The Importance of Life Safety Code Surveys for ICF/IID Programs

When ICF/IID programs deal with state issues, the three words that most hate to hear is "State is here."  It's the sign that an investigation, complaint, or a survey is about to start.  Usually none of those situations inspires any level of comfort.    Most facilities dread getting the paperwork together, answering the questions, supplying the information needed, and dealing with the potential of deficient practice being cited.  In Texas, once a health team shows up for survey, you can anticipate that Life Safety Code or LSC is not far behind.    As a result of LSC, the program generally goes from a sigh of relief that the surveyors have left the building, to the feeling of "Here we go again" as the LSC rolls through the door.  Suddenly there is an entirely new set of questions being thrown at the facility.  You end up showing fire alarm permits, fire marshal inspection (not always easy to get in many parts of Texas by the way) and dealing with a variety of other questions.  Everything suddenly shifts from the health, safety and well-being of the individuals living in the home, to the safety of the individuals from a view of the home being safe.   LSC doesn't care whether the individuals have gone for annual vision exams or not, but they sure do care if you haven't gotten an inspection required for a part of the home. 

Fortunately, I have found that the LSC survey can often be a vital and very important part of the survey process.  While you may not always agree with their findings, you can always be sure their findings are an attempt to ensure the safety of individuals, staff and visitors to the home.  During a survey recently, we found an example of how important having the second set of eyes of the LSC surveyor can be to the facility. 

The survey had gone great with only a few minor LSC issues being pointed out.  At the end of the survey, the surveyor asked for our Smoke Sensitivity Test.  We talked about it and the surveyor said I could email it to him. 

After a quick call to the alarm company, they sent the inspection paper and told us that there should be a blue tag in the alarm box with the sensitivity test information on it.  We copied both and sent them to the survey team.  Within a short time a call returned that indicated the paperwork we sent was not what they needed.  They gave us specific information to look for from the fire alarm company.  

Another call and clarification with the fire alarm company brought some "alarming" information to light.  The fire alarm company stated that according to their records, they had never done a smoke sensitivity test of the system at the home.  Needless to say we were shocked.   

The end result was a deficiency for failure to have the smoke sensitivity test completed.  However, the more important end result was that the process of the LSC survey had resulted in our facility finding that we did not have a smoke sensitivity test.  It was an issue that could have easily put all individuals living in the home at risk, and a clear example of why LSC surveys have an important role in the ICF/IID program. 

 

Intellectual Disabilities and Openings in the ICF/IID Programs in Texas

The following link will take you to the publication with the article above:

Intellectual Disabilities and Openings in the ICF/IID Programs in Texas

The Third Part of a POC for the ICF/IID Program

We have now looked at the first two parts of the POC which you must include to have a successful and accepted POC by the state of Texas.   First you had to determine who will fix the problem and how it is going to be addressed for the individual or individuals affected by the deficient practice.  The second part of this series discussed how you are going to ensure the deficient practice has not affected anyone else and who will accomplish that review or process.   At this point your plan identifies the problem, identifies who was affected, identifies how you plan to fix it, and identifies how you plan to review and ensure that anyone else affected by the deficient issues does not continue to be affected.

Finally, it is time for the third step in the process of preparing a successful POC.   This final step includes the monitoring of the issue and/or how you will ensure that the deficient practice does not occur again.  Usually at this time you find someone to oversee the person fixing the problem.  In most cases, you may have a QIDP, a manager, or a nurse correcting the issue.  For our sake, here we will assume the QIDP has addressed the deficient practice.  Who will oversee the QIDP and ensure that the problem does not occur again?  For many facilities the answer is usually an Executive Director, Administrator, Owner, or some other form of supervisor.  This person must review the correction made, and then set up a monitoring to ensure that it does not occur again. 

In the first section, we stated that “The QIDP will conduct an interim staffing for individual #1 to review the physician's recommendation for..... .an optional surgery and determine the client and his guardian's decision. ..a specialist to see the client.  The QIDP will ensure the follow up appointment is scheduled and coordinated with the IDT.

In the second section, we stated that “The QIDP will review physician recommendations for individuals #2-6 (assuming it is a six bed facility) and ensure that no physician recommendations have been overlooked.  In the event that recommendations have been overlooked, the QIDP will refer the recommendation to the IDTeam for review and direction per the guardian, surrogate, or individual as appropriate.

Now we must ensure that the QIDP continues to monitor and that no physician recommendations have been overlooked.  We must also ensure that someone is checking to ensure the QIDP completes this function.  A statement of correction might look something like this:

The QIDP will review Physician recommendations for individuals #1-6 on a monthly basis to ensure no recommendations are overlooked.  Issues or concerns will be presented to the IDTeam.  The Administrator will review physician recommendations on a quarterly basis and notify the QIDP in writing should a recommendation be found that has been overlooked and take corrective action as determined appropriate. 

At this point, you have now written all the major steps for the POC.  You have accomplished the following:

1.     Identified the individual or individuals affected by the deficient practices, who will correct that issue, and how that person will correct it.

2.     Identified how the person correcting the issue will ensure that no other individuals have been affected by the deficient practices.

3.     Identified how the facility will continue to monitor and ensure that the deficient practice does not occur again.

At this point you will put a corrective date – meaning the date you plan to have the POC accomplished by and all components in place, sign the document and submit it for review by the Regional Program Manager. 

You should be prepared for the possibility that the Program Manager may seek additional information.  There is always the chance you may have overlooked a component of the deficient that needs to be addressed.  There is always the chance that you may understand perfectly what you plan is, but that it may not be written in a way that someone else can understand it.  If additional information is requested, talk with the reviewer, determine what is needed and provide the update.  Some regions will accept an update letter and others may require that you modify your actual POC with the new information and send it in to them.  However, it is requested, simply make the corrections and send it in for final review.  However, in most cases if you review the three major areas noted above, and you have met the criteria of each, you will most likely not have to submit additional information.

The Second Part of a POC for The ICF/IID Program

In the first part of these installments, we discussed the fact that a POC must establish that in your plan you are going to fix the problem and who is going to address it and how they are going to address it.  Since the first part of the POC describes the individuals directly affected, who is going to set the corrective action in motion and how that person will do it, it is time to move on to the next part.

The second component of a POC requires the facility to identify everyone who may be affected by the deficient practice and how the facility will ensure that the deficient practice does not occur to someone else.  In simple terms, the survey team has usually looked at a sample of people.  Let's say you have a six-bed facility and they look at three people.  There are three other people who could have the same problem - even if surveyors only identified the problem for "One of three sampled individuals" this does not mean that individual number four might not have the same concerns or problems.  All this means is that the survey team did not look at individual number four and he or she may have the same issues.  To ensure that no individuals in the facility have the same issue or problem, the facility must identify how it is going to ensure the deficient practice does not affect others.

Thinking back to the last post, you will remember that the tag written was for failing to follow up on a physician's recommendation.   The POC has set forth that the IDTeam will meet, make recommendations and the QIDP will implement those recommendations.  The question at this point that must be considered is "Has the facility overlooked any other physician recommendations for anyone else residing in the facility?"  To answer the question, the ICF must address how it is going to ensure that anyone potentially affected has been reviewed.

At this point the POC may state something like the following:

The QIDP will review physician recommendations for individuals #2-6 (assuming it is a six bed facility) and ensure that no physician recommendations have been overlooked.  In the event that a recommendations has been overlooked, the QIDP will refer the recommendation to the IDTeam for review and direction per the guardian, surrogate, or individual as appropriate.

Based on the above statement, the POC now clearly indicates that the QIDP will be responsible to check and ensure that there are no other individuals in the home being affected by the deficient practice.  Further, if an  individual is being affected, the the plan indicates how it will be corrected.

For the third part of this series we will look at what must be done to ensure that the problem does not occur again.  This part is usually considered the "monitoring" to ensure the problem is caught or does not happen again section of the POC.  For our purposes it is the third part of a POC.