What is TJC's position on staff using written prompts or "cheat sheets" during a survey when responding to surveyor questions about PASS, RACE, and other emergency procedures?
Monday, February 28, 2011
Thursday, February 24, 2011
Friday, February 18, 2011
Generator Weekly Inspection Tip
Here is a quick tip for a useful and proactive task to do during your generator weekly inspections. How often do you see evidence of leakage beneath your generator sets - either fuel oil, lube oil, or cooling water? Make sure to note the presence of that oil, and then clean it up (remove it) so that the slab under the generator set is clean. That way if leakage is observed during future weekly inspections you will know that you have an active leak that must be dealt with proactively to avoid costly future problems and potential generator failures.
SEPSS testing and UPS’s
There is often confusion about whether the EC.02.05.07 EP3 SEPSS testing requirements apply to the ubiquitous hospital UPS’s that are powered by the emergency power “branches” (life safety branch, critical branch, and equipment system.)
The short answer is that a UPS that gets its power from an EPSS (Emergency Power Supply System) is not a SEPSS. Therefore SEPSS testing requirements do not apply to such UPS’s. Be careful though, you still need to maintain and test any of your non-SEPSS UPS’s that are critical for operations during a power failure in accordance with Note 1 of EC.02.05.07, EP3.
The short answer is that a UPS that gets its power from an EPSS (Emergency Power Supply System) is not a SEPSS. Therefore SEPSS testing requirements do not apply to such UPS’s. Be careful though, you still need to maintain and test any of your non-SEPSS UPS’s that are critical for operations during a power failure in accordance with Note 1 of EC.02.05.07, EP3.
Tuesday, February 15, 2011
CMS Occupancy Classifications
Pending CMS Revision to S&C Letter on Occupancy Classifications
On December 17, 2010, CMS issued a Survey and Certification letter updating its occupancy classifications to ensure alignment with the 2000 edition of NFPA 101: Life Safety Code. As a result of the content of this update-S&C 11-05-LSC-ASHE has been receiving numerous telephone calls, e-mails, and traffic on the LISTSERV® about the potential impact this "clarification" could have on our members' clinics and medical office buildings.
On December 17, 2010, CMS issued a Survey and Certification letter updating its occupancy classifications to ensure alignment with the 2000 edition of NFPA 101: Life Safety Code. As a result of the content of this update-S&C 11-05-LSC-ASHE has been receiving numerous telephone calls, e-mails, and traffic on the LISTSERV® about the potential impact this "clarification" could have on our members' clinics and medical office buildings.
Thursday, February 3, 2011
Compliance News: Risk of Suicides in Hospital ER and Inpatient Units
By Dean Samet, CHSP
The Joint Commission issued a Sentinel Event Alert in its warning of the increased number of reported non-psychiatric patients committing suicide in hospital emergency rooms/departments and medical/surgical inpatient units. Suicide has ranked in the top five most frequently reported events to The Joint Commission in the past 15 years and ranks number 11 by the Centers for Disease Control and Prevention (CDC) as a leading cause of death in the nation.
The Joint Commission issued a Sentinel Event Alert in its warning of the increased number of reported non-psychiatric patients committing suicide in hospital emergency rooms/departments and medical/surgical inpatient units. Suicide has ranked in the top five most frequently reported events to The Joint Commission in the past 15 years and ranks number 11 by the Centers for Disease Control and Prevention (CDC) as a leading cause of death in the nation.
Compliance News: Environment of Care Time Notations
By Dean Samet, CHSP
The Joint Commission has a number of time notations designated in the Environment of Care standards’ elements of performance for its expectations when certain inspections, tests, tasks, functions, events, or drills are to occur. TJC recognizes that it will not always be possible to meet the exact time frames cited in their EPs. Therefore, as delineated in the November 2010 Environment of Care News article Time Defined, TJC has provided the following definitions which include some leeway and allowable deviation.
The Joint Commission has a number of time notations designated in the Environment of Care standards’ elements of performance for its expectations when certain inspections, tests, tasks, functions, events, or drills are to occur. TJC recognizes that it will not always be possible to meet the exact time frames cited in their EPs. Therefore, as delineated in the November 2010 Environment of Care News article Time Defined, TJC has provided the following definitions which include some leeway and allowable deviation.
Compliance News: Manufacturer's Maintenance Recommendations - Alternatives Accepted by CMS
By Dean Samet, CHSP
The Joint Commission accredited hospitals, critical access hospitals, and ambulatory care programs can breathe a sigh of relief. As reported in the December 2010 The Joint Commission Perspectives®, TJC engaged the Centers for Medicare & Medicaid Services (CMS) in a collaborative exchange to explain its viewpoint on why it is important to allow health care organizations to continue to employ TJC standards’ three criteria for scheduled maintenance activities for medical equipment and for utility systems.
The criteria consist of manufacturer’s recommendations, risk levels associated with the equipment, as well as hospital experience (see applicable TJC standards and elements of performance below along with yet to be revised CMS Interpretive Guidelines). According to the Perspectives article, CMS agreed!
The Joint Commission accredited hospitals, critical access hospitals, and ambulatory care programs can breathe a sigh of relief. As reported in the December 2010 The Joint Commission Perspectives®, TJC engaged the Centers for Medicare & Medicaid Services (CMS) in a collaborative exchange to explain its viewpoint on why it is important to allow health care organizations to continue to employ TJC standards’ three criteria for scheduled maintenance activities for medical equipment and for utility systems.
The criteria consist of manufacturer’s recommendations, risk levels associated with the equipment, as well as hospital experience (see applicable TJC standards and elements of performance below along with yet to be revised CMS Interpretive Guidelines). According to the Perspectives article, CMS agreed!
Compliance News: TJC News Brief on Shortened Survey Time Frame
By Dean Samet, CHSP
The Joint Commission announced in the November 17, 2010 Joint Commission Online that effective Jan. 1, 2011, full survey time frames will change from 39 to 36 months (see note below) for all accreditation programs (except the laboratory accreditation program). TJC will conduct an organization’s full survey within 36 months instead of 39 months after its previous full survey primarily to maintain consistency in the timing of the survey window with the Centers for Medicare & Medicaid Services (CMS).
Note: Previously, per the 2010 Hospital Accreditation Standards manual, The Accreditation Process chapter, section Duration of Accreditation Award, “An accreditation award is continuous until the organization has its next full survey, which will be between 18-39 months after its previous full survey, unless accreditation is revoked for cause or as otherwise outlined in this chapter.” In the same chapter under the Duration of the Accreditation Decision, “An organization’s previous accreditation decision remains in effect until a decision is made either to accredit or to preliminarily deny accreditation to the organization.”
The Joint Commission announced in the November 17, 2010 Joint Commission Online that effective Jan. 1, 2011, full survey time frames will change from 39 to 36 months (see note below) for all accreditation programs (except the laboratory accreditation program). TJC will conduct an organization’s full survey within 36 months instead of 39 months after its previous full survey primarily to maintain consistency in the timing of the survey window with the Centers for Medicare & Medicaid Services (CMS).
Note: Previously, per the 2010 Hospital Accreditation Standards manual, The Accreditation Process chapter, section Duration of Accreditation Award, “An accreditation award is continuous until the organization has its next full survey, which will be between 18-39 months after its previous full survey, unless accreditation is revoked for cause or as otherwise outlined in this chapter.” In the same chapter under the Duration of the Accreditation Decision, “An organization’s previous accreditation decision remains in effect until a decision is made either to accredit or to preliminarily deny accreditation to the organization.”
Tuesday, February 1, 2011
Current Technologies Are Vastly Different Than The Technologies In Place When Most Mechanical Engineers Started
By J. Patrick Banse, PE, LEED AP, Smith Seckman Reid Inc., Houston
When mechanical engineers are in school, few of them know exactly where their degree might take them. I was one of those engineers. Being exposed to many aspects of this fascinating engineering program, I was awed by the range of career choices—steam and power generation, automotive design, structures. However, only a few courses—thermodynamics, fluid dynamics, and heat transfer—prepared me for the area I ended up in, partially by choice but mostly by having mentors that instilled a passion in me that continues to guide me more than 35 years after graduation. The area of mechanical engineering I ended up in was HVAC, plumbing, and fire protection design in buildings, specifically healthcare, but that was after a few years of preliminaries and, as I found out, nothing like I learned in school.
Read entire article here: Current Technologies Are Vastly Different
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