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Author(s): Ron Cote. Published on November 1, 2016.

Addressing deficiencies in health care facilities


IN THE SEPTEMBER/OCTOBER “In Compliance,” I reported that health care facilities in the U.S. were busy updating from compliance with the 2000 edition of NFPA 101®, Life Safety Code®, to the 2012 edition. The update was a condition of participation in the Medicare and Medicaid programs due to a rule change from the Centers for Medicare and Medicaid Services (CMS). The Medicare and Medicaid programs fund more than one third of the $3.2 trillion spent annually in the U.S. on health care services.

The system under which health care facilities prepare to show surveyors representing CMS that they are in compliance with NFPA 101 is complex. Like a well-oiled machine, though, that system performs effectively. Many facilities opt to use an accreditation organization such as The Joint Commission (TJC) as an intermediary in the compliance process, rather than a CMS survey team. By using the accreditation organization, the health care facility is able to show compliance with CMS regulations while acquiring the cachet of accreditation that draws new patients and helps retain existing ones.

The accreditation surveyor, working as an approved agent on behalf of CMS, visits the facility to ensure compliance with NFPA 101 and with the myriad accreditation requirements. In advance of the surveyor’s arrival, health care facilities perform their own compliance surveys to note deficiencies, create plans for improvement, make the fixes that can be achieved quickly, and schedule the fixes that will take more time. Larger or more complex facilities often engage the services of fire protection engineering firms to perform surveys to identify deficiencies and assist with the development of remedial plans.

For decades, health care facilities have self-reported their deficiencies and plans for improvement to the accreditation organizations in advance of the official surveys. In July, at the annual conference of the American Society for Healthcare Engineering, or ASHE, the TJC’s George Mills advised that facilities would no longer be required to file plans for improvement with TJC. Deficiencies would be noted by the accreditation surveyors at the time of the survey and facilities would be given 60 days to make corrections.

Given that many deficiencies cannot be effectively remediated within a 60-day period, health care facilities will continue to perform surveys and develop plans for improvement, prior to the accreditation surveys, as a tool for coming into and staying in code compliance. In an ideal world, the facilities will stay ahead of the game so that the accreditation surveyor will not find any deficiencies.

I recently accompanied Phil Jose and a team from his firm, P. R. Jose & Associates, on a pre-accreditation survey of the Shriners Hospital for Children in Boston. I’m thankful to the hospital’s facilities manager, Kevin Keating, for permitting me to accompany the survey crew. Even a normal tour of the hospital would have been fulfilling, as the Shriners perform great work, especially with children with burns. This extensive tour was even better, since I was able to see spaces above the ceilings and behind a lot of locked doors. (I was humbled to learn that Phil Jose, in the spirit of volunteerism and giving back to the community, conducted the survey and produced the survey reports at no cost to the hospital.) At one point during the survey, I stepped back and took in the scene. Nurses and other medical staff were providing patient care, non-medical staff and volunteers were providing a variety of services, and Phil and his associates were unobtrusively surveying the life safety systems to help ensure they perform reliably and round-the-clock to allow staff attention to be directed at what they do best—providing patient services.

RON COTÉ is NFPA technical services lead for life safety.