Aug 04 2016

How the Changes to the SOC Process Will Affect Life Safety Compliance

Category: BlogBKeyes @ 12:00 am
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On July 13, 2016, The Joint Commission issued the following statement:

 “Effective Aug. 1, 2016, changes will become effective to the Statement of Conditions™ (SOC) process that will affect the survey of Life Safety (LS) chapter requirements. Following Aug. 1, 2016, the following changes to survey will occur:

  1. The open Plan for Improvement (PFI) items will no longer be reviewed by the survey team.
  2. The open PFI will no longer be imported into the Final Report.
  3. All Life Safety (LS) chapter deficiencies identified during survey will become Requirements for Improvement (RFI) with a 60-day Evidence of Standards Compliance (ESC). For those deficiencies that require more than 60 days, a Time-Limited Waiver process is available.
  4. Only equivalency requests related to survey events will be reviewed.

The Joint Commission has had the SOC as part of its accreditation program since 1995. The SOC was originally created to allow organizations a process to develop a plan for improvement to correct deficiencies they self-identified within a justifiable time frame based on budgeting and scheduling needs, with Interim Life Safety Measures (ILSM) to ensure patient safety. Initially, these self-identified actions were not documented during survey because the SOC already documented the deficiency. The Joint Commission also created the ILSM process to mitigate risk while resolving the deficiencies. This allowed the SOC process to be the method for organizations to create and submit their Plan for Improvement (PFI), with an amount of time to make the correction that the organization could manage, while still providing a safe environment. Occasionally, an organization would need additional time to complete the corrective action, and The Joint Commission granted extension requests. Many of these extension requests occurred during the six-month automatic extension period.      

CMS has identified required changes to the SOC process, including:  

  • No longer allowing the SOC to document self-identified deficiencies, instead, taking the self-identified deficiencies and converting those to RFIs by the surveyor 
  • No longer allowing more than 60 days for corrective actions unless approved by the CMS regional office
  • The surveyor citing all deficiencies replacing the extension request component with a Time Limited Waiver process, using the Survey-related Plan For Improvement (SPFI) process that will be managed and tracked by the CMS regional office
  • Managing the survey-related equivalency process, as defined by CMS, using Salesforce and the SOC to manage and track the CMS regional office action  
  • Removing the six-month automatic extension
  • No longer granting requested extensions
  • Joint Commission leadership, after reviewing the restrictions being placed on the SOC, has determined that the Basic Building Information and PFI components of the SOC no longer fit the quality assessment program it was originally designed as, and will become an optional management program and will not be a part of the survey process. Post survey, the CMS Time Limited Waiver and equivalency components of the SOC will be used to manage survey-related deficiencies. All questions should go to The Joint Commission Department of Engineering at 630-792-5900.”

 

This is another sad event for patient safety caused by a federal agency that cannot see the positive that the SOC / PFI process had for healthcare organizations. This action by CMS is not a knee-jerk reaction that was not carefully considered; rather this decision by CMS to not allow the hospitals and ambulatory surgical centers to have a process of self-identification of Life Safety Code deficiencies and an incentive to be proactive has been long-coming for years.

Back in 2008 when Det Norske Veritas (DNV) Healthcare received deeming authority from CMS, the new accreditor wanted a system similar to the Statement of Conditions PFI list, but was told by CMS that they could not. Similarly, in 2012 HFAP applied for a system similar to the PFI list but was also denied by the federal agency.

In 2014 when CMS issued their proposed rule to adopt the 2012 Life Safety Code, the public responded with many comments. Quite a few commenters mentioned that CMS should keep the SOC/PFI system and allow all of the accreditation organizations a chance to utilize it.

When CMS issued their final rule on May 4, 2016, they made it very clear that there will not be any Plan For Improvement list in the way that Joint Commission was operating. That was the writing on the wall and it became clear that the major hospital accreditor would have to discontinue its use.

This is a very sad event, because now it is feared that many hospitals will no longer be proactive and self-identify their own Life Safety Code deficiencies because any incentive to do so (i.e. not citing the deficiency on the survey report) has been removed. CMS has struck harder and put a stop to hospital self-identifying the projected completion date, and now makes all LSC deficiencies cited during a survey to be resolved within 60 days of the end of the survey.

Since major LSC deficiencies cannot be resolved that quickly, CMS is now requiring the healthcare organizations to request a time-limited waiver through the accreditor. This is another example of CMS tightening their grip on the accreditation process. In this case, it reduces the level of safety for the patients. Where is the logic in that?

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Jul 16 2016

Asked a Question Lately?

Category: BlogBKeyes @ 8:31 pm
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If you tried to ask a question or send me a comment since July 5, 2016 via this website, you probably receive a notice that the email did not transmit properly. That is because of a failure in the security system, which has now been resolved.

Any questions or comments you wish to send should now reach me.

Thank you…

Brad.


Jun 24 2016

FM Approval on Waste Containers

Category: BlogBKeyes @ 12:00 am
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Q: In the fine print of the new 2012 Life Safety Code, under sections 18/19.7.5.7.2 for containers used solely for recycling clean waste or for patient medical records awaiting destruction, the following is noted:

(4) Containers for combustibles shall be labeled and listed as meeting the requirements of FM Approval Standard 6921, Containers for Combustible Waste; however, such testing, listing, and labeling shall not be limited to FM Approvals.

My question is: Does this in reality become a hard burden to prove? Are other hospital facility managers unwilling to utilize the CMS waiver for this for fear that they will have difficulty proving compliance?

A: I have not heard of any facility manager not using the CMS categorical waiver based on the reluctance to be able to prove that the containers meet the requirements listed. It is a real possibility, but I can’t say I am aware of anyone with this concern.

It sounds like you must have checked your own containers to see if they comply with this FM Approval listing requirement. If so, I assume you found some that did not meet the requirements. I do know that some manufacturers do meet this requirement and therefore there are containers out there for clean recyclables and patient records waiting for shredding that do meet this requirement.

I would suggest you make it a condition with the shredding company to provide FM Approval listed containers if they continue to want your business.

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Jun 17 2016

Sprinklers in Electrical Closets?

Category: BlogBKeyes @ 12:00 am
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Q: Does an electrical closet under 144 square inches need a sprinkler head?

A: The answer depends on your facility occupancy type and the requirements associated with that. If your facility is a hospital and the area in question was constructed prior to 1991, and there has not been any major renovation in the area, and the Construction Type does not require sprinklers, then there is no Life Safety Code condition that would require sprinklers in a small closet. However, if the Construction Type requires sprinklers (see 19.1.6.2 of the 2000 LSC) then sprinklers would have to be installed. If you conducted renovation in the area of the small closet since 1991, then sprinklers would have to be installed.

If your facility is a long-term care/nursing home facility, then the closet would have to be sprinklered. CMS has issued a memo that requires all nursing homes to be 100% protected with sprinklers, and a 12 inch x 12 inch closet would be included in this requirement to be protected with sprinklers.

If your facility is an ambulatory health care occupancy or a business occupancy, then sprinklers are not mandatory.

Also, please check with your state and local authorities to see if they have specific requirements for sprinklers.

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Jun 10 2016

Control Valve Tamper Switches

Category: BlogBKeyes @ 12:00 am
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Q: Please explain why The Joint Commission standard EP 1 identifies control valve signal devices and valve tamper switches as different pieces of equipment? The only difference I can see would be the bolt-on type tamper used to supervise an OS&Y valve as opposed to a butterfly type valve with a built-in tamper switch. Either way, they do the same thing as sprinkler control valves which are supervised by the fire alarm system, but the EP defines them, and the testing requirements for each differently. Why?

A: I’m not sure which EP 1 you are looking at, but EC.02.03.05, EP 1 says: “At least quarterly, the hospital tests supervisory signal devices (except valve tamper switches). The completion date of the tests is documented.” Nowhere does this EP differentiate between add-on after-market tamper switches for OS&Y valves, and those butterfly type valves which have a tamper switch built inside it. As far as the standard is concerned, a tamper switch is a tamper switch. EC.02.03.05, EP 2 does allow tamper switches to be tested every six months.

The EC.02.03.05, EP 1 and EP 2 are based on NFPA 72 which requires supervisory signal devices such as pressure switches and temperatures switches to be tested quarterly, but does allow tamper switches (which are supervisory signal devices) to be tested semi-annually. Why do tamper switches get a break? I don’t know… the NFPA 72 handbook does not say.

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Jun 07 2016

Keyes Life Safety Boot Camp – Last Chance to Register!

Category: BlogBKeyes @ 12:00 am
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Web 2Understand practical applications of the NFPA 101 Life Safety Code®! Learn from Life Safety surveyors on what to prepare for during surveys! A 2-day Boot Camp on the comprehensive examination of the NFPA 101 Life Safety Code®, as it applies to healthcare organizations; presented by Keyes Life Safety Compliance, LLC and Codenity, LLC.

Date: July 18 & 19, 2016

Location: Hilton Garden Inn, 2930 S. River Rd, Des Plaines, IL (847) 296-8900

Topics:
• LSC Origins & Organization • Smoke Compartments • Occupancy Designations
• Suites • Construction Types • Additions & Renovations
• Operating Features • Means of Egress • Door Locks
• Ambulatory Surgical Centers • Fire Barriers • Hazardous Areas
• Building Services • Fire Protection Systems • Understanding CMS
• Changes the 2012 LSC Will Bring • Key Interpretations by Accreditation Organizations • Documentation Needed for a Successful Survey

Who Should Attend:
• Facility Managers • Safety Officers • Chief Operating Officers
• Accreditation Coordinators • Architect/Engineers • Consultants

Presenters:
Brad Keyes, CHSP, owner of Keyes Life Safety Compliance, LLC; current advisor to Healthcare Facilities Accreditation Program (HFAP) and former Joint Commission LS surveyor.

Alise Howlett, Assoc. AIA, CFPE, CHFM, owner of Codenity, LLC; current LS surveyor for HFAP, and a plan reviewer for multiple municipalities.

Cost: $779.00 per participant. Includes workbook, seminar materials, opening night reception, and breakfast and lunch each day; Does not include hotel, or travel. Certificate of Attendance awarded on completion.

Hotel Registration link for special rates or mention Keyes Life Safety Boot Camp when calling: http://hiltongardeninn.hilton.com/en/gi/groups/personalized/O/ORDCHGI-LSB-20160717/index.jhtml?WT.mc_id=POG

Register: Online at www.Eventbrite.com and search “Keyes Life Safety Boot Camp” or complete registration below and submit check or money order. Do not send cash. Seating limited to 50 individuals. Registration is not confirmed until payment is received.

Registration closes June 10, 2016.

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

Name:_____________________________________________________

Date:______________________________________________________

Address: ___________________________________________________

City/State/Zip: _______________________________________________

Telephone: __________________________________________________

Email: _____________________________________________________

Organization: ________________________________________________

Send Registration to:

Keyes Life Safety Compliance, LLC

PO Box 54

Rockton, IL 61072

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Jun 03 2016

Storage of Flammable Liquids

Category: BlogBKeyes @ 12:00 am
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Q: It is my understanding that you are only allowed to have 10 gallons of flammable chemicals in a smoke compartment without having a fire cabinet. Does this amount change if it’s a one hour fire rated, fully sprinkled room?

A: According to section 9.4.3 of NFPA 30 Flammable and Combustible Liquids Code, 2012 edition, the storage of Class IB flammable liquids (which is the typical flammable liquids you would find in a hospital, such as ethyl-alcohol) is limited to 5.3 gallons (20 L) per container made of metal, approved plastic, and safety cans.

According to section 9.5.1 of NFPA 30, to total volume of Class I, Class II, and Class IIIA liquids stored in an individual storage cabinet cannot exceed 120 gallons (460 L). The description of an approved storage cabinet is listed in section 9.5.3 (2) which is the type that used to be referred to as “fire-rated” storage cabinets, or “NFPA 30” cabinets. They basically stopped calling these cabinets “fire-rated” and refer to them now by their construction. Incidentally, section 9.5.4 does not require storage cabinets to be ventilated, even though ventilation openings are usually provided.

The maximum allowable quantity of flammable liquids (outside of storage areas) per control area is 10 gallons (38 L) for healthcare occupancies. A control area is defined by NFPA 30 as an area protected with fire-rated barriers. So, technically, smoke compartment barriers in a healthcare occupancy would typically not comply with the NFPA 30 definition of a control area, because smoke compartment barriers doors typically do not comply with the requirements for fire-rated doors. However, CMS and the accreditation organizations have overlooked this detail and allow smoke compartment barriers to serve as control areas for the purpose of storing Alcohol Based Hand-Rub (ABHR) product, which contains ethyl-alcohol.

According to 9.3.6 of NFPA 30, Class I flammable liquids are not permitted to be stored in floors below the level of exit discharge (basements).

Fire resistive rating for rooms for the storage of flammable liquids is dependent on the area of the room. According to Table 9.9.1, a storage room no more than 150 square feet must have a fire resistive rating of 1-hour. A storage room greater than 150 square feet but no more than 500 square feet must have a fire resistive rating of 2-hours. Storage rooms greater than 500 square feet are not permitted, unless you meet the more extreme requirements of a flammable liquid warehouse.

So, you can store up to 120 gallons of Class IB flammable liquids in a storage cabinet that meets the requirements of section 9.5.1 of NFPA 30, but the total quantity does not change if the flammable liquid is stored in a properly fire-rated storage room based on the total area of the room. Be advised that NFPA 30 does not differentiate whether the storage room is sprinklered or not.

However, I disagree with your opening statement that you are allowed to have 10 gallons of flammable chemicals in a smoke compartment without having a fire cabinet. NFPA 30 section 9.4.3 limits the maximum volume to 5.3 gallons of stored flammable liquids without have a fire cabinet.

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Jun 01 2016

New Fire Door Inspection Requirements

Category: BlogBKeyes @ 12:00 am
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Cross Corridor door web 2When the new 2012 Life Safety Code becomes effective July 5, 2016, CMS will expect all healthcare organizations to be compliant with the requirements of the new 2012 Life Safety Code. One of the more challenging changes that the new 2012 Life Safety Code will require is compliance with NFPA 80-2010 edition, which requires all fire-rated door assemblies to be inspected annually.

This includes all of the side-hinged swinging fire-rated doors in your facility. And it applies to any fire rated door assembly, whether it is located in a required fire rated barrier or not.

The requirements for the annual inspection include the following:

  • Is the door and frame free from holes and breaks in all surfaces?
  • Are all the glazing, vision light frames and glazing beads intact and securely fastened?
  • Are the doors, hinges, frame, hardware and threshold secure, aligned and in working order with no visible signs of damage?
  • Are there any missing or broken parts?
  • Is the clearance from the door edge to the frame no more than 1/8 inch?
  • Is the door undercut no more than ¾ inch?
  • Does the active door leaf completely closes when operated from the full open position?
  • Does the inactive leaf close before the active leaf when a coordinator is used?
  • Does the latching hardware operate and secure the door in the closed position?
  • Is the door assembly free from are auxiliary hardware items which could interfere with its operation?
  • Has the door been modified since it was originally installed?
  • If gasketing and edge seals are installed, have they been verified for integrity and operation?

Anyone can do this inspection… there is no requirement that the inspector has to be certified. But the standard does require that the individual inspecting the door assembly is knowledgeable, so if you plan on using in-house people, make sure they have some sort of training. The IFDIA certification (see side panel) is one of many on-line courses to become trained for fire door inspections.

There is a Fire Door Inspection form you may down-load for free from this website. Just click on “Tools” and scroll down to the bottom to find it.

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May 31 2016

Keyes Life Safety Boot Camp – Last Week to Register!

Category: BlogBKeyes @ 12:00 am
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Web 2Understand practical applications of the NFPA 101 Life Safety Code®! Learn from Life Safety surveyors on what to prepare for during surveys! A 2-day Boot Camp on the comprehensive examination of the NFPA 101 Life Safety Code®, as it applies to healthcare organizations; presented by Keyes Life Safety Compliance, LLC and Codenity, LLC.

Date: July 18 & 19, 2016

Location: Hilton Garden Inn, 2930 S. River Rd, Des Plaines, IL (847) 296-8900

Topics:
• LSC Origins & Organization • Smoke Compartments • Occupancy Designations
• Suites • Construction Types • Additions & Renovations
• Operating Features • Means of Egress • Door Locks
• Ambulatory Surgical Centers • Fire Barriers • Hazardous Areas
• Building Services • Fire Protection Systems • Understanding CMS
• Changes the 2012 LSC Will Bring • Key Interpretations by Accreditation Organizations • Documentation Needed for a Successful Survey

Who Should Attend:
• Facility Managers • Safety Officers • Chief Operating Officers
• Accreditation Coordinators • Architect/Engineers • Consultants

Presenters:
Brad Keyes, CHSP, owner of Keyes Life Safety Compliance, LLC; current advisor to Healthcare Facilities Accreditation Program (HFAP) and former Joint Commission LS surveyor.

Alise Howlett, Assoc. AIA, CFPE, CHFM, owner of Codenity, LLC; current LS surveyor for HFAP, and a plan reviewer for multiple municipalities.

Cost: $779.00 per participant. Includes workbook, seminar materials, opening night reception, and breakfast and lunch each day; Does not include hotel, or travel. Certificate of Attendance awarded on completion.

Hotel Registration link for special rates or mention Keyes Life Safety Boot Camp when calling: http://hiltongardeninn.hilton.com/en/gi/groups/personalized/O/ORDCHGI-LSB-20160717/index.jhtml?WT.mc_id=POG

Register: Online at www.Eventbrite.com and search “Keyes Life Safety Boot Camp” or complete registration below and submit check or money order. Do not send cash. Seating limited to 50 individuals. Registration is not confirmed until payment is received. Registration closes June 10, 2016.

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

Name:_____________________________________________________

Date:______________________________________________________

Address: ___________________________________________________

City/State/Zip: _______________________________________________

Telephone: __________________________________________________

Email: _____________________________________________________

Organization: ________________________________________________

Send Registration to:

Keyes Life Safety Compliance, LLC

PO Box 54

Rockton, IL 61072

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May 27 2016

Linen Chute Doors

Category: BlogBKeyes @ 12:00 am
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Q: My question relates to fire ratings of linen chute doors. Do linen chute doors in an existing structure have to be rated if the room that houses the linen chute is protected by a 2 hour wall and the door for this room is rated at 90 minutes?

A: Yes, according to NFPA 82 (1999 edition) section 3-2.4.1, the chute doors must be fire-rated in a vertical linen chute enclosure. There is no exception in NFPA 82 for the chute doors in a vertical chute that opens into a room that has the same fire resistive rating as the shaft for the vertical chute, to not be fire rated.

Section 8.2.5.3 of the 2000 Life Safety Code which allows shafts to terminate in a room with the same fire resistive rating as the shaft does not apply in this situation because the shaft does not terminate at the room. It continues up through the building and extends (in part) through the roof. However, it may apply for the collection room that is at the bottom of the shaft for the linen chute, provided the room meets all of the requirements of section 8.2.5.3.

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