Recently there have been regulatory updates that affect healthcare facilities including standards that apply to hospital accreditation. The Joint Commission applies standards that pertain to federal Medicare and Medicaid reimbursement. Has your facility adapted to comply with the current and updated standards? Hear our expert provide a comprehensive look at the “Environment of Care” and see how to better adapt your facility to ensure the health and safety of hospital staff, patients, and visitors.

1. 2019 Healthcare Accreditation
Regulatory Updates: How Do the New
Regulations Affect Your Facility?
Erin Stolz
Environmental, Health, and Safety Consultant
Triumvirate Environmental

2. 2
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3. Erin Stolz
Environmental, Health, and Safety Consultant
Triumvirate Environmental
3
Meet Your Presenter

4. Agenda
4
Overview
Top Compliance Issues from 2018
TJC- Categories of Compliance
Dedicated Behavioral Health Units
Q&A

5. Overview
• Accreditation requirements pertaining to Healthcare Facilities
▪ The Center for Medicare and Medicaid
▪ The Joint Commission
• Managing EH&S programs
• Ensuring compliance at your facility
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6. The Center for Medicare & Medicaid
6
• CMS maintains oversight for compliance
with the Medicare Health and Safety
Standards
• The survey (inspection) for this
determination is done on behalf of CMS
by the individual State Survey Agencies

7. The Joint Commission
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• An independent, not-for-profit organization
• The Joint Commission accredits and certifies
over 22,000 healthcare organizations and
programs in the United States
• Joint Commission accreditation and
certification is recognized nationwide as a
symbol of quality that reflects an
organization’s commitment to meeting certain
performance standards

8. • Departmental integration is critical to ensure
compliance across the many sectors of
Healthcare Compliance
▪ Environmental, Health, and
Safety
▪ Engineering
▪ Infection Control
▪ Clinical Staff
▪ Environmental
Services
Departmental Integration
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9. Agenda
9
Introduction/Overview
Top Compliance Issues from 2018
TJC- Categories of Compliance
Dedicated Behavioral Health Units
Q&A

10. Top Compliance Issues from 2018
1. 88.85% Sprinkler pipe supports other items, dust in sprinkler heads,
missing plates, 18-inch rule
LS.02.01.05
2. 78.68% Risks associated with Utility Systems (electrical panel issues)
EC.02.05.01
3. 73.85% Safe and functional environment is maintained (pertaining to
ligature issues)
EC.02.06.01
4. 72.90% Building features protect from fire and smoke (penetrations)
LS.02.01.30
5. 70.85% High Level Disinfection
IC.02.02.01
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11. Top Compliance Issues from 2018 (cont.)
6) 70.73% Building and fire protection systems are designed/maintained to
minimize effects of fire and smoke (door latching)
LS.02.01.10
7) 67.42% Egress
LS.02.01.20
8) 64.73% Utility Systems are inspected, tested, maintained.
EC.02.05.05
9) 62.25% Safety and security risks are managed
EC.02.01
10) 62.11% Medical gas compliance (co-mingling of oxygen tanks, excessive
storage, blocked valves)
EC.02.05.09
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12. Agenda
12
Introduction/Overview
Top Compliance Issues from 2018
TJC- Categories of Compliance
Dedicated Behavioral Health Units
Q&A

13. The Joint Commission- Categories of Compliance
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• Fire Safety
• Safety Management
• Utilities
• Infection Control
• Hazardous Materials & Waste
• Security
• Medical Equipment
• Staff Knowledge

14. Categories of Compliance –Fire
Safety
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• Fire doors
▪ Latching, marked, not obstructed
• Emergency equipment
▪ Extinguishers/pull stations present
and not obstructed
• Egress
▪ Clear pathways
• Hazardous materials storage
▪ NYC fire code
• NFPA 99: Healthcare facilities code
• NFPA 101: Life safety code

15. • Housekeeping
▪ Ceiling tiles not stained/broken
▪ Slip/trip hazards
▪ Environmental Services
• Compressed gas management
▪ Securement
▪ Adherence to storage requirements
▪ Compressed oxygen cylinders
• EC Code
• NFPA 99
Categories of Compliance –Safety Management
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16. Categories of Compliance –Utilities
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• Electrical panels
▪ Secured, labeled properly, not obstructed
• Mechanical equipment rooms
▪ No storage, clean
• Outlets
▪ GFCI near water sources
▪ Tamper-resistant in pediatrics, waiting rooms, behavioral health units
• Retractable power taps
▪ No extension cords as a permanent fixture
▪ Patient vicinity power taps
- UL 1363A, UL 60601-1
• EC code
• NFPA 99

17. Categories of Compliance –
Infection Control
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• Designated locations
▪ For clean supplies vs.
dirty/soiled supplies
• Refrigerators
▪ Designated for food vs.
medications
▪ Temperature logs
▪ Expiration dates
• Ice Machines
• Bottom shelf storage

18. Categories of Compliance –Hazmat/Hazardous Waste
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• Biohazardous waste management
▪ Sharps
▪ Red-bagged
• Chemical Labeling/Storage
• Spill kits
• Personal Protective Equipment
• Emergency Equipment
▪ Safety shower, eyewash
• Hazardous Chemical Inventory
• Staff familiarization with waste disposal
• Hazardous waste management

19. • Hazardous Communication Standard
▪ 29 CFR 1910.1200 (g)
▪ Globally Harmonized System
▪ Chemical Labeling
▪ Safety Data Sheets
▪ Right to Know/Right to Understand
Hazmat- OSHA/GHS
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20. Hazardous Waste- NYS DEC, EPA
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• The Resource Conservation and Recovery Act of 1976
▪ 40 CFR 260-273
• New York State Hazardous Waste Regulations
▪ 6 NYCRR 372.2(a)(8)
• Hazardous waste management
▪ Staff training
▪ Labeling
▪ Container standards
oCompatibility
oClosed containers
oPharmaceutical Waste Disposal

21. • Ensuring Sensitive Patient Information
is kept confidential
▪ HIPAA
• Facility security requirements
▪ Employee ID badges
• Medication Diversion Prevention
• Securement of sensitive areas
Categories of Compliance –Security
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22. • Routinely inspected
• Maintained
• Cleanliness assurance
• Protocols in place for faulty
medical equipment
Categories of Compliance –Medical Equipment
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23. • Emergency plans/protocols
▪ Hospital policies
▪ Evacuation routes
• Familiarization of Emergency Equipment
▪ Location
▪ Methods of use
• Hazmat
▪ Chemical/Hazardous spill protocols
▪ Access to SDS
▪ Waste disposal
Categories of Compliance –Staff
Knowledge
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24. Agenda
24
Introduction/Overview
Top Compliance Issues from 2018
TJC- Categories of Compliance
Dedicated Behavioral Health Units
Q&A

25. • In-Patient Psychiatric Units/Psychiatric
Emergency Departments
▪ Develop & utilize Validated Screening
Tool to determine if patients at risk for
self-harm
▪ Identify environmental safety risks
▪ Provide environmental education and
training for employees and volunteers
▪ Identified deficiencies must be
addressed within 60 days from receipt
of Condition level finding
Dedicated Behavioral Health Units
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26. Non-Psychiatric Units
• Ligature resistant environment is
not a requirement for non-psych
units
▪ e.g. Emergency Rooms
• However, it is recommended to
have “safe room” and a screening
process to determine if a patient
is at risk of self-harm
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27. • Mitigation Plan must be implemented for Dedicated
Behavioral Unit Findings pertaining to Ligature Risk
▪ Comprehensive Risk Assessment
o Clinical/Security Interventions
o 1:1
▪ Evaluate effectiveness of mitigation plan
o Risk level
▪ Predicted date of resolution
▪ Actual date of resolution
o Aim for 60-day
Mitigation Plan- Risk Assessment
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28. • Provides recommendations for
ligature-resistant furniture/permanent
fixtures
▪Can modify current
equipment/fixtures
▪Chairs, beds, lights, bathrooms
• Concurs with CMS recommendations
NYS OMH Guidelines
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29. Agenda
29
Introduction/Overview
Top Compliance Issues from 2018
TJC- Categories of Compliance
Dedicated Behavioral Health Units
Q&A

30. Questions?

31. THANK YOU!
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www.triumvirate.com