Quest for the ‘Gold Seal’

Joint Commission accreditation isn’t mandatory for long-term care communities as it is for hospitals, but, according to the Commission, it is a means whereby these facilities can distinguish themselves from among the more than 16,000 nursing homes in the United States. Currently, accreditation has been granted to more than 1,100 long-term care communities, including nursing homes and skilled nursing facilities, communities associated with hospitals, and units run by government entities, such as veterans homes. To assist Joint Commission-accredited and certified organizations in promoting their special status, the Commission’s proprietary Gold Seal of Approval can be used on Web sites and external signage as well as certain printed materials.

George Mills, senior engineer for The Joint Commission’s Standards Interpretation Group, says accredited long-term care communities are required to plan and sustain environment of care standards, life safety, and emergency management. This includes undergoing a risk assessment, looking at both internal risks and safety issues, as well as external ones, such as those presented by the neighborhood in which the facility is located. Oftentimes, he says, companies will rely on local law enforcement to help assess external risk, provide crime statistics, and determine threat levels.

Required: A security management plan

Communities are required to write a security management plan that takes into account the risk identified. The surveys conducted by The Joint Commission’s accreditation team will look at how well the communities are following their security plans, Mills says, and if they are being reasonable in taking action against the potential risks.

For example, he says, a community in a high-crime area may say in its security management plan that there is no need to monitor visitors, but that isn’t adequately addressing potential problems. While the individual community sets its own standards, he says, “When we do a survey, we determine if they are appropriately assessing the risk.”

Under the environment of care standards, surveyors look at areas such as safety and security, handling of hazardous materials, fire safety, utilities management, and medical and lab equipment. A security management plan will cover items such as how staff and visitors are identified and monitored as they enter and exit the building. Most communities want to limit visitors at certain times and under certain circumstances, Mills says, and both the plan and the Joint Commission survey will look at how this is handled.

“We ask when we survey how they have addressed identifying visitors, and it’s up to the organization to define that and manage it,” he says.

Likewise, surveyors will look at how access is controlled to secure areas, such as drug supplies or even locked geriatric units. “There may not be as many secure areas as in a hospital,” Mills says, but it is based on how the community defines it in the security management plan.

Also required are written procedures in case of a security-related event. “We have to be sure they follow the protocols, and if there is an event, that it is documented,” he explains.

Communities do receive guidance on creating their plan, but it is up to the provider that is seeking accreditation to develop a security management plan it can follow. “If it’s in the plan, and they don’t do it, they can risk not getting or losing accreditation,” Mills says.

But, as he notes, a plan that does little or nothing to address risk, but is easy to follow, won’t make the grade either.

Objective: Quality control

Beyond the environment of care standards, life safety and emergency management are also part of what surveyors assess for accreditation purposes. This includes evacuation procedures, says Mills, who notes that while plans must be in place and practiced by staff, “we require procedures to the point of reasonableness, so we don’t want to disrupt treatment to do a fire drill.”

As to who within the community is ultimately responsible for developing and enforcing the security management plan, Mills says it varies by facility. Corporately owned units may well have a security director or similar person on staff, he says, while others may place the security plan in the hands of the community’s director or head of nursing. “What I find is that once they have a good program, and properly train the staff, it works no matter who is in charge,” Mills says.

While many states have required annual inspections of long-term care communities, the accreditation process is about quality of care, not just following rules, Mills says. “Inspections tend to be black and white,” he says, “while ours (Joint Commission) is about quality improvement.” Communities receiving accreditation hold that status for three years, but the cycle for maintaining that accreditation is from 18 to 39 months, so they are not sure when they will be surveyed again.

“The results of the surveys are important to them,” says Mills of the Joint Commission’s long-term care clients. Together with the surveyor, the communities “discuss processes and make recommendations to improve outcomes.” The results are often part of a community’s quality improvement initiatives, Mills says.

Click here to read more about the Gold Seal of Approval.

For further information, call George Mills at (630) 792-5000.

Reprinted from HEALTHCARE SECURITY AND SAFETY DIRECTIONS, the newsletter of the International Association for Healthcare Security & Safety,

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