CMS issues guidance on unannounced surveys

The Centers for Medicare & Medicaid Services (CMS) issued a memorandum reminding accrediting organizations (AOs) that no contact should occur with a facility prior to the surveyor or survey team’s entrance into the facility. Any prior notice of a survey, via email, phone, electronic portal or other means of communication, is a violation of CMS regulations. Additionally, CMS instructed AOs that the practice of “blackout dates” — allowing facility requests for dates that the facility prefers not to be surveyed — is inconsistent with the policies of unannounced surveys and the expectation that a facility must be “survey ready” at all times.

ASHRAE publishes new infectious aerosols standard

ASHRAE recently announced approval for the publication of its new airborne infection risk mitigation standard for buildings. ASHRAE Standard 241, Control of Infectious Aerosols, establishes minimum requirements to reduce the risk of disease transmission by exposure to infectious aerosols in new buildings, existing buildings and major renovations. The new standard applies during identified periods of elevated risk of disease transmission. Authorities having jurisdiction can determine when the enhanced protections of Standard 241 will be required, but its use can also be at the discretion of the owner/operator.

AORN updates surgical suite design guideline 

The Association for periOperative Registered Nurses updated its Guideline for Design and Maintenance of the Surgical Suite. One update to the guideline focuses on how to engage and incorporate input from perioperative registered nurses (R.N.s) on features and functions such as clinical workflows, equipment, space utilization and workplace safety. Other updates include how to share patient needs when developing functional design plans, ways to assess risk in facilities and recommendations to help perioperative R.N.s learn about the latest building standards in health care. The guideline was designed to help perioperative R.N.s build confidence when presenting feedback on design and maintenance.

The Joint Commission revises CAH standards

Effective Aug. 27, The Joint Commission is making several changes to the elements of performance (EPs) for its accredited critical access hospitals. The changes were made to better align with Centers for Medicare & Medicaid Services’ (CMS’) Conditions of Participation. The changes include new EPs to address CMS definitions of rural health network and personnel qualifications, and the expectation for compliance with the 2012 editions of the National Fire Protection Association’s NFPA 101®, Life Safety Code®, and NFPA 99, Health Care Facilities Code. Other revisions going into effect include removing the references to alternative equipment maintenance programs and manufacturer’s recommendations from the requirements for equipment maintenance.