Dec 18 2014

Contractors During a Survey

Category: BlogBKeyes @ 6:00 am
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images[3]It has always been my belief that as the surveyor team walks in the front door of the hospital on the first day of the survey, all of the contractors should be walking out the back door. For the most part (and I do understand that there are exceptions), contractors should be sent away once you know there are surveyors in the house. Why? Because they will get you in trouble one way or another.

I recently received an email from a reader who shared this story:

During our triennial survey the life safety surveyor asked me how we knew that the fire alarm system signal was received by our monitoring company. I could not immediately answer the question, but we were lucky to have the service contractor in the building doing his quarterly testing and I suggested we ask him.

The service technician explained that the software in the fire alarm control system will indicate if the alarm is received by the monitoring company within the designated amount of time. I was quite happy with the service technician’s explanation until the surveyor said “Prove that it happened at least quarterly for the past 12 months”.

The service technician said nobody could prove it; we just have to take his word for it. [Wrong answer.] The surveyor asked “Don’t you call them by telephone to confirm they received the signal?” The service technician replied, saying “Well, would you trust me if I said I did call?”

The surveyor was correct to ask the questions that he/she did. The service technician was probably answering them to the best of his ability, but the real problem is the facility manager allowed the surveyor to enter into a conversation with a contractor. During a survey, the hospital staff should try and control the process as much as possible. By allowing a surveyor to ask questions of a contractor, the facility manager lost control of the situation and will suffer any consequences of what a contractor may say.

Contractors are not trained and educated in the regulatory requirements the same way the hospital staff is (or should be). The contractors may not even know or understand the significance of an accreditation survey, or worse, a CMS certification survey. Service technicians have a tendency to take an attitude that they know more about the system they are working on than the hospital does, and for the most part they do. Otherwise, the hospital would not hire them. But the service technician my not know what specific regulations that the hospital must comply with and therefore may say something to a surveyor that may get you in trouble.

I’m not saying you should not be transparent in your processes, but during a survey, you need to control as much as you can of the survey process. This is not unethical or wrong; it is just smart business. Let the surveyor go where he/she wants; let the surveyor ask questions all they want; but eliminate the potential “loose cannons” that are not very well educated on the survey process by sending them home during the survey.

Another reader sent me an email earlier this year explaining that on a day during the accreditation survey a roofing contractor set a pallet of roofing material right in the middle of the exit discharge of a staff entrance/exit to the hospital. Nobody from the hospital was aware that the roofing contractor was about to do that, but the surveyor noticed it as soon as it happened and it went into the survey deficiency report.

When I was a surveyor for The Joint Commission, I would purposely seek out contractors and ask them what training the hospital provided them on fire safety procedures. Ultimately, contractors are expected to know the same fire response procedures as the staff. Invariably they could not answer the question satisfactory and it would be cited in the survey deficiency report.

I know that in some situations you cannot send the contractors home for the duration of the survey, but it seems that a large percentage of them could. At the hospital where I worked as the Safety Officer, I asked the project management team to send the contractors away during the week of the survey (this was when the surveys were announced). The project managers thought that was a good idea, but we were over-ruled by the COO of the hospital, because he did not want the opening of the new renovated unit to be delayed. That ended up being a costly mistake. The hospital had a policy that every contractor had to receive basic safety orientation before they begin their work on the campus of the organization. Unbeknownst to the hospital, the general contractor brought in a sub-contractor to install flooring in one area, and they did not go through the safety training because the general thought it would be “okay” since the sub was only going to be there for one day. Sure enough, the surveyor found that one sub who had not received the safety training which lead to a finding on the survey deficiency report.

You need to control what you can, and sending the contractors away is the smart thing to do during a survey.

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Dec 11 2014

Joint Commission PFI List

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images4ZUW90XGI received an email from a client who was confused about the changes to the Joint Commission Plan for Improvement (PFI) list found in the Statement of Conditions (SOC). He initially thought the recent CMS imposed changes on the PFI list meant that he should no longer use the PFI list for his life safety deficiencies. Then, he received advice from another consultant that he must list the life safety deficiencies on the PFI list and must do so with 45 days of discovering the deficiencies. He contacted me saying he thought he was in trouble because he was more than 45 past due and asked me for advice.

I responded saying I thought he was receiving some confusing advice, and I did not believe he was in trouble. Here is my take of the Joint Commission PFI program:

  • CMS no longer allows Joint Commission to not cite an organization on the survey deficiency report for a life safety deficiency just because it is listed in the PFI section of the Statement of Conditions.
  • Therefore, Joint Commission will cite all items listed on the SOC PFI list on the survey deficiency report, but will do so on a special section of the report at the end called the Plan for Improvement – Summary, and it looks like this:

Plan for Improvement – Summary

The Plan for Improvement (PFI) items were extracted from your Statement of Conditions™ (SOC) and represent all open and accepted PFIs during this survey. The number of open and accepted PFIs does not impact your accreditation status, and is fully in sync with the self-assessment process of the SOC. The implementation of Interim Life Safety Measures (ILSM) must have been assessed for each PFI. The Projected Completion Date within each PFI replaces the need for an individual ESC (Evidence of Standards Compliance) so the corrective action must be achieved within six months of the Projected Completion Date. Future surveys will review the completed history of these PFIs.

  • No evidence of standards compliance (ESC) is required on findings in the Plan for Improvement – Summary section, such as there would be for ‘normal’ deficiencies cited during the survey on the Requirements for Improvement section.
  • There is no Joint Commission standard that actually requires you to list your life safety deficiencies on the PFI list within 45 days of discovery. Joint Commission wants you to do so, but there is no standard that actually requires you to do it. If you choose to not list your life safety deficiencies on the PFI list, there is no repercussion. The sole purpose of the PFI list now (after the CMS imposed changes), is to provide you with a vehicle to manage your life safety deficiencies. I see the PFI list as a choice: You can manage your life safety deficiencies through the use of the PFI list, or you can manage your life safety deficiencies through the use of your computerized maintenance management system (work orders).
  • If you choose to not list your life safety deficiencies on the SOC PFI list, then you manage the deficiency through your work order system. If the surveyor observes the life safety deficiency during a survey (and the deficiency is not on the PFI list), then he/she will cite it under the ‘normal’ Requirements for Improvement section of the survey deficiency report, and you will need to submit evidence of standards compliance (ESC) within the designated 45 or 60 day timeframe. An acceptable ESC response is to either resolve the life safety deficiency, or to state you will list it on the PFI list with a projected date of completion. But this is all dependent on the surveyor observing the life safety deficiency and citing it on the survey deficiency report.
  • If you choose to list your life safety deficiency on the PFI list, then all the surveyor will do is take the items listed on the PFI list and enter them automatically into the survey deficiency report under the Plan for Improvement section, which does not require an ESC submitted within 45 or 60 days.
  • If you miss the 45 day window to enter a life safety deficiency in the PFI list of the SOC,  that is not a problem. Since there is no Joint Commission standard that says you have to list life safety deficiencies in the PFI list, then there is no standard that says you have to do it within 45 days of discovery. The 45 day rule is just a guideline… a suggestion, if you will. Joint Commission may want you to think it is a rule, but it is not. There are no repercussions if you listed the life safety deficiency on the 50th day, or the 75th day instead.

It’s your decision, but I would advise hospitals to continue to list their life safety deficiencies on the SOC PFI list; but you do not have to. There is no Joint Commission standard that says you have to do so. But there is a slight advantage to list the life safety deficiencies on the SOC PFI list: It will be entered under the Plan for Improvement section of the survey deficiency report which does not require a 45 or 60 day response, as opposed to listing the life safety deficiency under the Requirements for Improvement section which does require a ESC response within 45 or 60 days.

Having it listed under the Plan for Improvement section of the deficiency report will also provide awareness to the CEO/COO suite of the life safety deficiencies that they may not have been aware of otherwise. That may be a good thing… or perhaps it may not.

DON’T FORGET: You will need to assess the life safety deficiency for Interim Life Safety Measures (ILSM) regardless whether or not the deficiency is listed on the SOC PFI list.

I mention all of this because some facility managers may overlook placing a life safety deficiency on their SOC PFI list within the 45 day window of discovery, and feel they are in trouble.

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Dec 04 2014

Medical Gas Shutoff Valves

Category: BlogBKeyes @ 6:00 am
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imagesZ7K8PIAPI was recently a bystander amongst a discussion of healthcare facility industry experts, debating the NFPA requirements concerning the accessibility of medical gas shutoff valves in healthcare institutions. The original question asked was where does it specifically state that a medical gas zone valve box cannot have a wheeled obstruction in front it of it? While it is intuitive to keep the area in front of the shutoff valves clear, the question was a good one, as it appears the NFPA codes and standards do not specifically address the requirement to keep it clear.

The discussion that ensued was informative, as various standards were referenced as to support the opinion of the presenter. For example; Joint Commission standard EC.02.05.09, EP 3 says the valves must be accessible. But TJC does not define what ‘accessible’ means. According to the online dictionary, accessible is a place which is able to be reached or entered. So, if a wheeled gurney is placed in front of a medical gas shutoff valve, is it still accessible, if staff can reach over the gurney and actuate the valve? Or, is the shutoff valve still accessible if the gurney can be moved so staff can reach the valves?

The only one who can answer that question is the authority who is enforcing that standard, which is The Joint Commission in this case, but the other accreditation organizations have similar standards and they make their own interpretations as well. According to most of those in the discussion, Joint Commission and the other accreditation organizations are writing up hospitals and ambulatory surgical centers that have anything placed in front of the medical gas shutoff valves.

Another individual referenced NFPA 99, 1999 edition, which governs medical gas systems for healthcare institutions. Section 4-3.1.2.3 (i) which requires manual shutoff valves in boxes to be installed where they are visible and accessible at all times; the boxes should not be installed behind normally open or normally closed doors, or otherwise hidden from plain view. This description would seem to support the concept that the definition of accessible could include a wheeled object to be placed in front of the valves as long as the valves were accessible. At the least, it doesn’t seem to prohibit that.

But yet another individual said take a look at NFPA 99 (1999 edition), section 4-2.1.2.3 (d) on zone valves. For sake of clarity, I will repeat it here word-for-word (bold emphasis is mine):

Station outlets shall not be supplied directly from a riser unless a manual shutoff valve located in the same story is installed between the riser and the outlet with a wall intervening between the valve and the outlet. This valve shall be readily operable from a standing position in the corridor on the same floor it serves. Each lateral branch line serving patient rooms shall be provided with a shutoff valve that controls the flow of medical gas to the patient rooms. Zone valves shall be arranged that shutting off the supply of gas to one zone will not affect the supply of medical gas to the rest of the system. A pressure gauge shall be provided downstream of each zone valve.

The above description is found under a section titled “Zone Valve”. The bolded section in the above description refers to the requirement of a manual shutoff valve that is located on the same story which is readily operable from a standing position in the corridor. That’s not necessarily the zone valve, but why isn’t this description also included in section 4-3.1.2.3 (i) which describes shutoff valves? The 2012 edition of NFPA 99 further elaborates on ‘Zone Valves’ and describes them in the same way that most people think of shutoff valves.

According to the online dictionary, the word ‘readily’ means without difficulty or delay; easily or quickly. So section 4-3.1.2.3 (d) of NFPA 99 (1999 edition) makes it pretty clear that the manual shutoff valve for the room outlets must be operated easily, and without delay. Parking a wheeled gurney in front of a medical gas shutoff valve could easily delay the operation of the valve; or at the minimum, it would provide a hindrance to the operation of the valve. Therefore, the wheeled gurney (or any other object) would not be permitted to be placed in front of the medical gas shutoff valves.

I think the accreditation organizations have got this issue correct. Anything that blocks access to a medical gas shutoff valves (whether it is called a shutoff valve or a zone valve) hinders the ‘readily operable’ capability of the medical gas valves, and would be a citable offense.

 

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Nov 27 2014

OPIYRT

Category: BlogBKeyes @ 6:00 am
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The following comment is a result of an article that I ran last September on decorations (search: Decorations or Communications?). This comment is from a representative from a state agency that performs surveys on behalf of CMS.

I recently read your article on Decorations. I thought the advice was really good information. I was contacted by a facility not too long ago that asked me if a large, homemade tapestry brought to a resident’s room would need to be fire retardant if it was hung up. The question from the engineer was valid as it was to be hung as a “decoration”, was made of flammable material and the family wanted to hang it in the corridor. He wanted to know if it should be fire-treated. His argument was focused on not allowing the family to bring it in at all, mostly because he found it objectionable. I related to him the code; how it could be both stringently and loosely interpreted and suggested, as you pointed out, to err on the side of caution and either treat it or suggest to the family it wasn’t allowed by the standard. The main issue was that the family wanted to hang it in the corridor, which I pointed out could potentially affect safe egress. I then asked him what he felt would be a surveyor’s opinion if this same decoration was hung inside the room, or used as a blanket.

I pointed out that many times I am in a facility where the family has brought in a blanket, or other homemade decoration to make their loved ones feel at home during their stay, or possibly their final hours. I stated I view those items based upon the possible risk, and the intent of the standard. More often than not I find they pose no greater risk to the facility’s other occupants than the same person’s bathrobe knitted by their aunt (when solely used or displayed inside their respective room).

Point being that speaking for myself, I view it solely based on each individual situation: If the facility is providing it and it poses a possible risk to the safe housing or evacuation of all occupants, I will look at that risk and evaluate the issue, citing it if it is apparent and substantiated. I will not unnecessarily burden a resident, patient, client, family or staff member for the purpose of removing something that falls within the letter of the rule for the sole purpose of demonstrating that rule. As always, “it depends”.

I find it refreshing that a state surveyor would have compassion and evaluate issues on a case by case basis. But if this is not done carefully, it can lead to inconsistent interpretations and cause problems when AHJs do not agree on the same issue.

I think hospitals have too many AHJs conducting inspections and surveys in their facility, as it often leads to differences of opinion on how an issue should be interpreted by the AHJs. Ultimately, the hospitals often have to ‘do-over’ a construction project because they receive poor advice from an architect, or an incorrect interpretation from an AHJ.

No wonder healthcare costs so much…

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Nov 21 2014

Christmas Decorations

Category: BlogBKeyes @ 6:00 am
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I received the poem below from Jeff Clouse, Safety Officer at Baptist Health in Lexington, KY. He says it is his way of using humor with the staff of his hospital to stay compliant with the Life Safety Code during the holiday decorating season.

 

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‘Tis about a month before Christmas, and all through the halls,

I endeavor to walk, inspecting the walls.

Looking for wreaths made of twigs, and Santas of paper,

Don’t hide them from me, I will solve the caper.

 

 

Fake snow, pine cones and *gasp* open flames,

Get rid of these things; I will not play games!

Hang nothing from sprinklers, do not block the exits.

If you do, I’ll call Santa then for you…NO PRESENTS!

 

No real trees, no branches, no needles of pine,

Just please help me out, and save all the whine constructive input.

If these things spark up and begin to smoke,

It’ll be hard to get out, and that’s not a joke.

 

Now I’m almost done, but I need to mention,

Bring no cords here, not for extension.

Lights can be used, plugged right in the wall,

But not if they’re hot and stretch across the hall.

 

I’m not being mean; my heart’s not of stone,

But I just can’t leave those fire regulations alone!

And, hey, listen up, don’t be filled with woe,

Fire retardant decorations you can have; that’s the way to go!

 

Great people you are, be safe, that’s the trick,

Keep helping and healing our weary and sick.

I care, too; and that is the reason,

I want us to be safe, this entire holiday season!

+++++++++++++++++++++++++++++++

Do you use something unique to reinforce your decorations policy?

If so, send it to me and I’ll place it in the blog for all to see.

Merry Christmas!

Brad

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Nov 20 2014

Temporary Construction Barriers

Category: BlogBKeyes @ 6:00 am
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imagesPE2I5ORAI was a co-presenter in a recent HCPro webinar on the new 2012 Life Safety Code along with my good friend and colleague Jim Murphy, and I received quite a bit of feed-back after the session. In the webinar we covered many of the changes that may add to the work-load of the facility manager. In a handout, I summarized them as follows:

  • Annual fire door inspections
  • New stairwell identification signs
  • Certain wheeled equipment will be allowed to be left unattended in corridors
  • Existing high-rise hospitals will need to be fully sprinklered within 12 years of the adoption of the 2012 LSC
  • Changes to the NFPA 72 fire alarm system test report
  • Changes to temporary construction barriers

And that last item on my list (changes to temporary construction barriers) was the one that I received the most feed-back. It appears that this issue is catching facility managers off-guard, probably because not many organizations are actually discussing this change.

To be sure, no one knows how accreditation organizations and state agencies inspecting on behalf of CMS will actually enforce this issue. First, they have to be aware of this change and as mentioned, not many organizations are talking about it, so perhaps the accreditation organizations and state agencies are not aware of the new requirements.

The issue of temporary construction barriers is found in section 18/19.7.9.2 of the 2012 LSC, and says:

The means of egress in any area undergoing construction, repair, or improvements shall be inspected daily for compliance with 7.1.10.1 and shall comply with NFPA 241, Standard for Safeguarding Construction, Alterations, and Demolition Operations.

7.1.10.1 is the chapter 7 requirement for marking the means of egress. The edition of NFPA 241 which is referenced by the 2012 LSC is the 2009 edition, and it says this about temporary construction barriers:

8.6.2.1 Protection shall be provided to separate an occupied portion of the structure from a portion of the structure undergoing alteration, construction, or demolition operations when such operations are considered as having a higher level of hazard than the occupied portion of the building.

8.6.2.2  Walls shall have at least a 1-hour fire resistance rating.

8.6.2.3  Opening protectives shall have at least a 45-minute fire protection rating.

8.6.2.4*  Nonrated walls and opening protectives shall be permitted when an approved automatic sprinkler system is installed.

A.8.6.2.4   Construction tarps would not be considered appropriate barriers or opening protectives.

There are still some unknowns about this new requirement that are not clear yet:

  • Will flame retardant plastic visqueen be permitted as temporary nonrated walls when the construction area is protected with sprinklers? The portion that says “construction tarps” in NFPA 241 is found in the Annex section which is explanatory information and is not considered part of the enforceable standard.
  • Will accreditation organizations and state agencies allow a ‘grace’ period from the start of demolition until such time that the construction area is fully protected with sprinklers, without the need for 1-hour barriers? At times, it may take multiple days to demo the suspended ceiling before temporary upright sprinklers are installed.
  • Are the 1-hour fire rated temporary barriers only required where the construction area is contiguous to occupied means of egress areas (corridors), or are the 1-hour barriers required wherever the construction area is contiguous to occupied areas?

My advice: Start working now with your construction people to not only be aware of this new requirement, but to begin incorporating 1-hour temporary barriers in their projects. When the new 2012 LSC is finally adopted, you will be expected to be in full compliance with this, as well as all the new changes. Eventually, the accreditation organizations and the state agencies will explain what their expectations are.

For a copy of the handout that I made for the webinar, go to “Tools”, and click on “Changes the New 2012 Life Safety Code Will Bring”.

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Nov 13 2014

Use of Fire and Smoke Doors During a Fire Drill

Category: BlogBKeyes @ 6:00 am
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I was recently asked if the Life Safety Code addresses the use of smoke and fire doors during a fire drill. Here is what I responded with:

The Life Safety Code (LSC) does address certain key actions required by staff during a fire drill, but it does not specifically restrict the use of doors in fire or smoke compartment barriers while the fire alarm is activated. Section 18/19.7.1.1 of the 2000 LSC requires the healthcare occupancy to have a written plan for the protection of all persons in the event of a fire; for the evacuation to areas of refuge; and for the evacuation of the building when necessary. Section 4.7 of the same code also makes similar statements regarding orderly evacuation during a fire drill. It makes sense that opening and closing doors in a fire or smoke compartment barrier would be necessary in order to evacuate patients to another smoke compartment, or to evacuate the building. It also makes sense that responding emergency personnel (both internal and external) would have to open and close doors in order to assist with the evacuation or address the fire.

But perhaps what you are referring to is the action of the people who are not responding to the fire alarm, and they are going about their regular activity. Doctors, nurses, technicians, visitors, volunteers, vendors, and others may be ignoring the fire alarm and just continue to walk through doors to other parts of the building. These may be the people who you are referring to that are opening and closing fire and smoke compartment barriers doors during a fire alarm.

The Joint Commission standard EC.02.03.03, EP 4 says staff who work in buildings where patients are housed or treated participate in drills according to the hospital’s fire response plan. This is a little bit more than is required by section 18/19.7.1.3 of the 2000 LSC, which says employees of healthcare occupancies shall be instructed in life safety procedures and devices. A fire drill is certainly one method of instruction in life safety procedures and devices. But neither the Joint Commission standards (and EP) and the LSC reference actually requires all staff to participate in every fire drill. It just wouldn’t be practical in a healthcare facility that is providing treatment and care to patients.

Therefore, hospitals get to decide for themselves how their staff should react during a fire alarm, as stipulated in their fire response plan (also known as the Fire Safety Management Plan). Most hospitals that I have had the pleasure of working with require staff in the immediate area of the fire emergency respond by following R.A.C.E. (Rescue; Alarm; Contain; and Evacuate or Extinguish) and staff away from the origin of the alarm simply close doors and be ready to receive patients. Some hospitals have staff away from the origin of the alarm to dispatch one individual with a fire extinguisher to the scene of the alarm.

You can write into your plan what you want your staff to do. If you want them to stop at each closed door and not traverse through it until the ‘all-clear’ is given, that is your decision, but I don’t think that is a very practical idea, or one that would be followed. When a fire alarm is activated, it represents a potential disaster and even though it may seem that a ‘all-hands-on-deck’ call is needed, that is not the practical thing to do as a first response. If your facility has 1200 workers on the average day shift, and the fire alarm is activated in the 4th floor ICU, you do not want all 1200 workers to rush up to the 4th floor ICU; that is not practical.

The concept of fire response in a healthcare occupancy is all healthcare workers are trained in the facility’s fire response plan. You count on the staff in the immediate vicinity of the fire to respond appropriately and quickly. Once the alarm is announced, certain trained individuals rush to the area where the alarm originates. The rest of the staff is supposed to reply in accordance with your fire response plan. Quite honestly, unless the staff has specific duties during a fire alarm, moving about the hospital performing their normal duties in areas away from the alarm would be considered appropriate. You actually need the hospital to continue to function even during a fire drill. Each fire drill will not asses every staff member’s response; it just is not practical in such a large setting. That is one reason why there are so many fire drills in a hospital each year: By sheer quantity you hope to get nearly all of the staff to participate in at least one drill.

Another issue is physicians. What should they do during a fire alarm? Many hospitals are writing into their fire response plan that physicians on a nursing unit that are not actively providing care or treatment to a patient, should report to the nurse’s station and await direction. In a Surgery department, unless the operating room is the scene of the fire, you pretty much want surgeons and nurses to remain in the operating rooms and continue with the business at hand, and wait for further instructions from the surgery nurse’s station.

I don’t know if I’ve helped you with your question, but if it were me, I would let people do what they normally do, unless they have specific responsibilities during a fire alarm. If you are really concerned about certain fire or smoke compartment barrier doors being opened in close proximity to a fire, then it would be practical to station one person at the door preventing unauthorized individuals from opening that door.

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Nov 06 2014

A Follow-Up to “Comments on Corridor Clutter”

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The following comment is a result of an article that I ran last August on corridor clutter (search: Comments on Corridor Clutter), which quoted Randy Snelling, the Chief Physical Environment Officer for DNV.GL Healthcare, Inc. This comment is from a representative from a state agency that performs surveys on behalf of CMS.

First, I totally agree with both Randy and you. Both in principle and standard we should be  more up to date and facilities should know what the standard is and how to  follow it. Oddly, I spend more time assisting facilities on this issue even when I cite it. I tend to smile when they announce I have arrived and wonder “Were you in compliance yesterday?”

As a surveyor doing checks on all occupancies, I have found none ever seem to not have some issue with space and where to place those items needed for patient/resident care. Having worked in a healthcare facility, I can also fully relate that focus being first and foremost.

That being said, the standard is there for a reason and has been for some time.  Even though my initial peek into 2012 finds some increasing awareness of how clutter is viewed, I still believe that we have a wide arrangement of options if, as both you and Randy point out, senior management buys into it and
supports either their Safety Manager or Maintenance staff.

Inevitably, these are the ones who take it very personally when I cite a facility for a blocked or obstructed corridor. Administrators, Chief Nursing Officers on down need to understand the reasoning behind the code and what steps it takes to stay in compliance. I feel a majority of the time the facility management thinks “Oh we clear everything when the drills happen”. Now imagine those corridors filled top to bottom with smoke. The scenario will change considerably. I hope all who read your article and Randy’s comments take it to heart.

I think this representative for a state agency makes a very good point: The healthcare industry needs better education on the need to keep the corridors clear from clutter. I suspect we have become insensitive to this issue because the frequency of fires in hospitals has dropped dramatically since the mid-1980’s, when smoking was restricted in hospitals.

But fires still occur in healthcare settings as documented in either this blog or in the HCPro’s Healthcare Life Safety Compliance newsletter. And it is the belief of Randy and I (and this representative from a state agency) that corridor clutter still needs to be taken seriously.

In my opinion, it did not help that the NFPA Life Safety Code technical committee decided to allow certain unattended items in corridors of 8 feet as described in the 2012 edition. It also didn’t help that CMS decided to endorse this section of the 2012 edition last year as a categorical waiver. The decision on the technical committee to do this was not unanimous, as a representative from a state agency who surveys hospitals (not the same individual quoted above) enthusiastically opposed the decision. Since he had first-hand observation on how hospitals abuse codes and standards, he did not want to allow them to store items in the corridor.

I suspect corridor clutter will remain a problem until senior leadership decides to take an active role in resolving it.

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Oct 30 2014

Cellophane Bags on Sprinklers

Category: BlogBKeyes @ 6:00 am
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imagesZ6JZWAQ6I was conducting a mock survey at a hospital and during the building tour I came to their maintenance shop. They had a spray paint booth and in the booth was a sprinkler head.  Over the sprinkler head was what looked like a plastic bag. I said you can’t cover up the sprinkler heads with plastic bags like that, even in a spray booth. The hospital facility manager told me he received permission from their state agency that it was permissible to cover the sprinkler heads to keep paint overspray from covering the heads.

I knew the state agency people so I called them and asked if they in fact said that. It turns out they did, and they referenced NFPA 25 (1998 edition) section 2-4.1.5, which says:

Sprinklers protecting spray coating areas shall be protected against overspray residue. Sprinklers subject to overspray accumulation shall be protected using plastic bags having a maximum thickness of 0.003 inches (0.076 mm) or shall be protected with small paper bags. Coverings shall be replaced when deposits or residue accumulate.”

Hmm… That just didn’t seem right to me. Plastic bags wrapped around the sprinkler heads? I understand that you do not want paint overspray on the sprinkler head, but plastic? NFPA 25 says you cannot have any foreign material on sprinkler heads, and now the same standard says you can in spray booths? Well, I had to let it go since the NFPA standard permits it.

Fast forward to the 2011 edition of NFPA 25. The technical committee at NFPA addressed this issue and they changed the standard… a little. Now, section 5.4.1.7.1 says sprinklers subject to overspray accumulations shall be protected using cellophane bags having a thickness of 0.003 inches or less, or thin paper bags. Now NFPA 25 no longer says plastic bags, but says cellophane bags or thin paper bags must be used when protecting sprinklers from overspray. According to the commentary in the NFPA 25 handbook, here is the reason why:

“Testing has shown that lightweight cellophane or paper bags will not adversely affect the operation of the sprinkler. Sprinklers protected by the lightweight cellophane or paper bags may require more frequent inspection than the annual inspection outlined in 5.2.1.1.2 to prevent excessive buildup on the bags. Depending on the use of the spray coating area, the inspection and subsequent replacement of the bags may need to be done daily. In prior editions, NFPA 25 allowed the use of a plastic bag, but this was changed due to concerns about the potential for a plastic bag to shrink prior to sprinkler activation and disrupt the discharge pattern.”

So… My suspicions were partly justified. A plastic bag on a sprinkler head would melt and disrupt the spray pattern of the sprinkler. I thought it could delay the sprinkler head from operating, especially if it coated the thermal sensing bulb (or solder) and act as an insulator. Anyway, once the new 2012 LSC is adopted, then it will reference the 2011 edition of NFPA 25, and the covers to protect the sprinklers from overspray due to a spray paint booth must be cellophane or paper. And, they need to be changed frequently, perhaps as much as daily, depending on the use of the spray booth.

Today, I would just recommend the hospital remove the spray booth all-together, from their building. It doesn’t seem that the risk of failure to change out the bags once they are accumulated with paint, is worth the advantage of having a spray paint booth.

 

 

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Oct 23 2014

Infant Abduction Locks

Category: BlogBKeyes @ 6:00 am
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Hospitals want to keep their nurseries, mother/baby units, and pediatric units secure, so they lock the doors. This causes a problem with the Life Safety Code because you can’t lock the doors in the path of egress in a hospital, other than three exceptions: 1) Clinical needs locks, which nurseries, mother/baby units, and pediatric units do not qualify; 2) Delayed egress locks; and 3) Access-control locks. Access-control locks really do not lock the door in the path of egress because a motion sensor will automatically unlock the door as a person approaches. So, in this situation the doors can only be locked using the delayed egress provision (found in section 7.2.1.6.1 of the 2000 Life Safety Code).

But hospitals want the infant security systems used on the babies. These systems have a bracelet that is attached to the baby, and some have bracelets to attach to the mother as well. If the bracelet gets too close to the exit door, an alarm will sound and the door will lock. The problem is, these infant security systems do not comply with any of the three exceptions for locking the doors in the path of egress, listed above. Even if the doors will unlock on a fire alarm the hospital says, that is still not enough to qualify for the any of the three exceptions.

But then the hospital says their accreditation organization approved this door locking arrangement. Why should it be considered non-compliant if the accreditor allows it?  Sorry… just because the accreditation organization says it is okay, still does not make it compliant with the requirements of the Life Safety Code. When the state agency who surveys on behalf of CMS takes a look at it, they will not be as benevolent as the accreditor, and they will cite it as a deficiency.

So, to be compliant with the Life Safety Code, when the doors lock because the bracelet gets too close to the door sensor, the doors should lock into a delayed egress mode (again… see section 7.2.1.6.1 in the 2000 Life Safety Code). Then it would be legal. But the 2012 LSC has made a change in this area and will allow locks on doors for the specialized protective measures for the safety of the occupants (see section 18/19.2.2.2.5.2 in the 2012 LSC). This will allow you to lock the doors without delayed egress, provided you meet the requirements listed in that section. CMS has already approved categorical waivers to allow hospitals to begin using this new section of the 2012 LSC before they adopt it.

Take a look at your locks that are used on the nurseries, pediatric, mother/baby units, and even the ICUs and the ERs. If they are not delayed egress, then take a look at the CMS categorical waivers and consider modifying the doors to meet those requirements.

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