MOSHE Advocacy & Regulatory Report
Healthcare Life Safety Specialist, Facility Operations
St. Louis Children's Hospital
CMS has put a hold on surveys, starting on March 16th through the end of May. We are waiting on information as to how they will make up the time or if the surveys will be pushed back 2 ½ months.
CMS has put out a waiver to postpone some inspections while COVID-19 is active. We will send out a list of the possible PMs that we can postpone/move back for discussion.
TJC - Consistent interpretation with LS.02.01.035 code has been that the hospital provides and maintains system for extinguishing fires. This was found in 2019 surveys in 49.8% of the hospital surveyed. Items identified where:
o Significantly broken ceiling tile with a portion missing
o Blocked kitchen suppression pull station
o Missing ceiling tile in a room with only sprinkler protection only
o Fire suppression system in kitchen did not cover the deep fryer
o Gaps between the baffles in the kitchen exhaust hood
o Blocked fire extinguisher
o Exterior fire department connections were not identified
TJC sent out the top 10 items identified in 2019 surveys. These items are in the higher section of the safer matrix, most hazardous items.
1) IC.02.02.01-hospital reduces the risk of infections associated with medical equipment, devices, and supplies
Intermediate and high-level disinfection and sterilization
2) EC.02.06.01-hospital establishes and maintains a safe, functional environment
Dirty ceiling tiles and porous surfaces
3) NSPG.15.01.01-identify patient at risk for suicide
Ligature risks, environmental risk assessment, suicide risk reduction, door hinges
4) IC.02.01.01-hospital implements its infection prevention and control plan
Processes for cleaning, soiled equipment, no evidence of cleaning
5) EC.02.05.01-the hospital manages risks associated with its utility system
Temperature and humidity readings, appropriate pressure relationships,
control of airborne contaminates
6) MM.06.01.01-the hospital safely administers medications
Medication administration safety, verification of orders and dosages, expiration dates
7) LD.01.03.01-the governing body is ultimately accountable for the safety and quality of care, treatment, and service
Conditions of participation deficiencies, leadership, governing body, accountability
8) IC.02.02.01-the hospital reduces the risk of infections associated with medical equipment, devices, and supplies
Safe storage of medical devices, supplies, and Ultrasound probes
9) NPSG.15.01.01-Identify patients at risk for suicide
Suicide risk screening, suicide validated screening tools, suicidal ideation
10) PC.02.02.03-the hospital makes food and nutrition products available to its patients
Food storage, food and nutrient safety, sanitation, refrigeration temperatures,
labeling/expiration dates
