By: Rick Joslin, Senior Advisor, Healthcare Strategy
The regulatory landscape in healthcare is constantly changing – and that will be no different in 2022, as healthcare organizations must meet new requirements to continue receiving Centers for Medicare & Medicaid Services (CMS) funding. Let’s talk about a few of them.
Water Management
In 2017, CMS issued requirements targeting Legionella in healthcare water systems (S&C 17-30), with the goal of reducing risks associated with Legionella. Since then, accrediting bodies have worked to implement criteria that ensure compliance with these CMS requirements. This month, The Joint Commission’s (TJC) new requirements on water management go into effect.
Effective January 1, 2022, TJC will enforce new water management standards via EC.02.05.02, EPs 1-4 on hospitals, critical access hospitals, and nursing care centers. At that time, the existing EC.02.05.01 EP 6 and EP14 will be deleted for these programs. These new EPs will require the establishment of the program (EP1), contain specific and measurable functions of the program (EP2), describe documentation requirements (EP3), and annual (or event-based) reviews (EP4).
These new EPs contain more detail than most. For example, EP2 requires:
- A diagram mapping all water supply sources, treatment systems, processing steps, and end-use points (showers, sinks, toilets, etc.).
- A risk management plan based on the diagram considering both physical and chemical conditions. The CDCs “Water Infection Control Risk Assessment (WICRA) for Healthcare Settings” is an available tool for this step.
- A written plan addressing the area of buildings where water can become stagnant (unoccupied or closed areas, end-use points no longer in active use).
Similarly, EP4 requires documented reviews and updates (as needed) when:
- New equipment is added that could produce aerosols
- System changes that introduce new risks
Legionella is an often-fatal bacterial infection that can be mitigated by implementing the required processes and programs. Once implemented, facilities management departments are often tasked with maintaining and documenting issues with the water system via work orders, scheduled checks and services, and regular reporting. Once established, these documents can offer significant support of your organizations water management program.
Updates to NFPA-related EPs
TJC made changes to their Environment of Care section of accreditation standards for 2022 that affect most occupancy types. These will take effect on July 1, 2022. To access a listing of changes by occupancy type, read the notice published here.
- EC.02.03.03: EPs 1 and 3 are getting minor changes targeting alternative methods for fire drills during nighttime hours. Specifically, the words “alternative methods” is being swapped for “a coded announcement” (see the CAH prepublication here). EP3 has a new note added related to timing of drills, adding a new requirement to run drills at different times.
TJC has added two new EPs (7 and 8), adding documentation requirements for anesthetizing locations and hyperbaric facilities on conducting fire drills in these areas.
- EC.02.03.05: Although minor in scope, EPs 7 and 8 were deleted effective July 1, 2022. These EPs affect Ambulatory Care, Behavioral Health and Human Services, Critical Access Hospital, Home Care, Hospital, and Office-Based Surgery organizations. It has been found that most of these don’t have water storage tanks and, therefore, they were no longer applicable. TJC also added more examples of asset types (EP 1) and checks to be documented (EPs 11 and 14). Since these are documentation requirements, you’ll want to ensure the specific items are visible in any reporting provided to the surveyors.
- EC.02.04.01: Added a new EP (11) relating to medical equipment attributing to adverse patient outcomes.
- EC.02.05.01: EP 27 was completely rewritten to fully reference NFPA 101-2012: 18/19 and eliminate any confusion on the spaces, systems and checks involved.
There are also significant changes to the Health Care Staffing Services Certification program that become effective July 1, 2022. These changes involve required data collection for types of staffing turnover and may apply to your organization (depending on personnel policies).
TJC continues to review and amend their accreditation standards to keep in line with CMS and other regulatory agencies. These recent changes continue that effort.
About the author:
Rick Joslin is Senior Advisor, Healthcare Strategy with Accruent with 35+ years in maintenance management. He focuses on supporting customers’ continuous improvement, driving operational efficiency, and ensuring regulatory compliance by assisting customers in developing implemented solutions to unique and changing business needs.
.svg){kind=small}
