Inpatient Facility Coding & Compliance Alert

OIG surveys reveal more that 50 percent noncompliance to basic health standards.

On March 30, 2016, the Joint Commission released its survey findings about the compliance rates relative to basic health care standards and National Patient Safety Goals (NPSGs), and the Universal Protocol for preventing:

• Wrong Site,
• Wrong Procedure,
• Wrong Person Surgery^TM
• and certification and accreditation participation requirement

The Joint Commission surveyed and reviewed organizations from Jan.1, 2015, through Dec. 31, 2015, to assess, identify trends, and address the deficits thereof.

“Percentages can sometimes be misleading,” warns Duane C. Abbey, PhD, president of Abbey and Abbey Consultants Inc., in Ames, IA. “For instance, I don’t know how many CAHs (critical access hospitals) are accredited through the Joint Commission. If the number is relatively small, then the percentages may not mean that much. I think that it is appropriate to report after we have all had some time to study, so that further information can be provided.”

Here is how they fared in terms of compliance with the five basic Joint Commission requirements:

• The noncompliance percentage soared high in many basic aspects of functioning of any healthcare setup. As many as 62 percent of hospitals and 55 percent of critical access hospitals (CAHs) could not conform to the standard EC.02.05.01 (The hospital establishes and maintains a safe, functional environment).This was followed by a whopping 59 percent noncompliance by hospitals and 60 percent nonconformity by CAHs on another basic hygiene standard, IC.02.02.01 (The hospital reduces the risk of infections associated with medical equipment, devices and supplies).
• As many as 58 percent of hospitals and 67 percent of CAHs failed to manage risks associated with utility systems, standard EC.02.01.20 (The hospital manages risks associated with its utility systems).
• That’s not all, 51 percent of hospitals could not meet yet another simple standard, LS.02.01.20 (The hospital maintains the integrity of the means of egress), and 50 percent of hospitals lacked fire safety features required as per standard LS.02.01.30 (The hospital provides and maintains building features to protect individuals form the hazards of fire and smoke).

The CAHs also did not fare well on fire safety standards. As many as 52 percent of CAHs failed to comply with EC.02.03.05 (The critical access hospital maintains fire safety equipment and fire safety building features). Further, 43 percent of CAHs could not meet the standard LS.02.01.10 (Building and fire protection features are designed and maintained to minimize the effect of fire, smoke and heat).

The road ahead: “Obviously, staff at any given hospital (particularly if accredited through the Joint Commission) should check to see what their hospital’s status is relative to these compliance issues,” tells Abbey. “Also, this may tie up with the Conditions of Participation under the Medicare program.”

For further details go to: http://www.jointcommission.org/issues/article.aspx?Article=hHGk6T9xK/RCGTH7bfU5lPsR9uLRLtnRSmvhmuRBfgQ=.