Jul 24 2014

New vs. Existing Conditions

Category: BlogBKeyes @ 6:00 am

10100[1]At times we struggle to decide when do new construction requirements (chapter 18 of the LSC) apply and when do existing conditions (chapter 19 of the LSC) apply. CMS seems to go on the principal that anything constructed on or before the date that they adopted the latest edition of the LSC will be considered existing, and anything constructed after the date they adopted the LSC will be considered new. For the current 2000 edition of the LSC, that date is March 11, 2003.

But the Annex section of 1.4 in the 2000 LSC specifically says anything designed to meet the requirements of a prior edition of the LSC must be required to meet those conditions for the life of the building. So, if a previous edition of the LSC (such as the 1985 edition) required a new hazardous room to be sprinklered and protected with 1-hour barriers, then that room must be maintained with sprinklers and 1-hour barriers for the life of the room, and does not qualify for the less restrictive smoke resistant barriers for an existing hazardous area in the 2000 edition of the LSC. This can get confusing, because one does not always know when a hazardous room was created. Also, there are other examples such as smoke compartment barrier construction, and corridor door latching that can apply to this requirement as well.

As a default, many (but not all) authorities having jurisdiction will follow CMS’s lead and use the date March 11, 2003 as a general date to determine new vs. existing when they do not have prior knowledge of when a feature of life safety was constructed or what was required by prior editions of the LSC. Accreditation organizations do not expect their surveyors to spend much time during a survey to research when a feature of life safety was constructed, but if this information is provided for them, here is how they may interpret the LSC:

Research shows that CMS adopted the 1967 edition of the LSC in 1971, and then the next update was the adoption of the 1985 edition in 1988. Then, as mentioned, the next update was the adoption of the 2000 edition on March 11, 2003. For now, we have prior knowledge on the following issues:

Hazardous Areas

The 1967 LSC required new construction hazardous areas to be either 1-hour fire rated or protected with automatic sprinklers; not both. The 1985 LSC similarly said new construction hazardous areas could be either 1-hour fire rated or protected with sprinklers, but did specify that certain rooms had to have both. Therefore, it is possible that certain hazardous rooms constructed prior to March 11, 2003 did not have to be both 1-hour fire rated and be protected with sprinklers, while certain other hazardous rooms did.

So, for purposes of assessing compliance with the 2000 LSC, if the hazardous room is one of the following, then the date to decide if new or existing requirements apply is March 11, 2003:

  • Boiler room and fuel-fired heater room
  • Laundry rooms greater than 100 square feet
  • Repair shops

However, if the hazardous room is one of the following, then the date to decide if new or existing requirements apply is January 1, 1988:

  • Soiled linen rooms
  • Paint shops
  • Trash collection rooms
  • Rooms greater than 50 square feet used for the storage of combustibles

Smoke Compartment Barriers

The 1967, 1985, and the 2000 editions of the LSC require new construction smoke compartment barriers to be 1-hour fire rated with non-fire-rated doors. The 2000 LSC allows existing smoke compartment barriers to be 30-minute fire rated. Therefore, for the purpose of assessing compliance with the 2000 LSC the date to decide if new or existing requirements apply is January 1, 1971. Every smoke compartment barrier constructed on or after January 1, 1971 must meet new construction requirements, and constructed to 1-hour fire rated, with non-fire-rated doors.

Corridor Latching

The 1967, 1985 and the 2000 editions of the LSC require new construction corridor doors to be positive latching. The 2000 LSC allows existing corridor doors to be held shut with a device capable of keeping the door closed with a force of 5 foot-pounds. Therefore, for the purpose of assessing compliance with the 2000 LSC the date to decide if new or existing requirements apply is January 1, 1971. Every corridor door constructed on or after January 1, 1971 must meet new construction requirements and have positive latching hardware.

Again; most accreditation organizations do not expect their surveyors to spend much time figuring out when a particular hazardous room, smoke compartment barrier, or corridor door was constructed. But, if the hospital is claiming existing conditions on these issues, and they provide a date of construction which is inconsistent with the above stated dates, then an issue may exist whereby you may not qualify for existing conditions.


Jul 18 2014

Register Your Wireless Medical Telemetry Band Devices With ASHE

Category: BlogBKeyes @ 6:00 am

ASHE[1][The following information is taken from an online ASHE Advocacy notice, published July 17, 2014, and reprinted here for your information.]

The Federal Communications Commission (FCC) has issued a Report and Order that will result in TV Channel 37 being available for use by unlicensed devices. To protect your Wireless Medical Telemetry Service (WMTS) devices, it is essential to be registered with ASHE.

All hospitals using WMTS devices must be registered with the American Society for Healthcare Engineering. Hospitals that fail to register devices are at risk for harmful interference to the operation of their wireless medical telemetry equipment.

The FCC requires registration before an organization operates a WMTS system in the TV Channel 37 band (and in the upper bands of 1395-1400 MHz and 1427-1432 MHz). If a WMTS system is not registered, the FCC considers it to be unlicensed and not entitled to protection from interference caused by other transmitters.

In June, the FCC issued the Report and Order that will result in TV Channel 37 being made available for use by new unlicensed devices. This action may cause harmful interference to unregistered WMTS devices operating on TV Channel 37 (608–614 MHz). The FCC feels that technical parameters can be developed to protect registered WMTS users from this interference, but this protection will be available only to registered WMTS systems.

ASHE is the designated WMTS coordinator and maintains a dataset of WMTS users for the FCC. ASHE will also assist with development of technical parameters to maximize protection for registered WMTS users.

If your hospital operates WMTS devices, make sure your facilities are registered with ASHE by taking the following steps:

  • Share this advisory with your clinical and biomedical engineering professionals, critical care physicians, nursing staff, and risk managers.
  • Check www.ashe.org/resources/WMTS/registeredhospitals.html to confirm that your hospital is registered.
    • If your hospital is not registered, register your WMTS equipment now.
    • If your hospital is registered, verify that the equipment and locations listed in the database are accurate and complete.
  • For more information, visit www.ashe.org/resources/WMTS.

The American Hospital Association (AHA) and ASHE will continue to work closely with the FCC and FDA to ensure that interference does not compromise patient care and safety.

If you have questions, please contact ASHE Engineering & Compliance Director John Collins at jcollins@aha.org or 312-422-3805.

Jul 17 2014

Follow-Up on Documentation

Category: BlogBKeyes @ 5:00 am

imagesIDI1GACXMy recent series of articles on Documentation created quite a bit of response. One individual had this question:

“What is your opinion of documentation being kept electronically rather than in hard copy format?  We will have things organized and easy to find and search, but I don’t want to go through the process of electronic files if a surveyor is going to request hard copies.”

My understanding is most authorities will accept electronic documentation provided it meets all of the requirements for documentation. Many AHJs have specific requirements concerning what’s included in the documentation, such as:

Testing & Inspection- Documentation.

Unless otherwise stated, testing, inspection and maintenance documentation must include, at the minimum, the following information:

  1. Name of individual performing the activity
  2. Affiliation of the individual performing the activity
  3. The signature of the individual performing the activity
  4. Activity name
  5. Date(s) (month/day/year) that activity was performed
  6. The frequency that is required of the activity
  7. The NFPA code or standard which requires the activity to be performed
  8. The results of the activity, such as ‘Pass’ or ‘Fail’

An electronic signature typically would be acceptable in lieu of a hand-written signature. That usually means the technician performing the work would have to enter the data in order to create the electronic signature. Most authorities would not accept an electronic signature from a data-entry person in lieu of the technician performing the work. Most authorities also would not accept a data-entry person issuing an electronic signature of another individual, such as a jpg picture of a signature. However, pdf copies of documentation with all of the above requirements is acceptable. Essentially, it would be similar to a photo-copy of a report.

There are stories of the data-entry person not being present during the survey and they were the only one with the passcodes to access the data, or with the knowledge on how to retrieve the data. I also witnessed a situation where weekly reports were turned into a clerical person to enter the data into the computer. The clerical person allowed the reports to accumulate and the data was not entered during the week that the test/inspection was performed. The data-entry person used the ‘default’ date stamp provided by the software platform when the data was entered, which effectively said the test/inspection was not performed during the required time-period.

It is difficult to attach follow-up reports to electronic copies, such as ILSM assessments or repair work orders to a particular LSC deficiency. With paper files, they can easily be inserted into a binder or a folder.

Bottom line: Electronic documentation is permitted, but most hospitals realize the risks do not out-weigh the rewards. I am not a fan of electronic documentation because I have witnessed the problems with using them. But as with all technology, time is needed to work out the problems and make improvements. I’m an old man, and perhaps the younger generation has already implemented solutions to this problem.

I welcome your feedback on the use of electronic documentation.

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Jul 10 2014

Kitchen Hood Fire Suppression System

Category: BlogBKeyes @ 5:00 am

imagesWAHA2STKThe fire suppression system that is required to be mounted in kitchen cooking hoods is typically a wet-chemical extinguishing system that automatically releases the extinguishing agent when the system detects a fire. Back in the early 1990’s the common system used then was a dry-chemical system but was found to be ineffective in extinguishing certain cooking-oil based fires. While NFPA, CMS and the Accreditation Organizations has not prohibited the use of dry-chemical extinguishing systems in kitchen cooking hoods, most state authorities have. There was a major undertaking in the fire extinguishing industry to replace all dry-chemical system with the better suited wet-chemical systems.

 The kitchen hood fire extinguishing system is required to be maintained semi-annually and the fusible links replaced annually. However, the owner’s representative (i.e. facility manager) is required to perform monthly inspections of the cooking hood extinguishing system. These requirements can be found in NFPA 17A, 1999 edition (for wet-chemical systems), and at a minimum, the quick check inspection must verify:

  • The extinguishing system is in its proper location
  • The manual actuators (pull stations)  are not obstructed
  • Tamper seals are intact on the pull station
  • The semi-annual maintenance tag is clearly visible and in place
  • There is no obvious physical damage or condition that would prevent operation
  • The pressure gauge is in the operable range
  • The nozzle blowoff caps are intact and undamaged
  • The hood, duct, and protected cooking appliances have not been replaced, modified or relocated

A record of this monthly inspection is required to be maintained, and is usually documented on the semi-annual inspection tag tied to the manual pull station that activates the system.

One of the lessor-known items that surveyors like to do during the building tour is interview a kitchen staff individual who works near the cooking hood, on whether or not they have received training on the correct operation of the hood extinguishing system. Another question surveyors like to ask is where does the kitchen staff individual go to manually activate the extinguishing system? A negative answer on either question will likely result in a finding under a staff fire safety training standard.

Take a look at NFPA 17A (1999 edition) and make sure you are doing two basic things:

  1. Conduct monthly inspections of all cooking hood suppression systems.
  2. Train all kitchen staff on the correct operation of the cooking hood suppression system.

Also, make sure the extinguishing system is being maintained on a semi-annual basis.

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Jul 03 2014

Smoke Dampers

Category: BlogBKeyes @ 5:00 am

imagesW9BNC02CWhat do we do with smoke dampers now that the hospital is fully protected with sprinklers? That question is asked many times by facility managers who are looking to cut back on what they believe are unnecessary maintenance costs. For new construction purposes, chapter 18 in the Life Safety Code does not require the installation of smoke dampers in smoke compartment barriers provided the HVAC ductwork that penetrates the smoke compartment barrier is fully ducted (no open return air plenum ceilings), and both smoke compartments served by the smoke compartment barrier are fully protected with quick-response automatic sprinklers. But sprinklers were not always required for healthcare occupancies and only became a rule for new construction in the 1991 edition of the LSC.

Until then, sprinklers were an option (unless state or local laws required it, and the construction type required it), and not all hospitals choose to invest in the systems when the building was constructed. That means smoke dampers had to be installed in the smoke compartment barriers. After the facility became fully protected with sprinklers, many hospitals believed they could remove the smoke dampers (or disable them in place), since new construction specifications did not require the smoke dampers. Section 4.6.7 of the 2000 LSC says whenever alterations or renovations are made, the requirements of new construction must apply. Since new construction (chapter 18) requirements for hospitals did not require smoke dampers where both smoke compartments are protected with sprinklers, facility managers thought they had good ground to stand on.

While this may be acceptable for NFPA, it is not for the International Code Council which publishes the International Building Code (IBC). The organization needs to request permission from their local and state authorities before they remove them. Usually, permission will not be granted because the IBC does not recognize the removal of existing fire safety equipment. I’ve also been told that in those jurisdictions where the smoke dampers were installed prior to the adoption of the IBC, there is a chance that the authorities may permit it.

Bottom line… Don’t be in a hurry to remove the smoke dampers even if you believe they are no longer required. Check with the state and local AHJs and seek their permission. It will save you a lot of work of re-installing them if you don’t ask for permission, and they find out later.

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Jul 01 2014

Congratulations! CMS Approves The Joint Commission for Six More years

Category: BlogBKeyes @ 6:00 am

I suspect most of you didn’t give this much thought, but ever since 2009, The Joint Commission has had to apply to CMS for their deeming authority to survey hospitals and other healthcare organizations on behalf of the federal agency for Medicare & Medicaid reimbursements. Joint Commission was approved by CMS in 2010 for 4 years, which would expire this year if they did not re-apply.

Re-apply they did and this time it appears CMS was waiting for them and gave them a huge list of things they needed to change about their standards and practices, or they would not receive CMS deeming approval. In all, CMS identified at least 52 specific items that Joint Commission needed to address before they would receive the deeming status that they needed to stay in business.

To their credit, The Joint Commission did the work necessary to comply with the CMS demands. The changes they made that would be most notably in the physical environment areas, include:

  • Open PFIs will be cited on the final survey report;
  • Agreeing that only CMS can approve equivalencies;
  • Issuing two new Elements of Performance (EPs) which address the requirements for the organization to conduct risk assessments when determining the best equipment maintenance strategy, under EC.02.04.03, EP 24, and EC.02.05.05, EP 6;
  • Issued new EC.02.02.01, EP 18 requiring radiation workers to be checked periodically;
  • Issued new EC.02.02.01, EP 19 requiring procedures for trash storage and disposal;
  • Changed EC.02.03.01, EP 10 to include the phrase “and report fire alarms”;
  • Changed EC.02.05.03 to add the rooms “intensive care, and emergency rooms”.

You might be surprised to learn how hard The Joint Commission has been working to re-write their standards to comply with CMS’s demands. It is easy to think of the largest accreditor as an agency that perpetuates itself year after year, but that is not the case anymore. They have a boss (CMS) that they have to report to, and follow their directives. One indication of the seriousness of this issue, is usually The Joint Commission announces changes to the standards six months before they become effective. The fact that most of the changes mentioned above are effective July 1 (or July 2), 2014, and were only announced to the public during June, says they deviated from their normal practice to satisfy CMS.

It must have worked, since CMS published a statement in the Federal Register on Friday, June 27, 2014 announcing their approval for The Joint Commission as a deeming authority, for another six years. I seriously mean this when I say Congratulations! to The Joint Commission for this achievement. I know it must have been difficult.

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Jun 30 2014

Relocatable Power Taps (Power Strips)

Category: BlogBKeyes @ 6:30 am

12-120-878-TS[1]There has been a lot of discussion about power strips (or relcoatable power taps, as some authorities call them) lately, and most of it is not to our advantage. None of the discussion is actually news to us, it’s just a re-hash of existing positions.

During the recent NFPA Annual Conference in Las Vegas earlier this month, George Mills, the Director of Engineering for The Joint Commission said he approached the NFPA Healthcare Interpretation Task Force (HITF) back in 2007 and asked them to make a ruling on whether power strips are acceptable for use in patient care areas. George said after much discussion, the HITF did not come to a consensus, and therefore no interpretation was issued.

Since then, The Joint Commission surveyors have been allowing power strips in patient care areas, and some surveyors even required the devices to be UL listed for the application. Then, earlier this year, the leadership at The Joint Commission asked George what the accreditor’s official position was on the use of power strips, so he decided to contact the CMS home office in Baltimore to see what they allow.

George reported at the May AAMI Annual Conference in Philadelphia that CMS is taking the hard line of saying power strips (relocatable power taps) are not to be used in anesthesia areas and on medical equipment. This is based on NFPA 99 (1999 edition), section 7- which only allows relocatable power taps provided they are an integral part of the equipment assembly and permanently attached; and the sum of the ampacity of all appliances connected to the relocatable power tap shall not exceed 75% of the ampacity of the relocatable power tap. A regular program to verify the integrity of the above permanently attached relocatable power taps is required.

This piece of information was picked up by a lot of different healthcare news outlets, blogs and online notification services (including yours truly) and re-distributed to the point where CMS had to make an unofficial email announcement to their deemed accredited organizations (and presumably to their state agencies) that in fact no new issuance of a policy or an announcement was made concerning power strips, and they referred to NFPA 99 as their standard. Now ASHE has made an announcement acknowledging CMS’ position, and to say they are working to convince CMS to consider issuing a categorical waiver to allow the immediate use of NFPA 99 2012, which seems to have a more user friendly approach to power strips.

But, the bottom line is The Joint Commission (and the other accreditors) do not have any option but to follow this difficult interpretation of the standard as dictated by CMS. George Mills unofficially said they will enforce no power strips in patient care areas, and no power strips on medical equipment, unless it meets the requirement of NFPA 99 7- and it is integrated with the medical equipment, and this is all regardless of the UL listing. So power strips like UL 1363A which are listed for use in anesthetizing locations would not be acceptable to the accreditors.

For the record, the HITF wrestled with the issue of power strips once more this year in Las Vegas but again did not arrive at a conclusive interpretation. Chad Beebe representing ASHE said he wants to take this issue to CMS to attempt them to change their minds on the rigid interpretation.  I guess you need to stay tuned to see what transpires next…

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Jun 26 2014

Emergency Showers

Category: BlogBKeyes @ 5:00 am

imagesRFIMRIFGEmergency showers are often found in hospital laboratories and at times, in plant operation areas. There seems to be some confusion about emergency showers and eyewash stations, and what is acceptable to the accreditation organizations. To be sure, there are no standards that are being enforced by a national authority over hospitals that are specific to emergency showers and eyewash stations. Even OSHA does not rigidly enforce a specific set of rules concerning these emergency first-aid devices, although they do refer to ANSI Z358.1-2009 as a guide.

George Mills, director of engineering for The Joint Commission recently commented during a meeting of hospital engineers that they (Joint Commission) do not rigidly enforce the guidelines in ANSI Z358.1-2009. Joint Commission only requires a monthly water-flow test for an unspecified amount of time, and then it appeared to only apply to eyewash stations.

A lot has been written about eyewash stations (search: eyewash), but not so much for emergency showers. What should a hospital do in regards to testing and inspecting an emergency shower? In order to be prepared for any inspection by an authority who may enforce the full requirements of ANSI Z358.1-2009, here are the basics concerning emergency showers:

There are two types of Emergency Showers:

  • Plumbed Shower:      An emergency shower permanently connected to a source of potable water
  • Self-Contained Shower:      A shower that contains its own flushing fluid, and must be refilled or      replaced after use

 The specifications below are for plumbed showers only.

  • Heads
    • Positioned 82″-96″ from floor
    • Spray pattern will have a minimum diameter of 20″ at 60″ above the floor
    • Flow Rate equals 20 gallons per minute (GPM) at 30 pounds per square inch (PSI)
    • The center of the spray pattern shall be located at least 16 inches from any obstruction
  • Valves
    • Activate in one second or less
    • Stay-open valve (no use of hands)
    • Valve remains on until the user shuts it off
  • Installation
    • Emergency Shower shall be located in an area that requires no more than ten seconds to reach.
    • Shower location shall be in a well-lit area and identified with a sign
    • Shower shall be located on the same level as the hazard
  • Maintenance and Training
    • Plumbed emergency showers will be activated weekly to verify correct operation
    • All employees who might be exposed to a chemical splash shall be trained in the use of the equipment
    • All showers shall be inspected annually to make sure they meet with ANSI Z358.1 requirements

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Jun 19 2014

Consultants Present During Survey

Category: BlogBKeyes @ 5:00 am

images7E1G3SXKWhen I was a surveyor for Joint Commission, I had a few surveys where the hospital invited their consultant to join in on the building tour.  Back then surveys were scheduled with the hospital and were not unannounced, which allowed them time to have their consultants at the facility. The consultants were typically architects or engineers who had expertise in the Life Safety Code and wanted to observe the survey process. For the most part, they were very polite and respectful of the survey process and did not cause any problems.

But there was one survey where the hospital had their consultant stalking me. He found out what hotel I was staying at and showed up at the breakfast table and introduced himself, and announced that he would be joining me at the hospital. I thought that was odd, because the survey hadn’t even started yet. Back then surveyors typically stayed at hotels recommended by the hospital, so finding out where we stayed wasn’t that difficult.

Sure enough, when I arrived at the hospital there was Mr. Consultant with a sly grin on his face that implied “I told you so”. I had the sneaky feeling I was going to have a bad day. During the building tour, Mr. Consultant seemed to contradict everything I said, and before too long it was apparent to me that he was grand-standing in front of his client. I suspect he thought if he could discredit what I was finding deficient during the survey, it would put him in a favorable light with his client. After an hour of his constant interruptions and disagreements with my observation, I told him he needs to remain quiet and if he couldn’t I would ask the hospital to remove him.

That didn’t work and only seemed to pour gasoline on the fire. I then went to the survey team leader and explained the problem to her, and together we approached the CEO and explained the situation. Shortly after that meeting, Mr. Consultant was gone and out the door.

Why do I tell you this story? Because, at times hospitals want their consultant(s) present during the survey in order to provide answers that the facility manager may not know. That’s okay and permitted by most accreditation organizations, but when the consultant becomes disruptive, then it is a problem that must be dealt with.

Here are some basic ‘unwritten’ rules concerning consultants present during the survey, that I have developed. These are not based on any particular accreditation organization’s policy or procedures:

  • The surveyor’s questions and comments should be directed towards the hospital staff, such as the facility manager, safety officer or other such employee, and not to the consultant.
  • If the surveyor asks a question, the answer should come from the hospital staff.
  • Avoid the situation where the consultant tries to debate or argue with the surveyor about an observation.
  • Use the consultant as a resource only when the hospital staff is unable to answer a surveyor’s question.
  • Remember, the hospital staff can always share the report with the consultant after the survey.

Whatever happened to Mr. Consultant? I ran into him a couple of years ago at the annual ASHE conference and he remembered me (and I him). He picked up where he left off and continued to tell me I was wrong in my observations. Perhaps I was… I don’t remember the issues, but some things never change. Mr. Consultant was still grandstanding only this time there was no one there to observe him.

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Jun 12 2014

Critical Access Hospitals vs. Acute Care Hospitals

Category: BlogBKeyes @ 5:00 am

research[1]I’m no expert on the differences between a Critical Access Hospital (CAH) and an Acute Care Hospital (hospital), but I’m learning. Having been an advisor to American Osteopathic Association/Healthcare Facilities Accreditation Program (HFAP) for nearly 3-years now has provided me with an enlightenment that I never expected.

First of all, I learned that CAHs are not hospitals. Well, technically they are not according to CMS, who determines whether a healthcare facility is a CAH or a hospital. If you are ill and need help that a hospital can offer, a CAH healthcare facility will take good care of you and you would not necessarily know the difference. From all appearances, a CAH looks like a hospital, only smaller. Did you know that in 2013, there were 1,332 certified Critical Access Hospitals in the United States, according to reports from CMS? That over 25% of all the acute care hospitals registered in the country.

A new CAH cannot start out by being a CAH. It first must be accredited as a hospital; then it must apply to CMS to become a CAH. There are many qualifying factors that contribute to becoming a CAH, of which this is what I know:

  • CAHs can only have 25 inpatient beds
  • CAH locations have to be more than a 35 mile drive from any other hospital or CAH
  • CAH locations have to be more than a 15 mile drive from any other hospital or CAH in area with mountainous terrain or secondary roads
  • Be located in a rural area
  • Furnish 24-hour emergency care services, 7 days a week
  • Have an average length of stay of 96 hours or less

Why do hospitals want to become a CAH? Mainly for the reimbursement rate that CMS offers to CAHs. Critical Access Hospitals are certified to receive cost-based reimbursement from Medicare. This  reimbursement is intended to improve their financial performance and reduce hospital closures. Each hospital  is responsible for reviewing its own situation to  determine if CAH status would be advantageous. Critical  Access Hospitals are certified under a different set of  Medicare Conditions of Participation that are more  flexible than the acute care hospital conditions of  participation. Since most hospitals (and CAHs) earn the majority of their income from Medicare reimbursements, having the advantage of being a CAH is definitely a benefit. As of January 1, 2004,  CAHs are eligible for cost plus 1% reimbursement, and capital improvement costs are included in allowable costs  for determining Medicare reimbursement. Without the financial advantage of being designated as a CAH, many rural areas in the country would not have healthcare available to them.

There is a story of hospital attempting to become a CAH but they didn’t meet the driving distance from a specialty hospital that did not serve the general public. It took them nearly five years to convince CMS that they qualified as a CAH because the other hospital within their 35 mile radius did not serve the people from that area. Fortunately, CMS finally agreed.

So, you’re wondering why am I telling you all this? Well, Joint Commission recently published the top five findings by surveyors in 2013 for all of the disciplines, CAHs and hospitals alike. Now, from what I understand the same LS surveyors who survey hospitals also survey CAHs. If that is true, then there is one significant difference in the results of those surveys in 2013. Take a look at this:

 Critical Access Hospital

% of Surveys





The critical access hospital maintains fire safety equipment and fire   safety building features.



The critical access hospital manages risks associated with its   utility systems.



The critical access hospital maintains the integrity of the means of   egress.



The critical access hospital reduces the risk of infections   associated with medical equipment, devices, and supplies.



The critical access hospital provides and maintains building features   to protect individuals from the hazards of fire and smoke.


% of Surveys





The hospital maintains the integrity of the means of egress.



The hospital maintains complete and accurate medical records for each   individual patient.



Building and fire protection features are designed and maintained to   minimize the effects of fire, smoke, and heat.



The hospital manages risks associated with its utility systems.



The hospital reduces the risk of infections

The difference that is notable is EC.02.03.05, which is the standard for testing and inspection of fire safety features. For CAHs it is number 1 on the list, cited on 60% of all the surveys. For hospitals it is number 6 on the list and cited on 44% of the surveys. Not sure why there is such a difference, but perhaps it is because CAHs have less resources available to the facility manager to ensure all of the work is actually accomplished.

The rest of the standards are pretty close to being even:

  • EC.02.05.01              54% for CAHs;           47% for hospitals
  • LS.02.01.20              49% for CAHs;           52% for hospitals
  • LS.02.01.30              44% for CAHs;           43% for hospitals

 I think Critical Access Hospitals are neat… especially when you need one out in the rural areas.

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