs Temperature Controls Emergency Power and Stand-by Systems EMERGENCY PREPARDNESS 108 S&C 17-05-ALL: Information on the Implementation Plans for the Emergency Preparedness Regulation Applies to all 17 Providers and Suppliers S&C 17-21-ALL: Information to Assist Providers and Suppliers in Meeting the New Training and Testing Requirements of the Emergency Preparedness Frequently Asked Questions (FAQs) November 15, 2017 Implementation Date Training and Testing by November 15, 2017 S&C-17-22-ALL: National Provider Call (NPC) for Emergency Preparedness Training from 12:30 pm to 1:30 pm on Thursday April 27, 2017 DPHHS Public Health Emergency Preparedness (PHEP) http://dphhs.mt.gov/publichealth/phep S&C-17-29-ALL: Advanced Copy- Appendix Z, Emergency Preparedness Final Rule Interpretive Guidelines and Survey Procedures Fall 2017 Presentation 36
Information So Far 109 Questions Fall 2017 Presentation 37