Jul 01 2017

Clarification on Emergency Department Occupancy Classification

Category: BlogBKeyes @ 12:00 am
Share

If you’ve been reading my blog postings over the past few months ( see http://keyeslifesafety.com/?s=emergency+department), you’ve read were I have reported that CMS has issued informal, non-public letters to the accreditation organizations (AOs) regarding the occupancy classification of emergency departments. To review how this issue started, CMS issued a letter to one of the AOs last fall (in 2016) regarding the occupancy classification of Emergency Departments. In this letter, CMS said Emergency Departments needed to be classified as healthcare occupancies. This information was then shared to the other AOs.

This set-off quite a stir in the healthcare community, as many people and organizations objected to this strict interpretation, since the 2012 Life Safety Code actually permits Emergency Departments to be classified as ambulatory healthcare occupancies.  Many free-standing Emergency Departments have already been constructed to meet ambulatory healthcare occupancy requirements, and to make physical changes after the facility has been occupied would be an unreasonable hardship.

Apparently, the objections to this rather strict interpretation have been heard, and CMS has again issued an informal, non-public communication that says they have not issued any policy regarding Emergency Department classification. Therefore, according to CMS, occupancy classification of Emergency Departments would be determined in accordance with 2012 Life Safety Code.

This means according to 3.3.188.1, an Emergency Department may be classified as an ambulatory healthcare occupancy provided it does not have sleeping accommodations for 4 or more patients on a 24-hour basis. CMS considers a bed used for 24-hour observation to be ‘sleeping accommodations’ and if the Emergency Department has 4 or more observation beds, then the Emergency Department must be classified as a healthcare occupancy.

Also, another item to consider… If you have an Emergency Department that is considered a suite and is required to be classified as a healthcare occupancy due to ‘sleeping accommodation’ rooms, then the Emergency Department would have to meet the requirements of section 19.2.5.7.2 “Sleeping Suites”. This means, where you previously may have enjoyed a suite that is up to 10,000 square feet in size, you may now be limited to just 5,000 square feet. However, take a look at section 19.2.5.7.2.3 as you may qualify to meet the requirements to bump the suite size up to 7,500 square feet or perhaps even to 10,000 square feet.

This clarification from CMS is helpful, and should go a long way to explain the occupancy classification of Emergency Departments.

Tags: , ,


Mar 02 2017

CMS Interprets Emergency Departments to be Healthcare Occupancies

Category: BlogBKeyes @ 12:00 am
Share

The following article was published today online by the HCPro newsletter ‘Healthcare Life Safety Compliance’, and is reprinted here with permission.

In a rather surprising interpretation by the Centers for Medicare and Medicaid Services (CMS), all Emergency Departments (ED) are now required to be classified as healthcare occupancies only. For many hospitals this may not be a problem, but for those hospitals that have already classified their EDs as ambulatory healthcare occupancy, they will have to make a change back to healthcare occupancy. This also affects those free-standing Emergency Departments that were designed and approved as ambulatory healthcare occupancies; according to CMS’ recent interpretation, they also must meet the requirements for a healthcare occupancy. And it appears this decision is retroactive to existing conditions.

This all came-about when the accreditation organizations (AO) submitted their revised and updated standards to CMS last fall for the change to the new 2012 Life Safety Code. One particular AO created an introduction to their Life Safety chapter and explained the differences in occupancies and gave an ED as an example of an ambulatory healthcare occupancy. CMS wrote back and said EDs cannot be ambulatory healthcare occupancies and must be classified as healthcare occupancies because they provide sleeping accommodations for patients who are on 24-hour observation.

Many of the AOs objected to this change and pointed out that the ED does not provide sleeping accommodations but rather examination rooms. Even patient-safety advocate groups like the American Society for Healthcare Engineering (ASHE) objected to this new ruling in the initial proposed rule.

“If a patient is on 24-hour observation in an ED, they are still being examined even if they are sleeping”, says Chad Beebe, Deputy Executive Director of ASHE. “It’s an entirely different staffing model than you would find in a nursing floor. It is very similar to Sleep Labs; even though the patient is sleeping, the patient is still being examined. And Sleep Labs are not required to be located in healthcare occupancies because they are providing outpatient services.”

Just like Sleep Labs, patients in an Emergency Department are considered to be out-patients and not inpatients. According to section 3.3.188.7 of the 2012 LSC, a healthcare occupancy is used to provide medical or other treatment of care simultaneously to four or more patients on an inpatient basis, where such patients are mostly incapable of self-preservation.

“How can CMS consider an Emergency Department is required to meet healthcare occupancy if the patients in the department are not even inpatients?” says Brad Keyes, owner and Senior Consultant for Keyes Life Safety Compliance, LLC. “The NFPA definition for ambulatory healthcare occupancy specifically describes emergency departments as ambulatory healthcare occupancies because they are outpatients, not inpatients. Why does CMS feel the need to depart from the NFPA definitions, that have been used in healthcare for decades?”

The financial implications by this excessive interpretation is far-reaching. Many free-standing Emergency Departments have been designed, approved and constructed in compliance with ambulatory healthcare occupancy requirements. Basic egress issues would suddenly be non-compliant, such as corridor width. Healthcare occupancies require 8-foot corridor widths for new construction, where ambulatory healthcare occupancies only require 44 inches. In healthcare occupancies, doors are required to separate the corridor from the exam rooms. In ambulatory healthcare occupancies, doors are not required. The cost to meet these new egressing requirements would be excessive.

Another difference between healthcare occupancies and ambulatory healthcare occupancies is the construction type, which identifies the combustibility and fire-resistance rating of the structural members of the building.

“A free-standing single-story Emergency Department that was constructed to ambulatory healthcare occupancy requirements, is not restricted in the construction type used to build the facility”, says Keyes. “However, that’s not true for Emergency Departments that are required to meet healthcare occupancy requirements. Unprotected wood-frame facilities and certain buildings with exterior non-combustible structural elements are not permitted to be used for healthcare occupancies.”

Converting an existing Emergency Department that has non-compliant construction type for healthcare occupancies would be very costly, if not prohibitively so.

“An additional cost may be in sprinklers”, says Keyes. “New ambulatory healthcare occupancies are not required to be protected with sprinklers, but new healthcare occupancies are. So, if the ED that was constructed to ambulatory healthcare occupancy requirements was not protected with sprinklers, it would have to when it is converted to healthcare occupancy. That will be a substantial cost to install sprinklers in an occupied facility.”

Even if the Emergency Department was constructed as a healthcare occupancy and designed to meet egress requirements for suites, that would have to change. If designed as a non-sleeping suite, the maximum size of the suite is 10,000 square feet. Now, according to CMS the Emergency Department is no longer a non-sleeping suite, but must meet the requirements of a sleeping suite which can be required to be half the area of a non-sleeping suite. That would require the installation of new barriers and doors.

“For many Emergency Departments, the cost to comply with the new CMS interpretation will be an unreasonable hardship”, says Beebe. “Facilities will have to be cited for non-compliance and then submit a waiver request. And there is no guarantee that the waiver will be approved by the CMS regional office.”

This latest interpretation by CMS seems to be in contrast to President Trump’s initiative to lower the cost of regulation. In fact, the new Administration is working to identify and repeal federal regulations that are unreasonable and costly. This interpretation by CMS seems to fit that bill.

Keyes offers an explanation why this interpretation by CMS is not made public. “CMS did communicate with those AOs with hospital deeming authority last fall regarding this interpretation, but so far, they have not notified the public”, says Keyes. “It could very well be that CMS has always believed Emergency Departments to be healthcare occupancies and they now feel there is no reason to make a formal notice, such as a Survey & Certification letter.”

“ASHE has already received reports from members that they have been cited for having Emergency Departments and hospital outpatient departments located in ambulatory healthcare occupancies or even business occupancies”, says Beebe. “The enforcement of this interpretation has already started, and will only grow when the AOs begin their enforcement as well.”

Tags: , ,


Feb 10 2017

Emergency Department Classification

Category: Emergency Department,Questions and AnswersBKeyes @ 12:00 am
Share

Q: Should Emergency Departments be classified as healthcare, ambulatory healthcare, or business occupancies?

A: According to the 2012 Life Safety Code, a typical Emergency Department (ED) may be classified as healthcare or ambulatory care occupancies, but never business occupancy. The patients brought to a typical ED are not necessarily ambulatory or put in the NFPA vernacular, “capable of self-preservation”. So that would eliminate the business occupancy as a choice.

But informal communications from CMS reveals that they do not agree with this interpretation, entirely. While the typical ED does not provide sleeping rooms, it is understood that the ED may have 24-hour observation beds. In the way that CMS thinks, they consider these 24-hour observation beds as sleeping accommodations, so the designation of healthcare occupancy is mandatory.

Now, if your ED does not have 24-hour observation beds, then it is clear the ED could be classified as ambulatory healthcare occupancy.

Other issues that hospitals may have in deciding whether to classify the ED as ambulatory care or healthcare occupancy are:

  • A 2-hour fire rated barrier is necessary to separate ambulatory care occupancy from the rest of the hospital that is classified as healthcare occupancy;
  • Exiting from the healthcare occupancy through the ambulatory has to meet all of the requirements for healthcare occupancy, unless there is a horizontal exit involved;
  • Suites are permitted in ambulatory occupancies, and according to the 2012 Life Safety Code, they are allowed to be unlimited in size, but still have certain travel distance limitations;
  • Corridors in ambulatory care occupancies are only required to be 44 inches wide in clear width;
  • As long as the ambulatory care occupancy is a single tenant, or as long as the ambulatory care occupancy is fully protected with automatic sprinklers, rooms are not required to be separated from the corridors. Therefore, there are no requirements for doors to ED exam rooms, and if they do have doors, they are not required to positively latch.

Most of the times that I have observed organizations classify their EDs as ambulatory care occupancies, it was due to the fact that the ED did not qualify as a suite as described in the healthcare occupancy chapters, but they wanted to take advantage of the 44 inch wide corridors issue, and the no-door issue permitted in the ambulatory care occupancy. That would allow them to pretty much maintain the ED similarly to a suite, with some limitations.

 


Jan 24 2017

Emergency Departments: Healthcare Occupancy Only

Category: BlogBKeyes @ 12:00 am
Share

In a rather surprising interpretation by the Centers for Medicare and Medicaid Services (CMS), all Emergency Departments are now required to be classified as healthcare occupancies only. For most of the hospitals this will not be a problem, but for those hospitals that have already classified their ERs as ambulatory healthcare occupancy, they will have to make a change back to healthcare occupancy. This also affects those free-standing Emergency Departments that were designed and approved as ambulatory healthcare occupancies; they also must meet the requirements for a healthcare occupancy.

This all came-about when the accreditation organizations (AO) submitted their revised and updated standards for the change to the new 2012 Life Safety Code. One particular AO created an introduction to their Life Safety chapter and explained the differences in occupancies and gave an ER as an example of an ambulatory healthcare occupancy. CMS wrote back and said no, ERs cannot be ambulatory healthcare occupancies because they provide sleeping accommodations for patients who are on 24-hour observation.

Many of the AOs objected to this change and pointed out that the ER does not provide sleeping accommodations and besides there are situations where there are less than 4 patients under 24-hour observation. CMS would not budge on this issue, and it is their (CMS’) position that the ER does provide sleeping accommodations for 4 or more patients and therefore they must be classified as healthcare occupancies.

This rather severe interpretation by CMS was communicated with the AOs, however it has yet to be released by CMS to the general public. Be aware: It appears that the AOs are prepared to enforce this decision by CMS, because if they do not, and CMS conducts a validation survey after the AO survey, then the AO can be held accountable for not citing the issue.

It is important to understand that there were advantages for a healthcare organization to claim their ER is an ambulatory healthcare occupancy. If the ER was too large to qualify as a suite under the healthcare occupancy requirements, then it may qualify as a suite under the ambulatory healthcare occupancy requirements because under the ambulatory healthcare chapters, suites are unlimited in size. Also, if the ER cannot qualify as a suite, there are no requirements for corridor doors to the exam rooms in an ambulatory healthcare occupancy.

So, for some healthcare organizations, re-classifying their ERs back to be a healthcare occupancy may be a serious challenge.

Tags: ,


May 17 2017

Fire-Fighter Emergency Phones

Category: Emergency Phones,Questions and AnswersBKeyes @ 12:00 am
Share

Q: Are firefighter emergency call phones still required in new construction? We have an existing hospital and management is wanting to add a whole new patient tower and the construction company is trying to say they are no longer required. I know the old system was the red phones and the new system is the plug in phones. Can you shed any light on this?

A: Generally speaking, two-way communications are only required in high rises according to section 11.8.4.2.1 of the 2012 Life Safety Code. However, section 11.8.4.2.2 allows for a fire department radio system installation in lieu of the fire-phones.  Most AHJs utilize these radios so the method of two way communications in a high rise hospital must be coordinated with the fire department.  Most will require the installation of a compatible radio system and will not require the fire-phones.


Sep 09 2016

CMS Announces New Rule on Emergency Management

Category: BlogBKeyes @ 12:00 am
Share

Well… here it is. CMS has announced that they will publish their Final Rule on the new standards for Emergency Management. It appears the new rule will not be published in the Federal Register until September 16, 2016, which is a week away, but take time now to read their press release below… and start learning all the changes you will need to know.

According to the press release, the new rule becomes effective 60 days after it is published in the Federal Register, which would be November 15, 2016. But it also says the new requirements will not be enforced until November, 2017, so the healthcare organizations and the AOs have a year to get ready for these changes.

CMS News

FOR IMMEDIATE RELEASE September 8, 2016

Contact: CMS Media Relations (202) 690-6145 | CMS Media Inquiries

CMS finalizes rule to bolster emergency preparedness of certain facilities participating in Medicare and Medicaid

Today, the Centers for Medicare & Medicaid Services (CMS) finalized a rule to establish consistent emergency preparedness requirements for health care providers participating in Medicare and Medicaid, increase patient safety during emergencies, and establish a more coordinated response to natural and man-made disasters.

Over the past several years, and most recently in Louisiana, a number of natural and man-made disasters have put the health and safety of Medicare and Medicaid beneficiaries – and the public at large – at risk. These new requirements will require certain participating providers and suppliers to plan for disasters and coordinate with federal, state tribal, regional, and local emergency preparedness systems to ensure that facilities are adequately prepared to meet the needs of their patients during disasters and emergency situations.

“Situations like the recent flooding in Baton Rouge, Louisiana, remind us that in the event of an emergency, the first priority of health care providers and suppliers is to protect the health and safety of their patients,” said CMS Deputy Administrator and Chief Medical Officer Patrick Conway, M.D., MSc. “Preparation, planning, and one comprehensive approach for emergency preparedness is key. One life lost is one too many.”

“As people with medical needs are cared for in increasingly diverse settings, disaster preparedness is not only a responsibility of hospitals, but of many other providers and suppliers of healthcare services. Whether it’s trauma care or long-term nursing care or a home health service, patients’ needs for health care don’t stop when disasters strike; in fact their needs often increase  in the immediate aftermath of a disaster,” said Dr. Nicole Lurie, HHS assistant secretary for preparedness and response. “All parts of the healthcare system must be able to keep providing care through a disaster, both to save lives and to ensure that people can continue to function in their usual setting. Disasters tend to stress the entire health care system, and that’s not good for anyone.”

After reviewing the current Medicare emergency preparedness regulations for both providers and suppliers, CMS found that regulatory requirements were not comprehensive enough to address the complexities of emergency preparedness. For example, the requirements did not address the need for: (1) communication to coordinate with other systems of care within cities or states; (2) contingency planning; and (3) training of personnel. CMS proposed policies to address these gaps in the proposed rule, which was open to stakeholder comments.

After careful consideration of stakeholder comments on the proposed rule, this final rule requires Medicare and Medicaid participating providers and suppliers to meet the following four common and well known industry best practice standards.

1. Emergency plan: Based on a risk assessment, develop an emergency plan using an all-hazards approach focusing on capacities and capabilities that are critical to preparedness for a full spectrum of emergencies or disasters specific to the location of a provider or supplier.

2. Policies and procedures: Develop and implement policies and procedures based on the plan and risk assessment.

3. Communication plan: Develop and maintain a communication plan that complies with both Federal and State law. Patient care must be well-coordinated within the facility, across health care providers, and with State and local public health departments and emergency systems.

4. Training and testing program: Develop and maintain training and testing programs, including initial and annual trainings, and conduct drills and exercises or participate in an actual incident that tests the plan.

These standards are adjusted to reflect the characteristics of each type of provider and supplier. For example:

  • Outpatient providers and suppliers such as Ambulatory Surgical Centers and End-Stage Renal Disease Facilities will not be required to have policies and procedures for provision of subsistence needs.
  • Hospitals, Critical Access Hospitals, and Long Term Care facilities will be required to install and maintain emergency and standby power systems based on their emergency plan.

In response to comments, CMS made changes in several areas of the final rule, including removing the requirement for additional hours of generator testing, flexibility to choose the type of exercise a facility conducts for its second annual testing requirement, and allowing a separately certified facility within a healthcare system to take part in the system’s unified emergency preparedness program.

The final rule also includes a number of local and national resources related to emergency preparedness, including helpful reports, toolkits, and samples. Additionally, health care providers and suppliers can choose to participate in their local healthcare coalitions, which provide an opportunity to share resources and expertise in developing an emergency plan and also can provide support during an emergency.

These regulations are effective 60 days after publication in the Federal Register. Health care providers and suppliers affected by this rule must comply and implement all regulations one year after the effective date.

For more information please see a blog by Dr. Lurie, HHS assistant secretary for preparedness and response, and the CMS Survey & Certification – Emergency Preparedness webpage.

 

Tags: ,


Jun 09 2014

Emergency Response Plan

Q: We are going to prepare an action card for fire safety as part of our major emergency response plan. What information regarding fire safety would you suggest we include on the Emergency Response job action card?

A: Emergency response preparedness (i.e. Emergency Preparedness) involves many different aspects, including fire safety. In order to write a job action sheet (or job action card) for fire safety, I would suggest that you utilize your basic fire response plan for the internal portion of emergency preparedness. Many hospitals utilize the familiar acronym RACE to help remind their staff as to the organization’s fire response plan:

  • R = Rescue anyone in harm’s way of the fire
  • A = Activate the alarm by pulling the manual fire alarm station and dialing______
  • C = Contain the fire by closing all the doors
  • E = Extinguish the fire with portable extinguishers, OR Evacuate patients from the scene of the fire

For external fires, a job action sheet may include some (or all) of the following:

  • Shutting down all of the fresh-air intakes for the hospital’s ventilation system.
  • Placing boards on windows
  • Taking pro-active action and wetting-down combustible portions of the facilities or grounds
  • Possible relocating patients from one wing or area to another
  • Emptying parking lots and garages which are close to the hospital
  • Possible evacuation of hospital
  • Re-directing traffic away from the hospital
  • Controlling access to the Emergency Department
  • Suspending shift change and proceeding to a 12 hour on/12 hour off rotation


Jun 01 2011

Emergency power for magnetic door locks

Category: Door Locks,Questions and AnswersBKeyes @ 8:13 pm
Share

Q: I was recently informed by a contractor the magnetic locks that we use to lock our ER department doors are not allowed to be connected to our emergency generator power. I cannot find this exclusion to connect to emergency power in the LSC. Are you aware of this requirement?

A: What you are referring to are either delayed egress locks or access control locks, which are allowed to be used on a door in the path of egress with some limitations. LSC section 7.2.1.6.1 for delayed egress locks and section 7.2.1.6.2 for access-control locks have multiple requirements for their use, but one requirement that is shared by both sections states the doors must unlock upon loss of power controlling the locking mechanisms. Nowhere does it say that emergency power cannot be used. However, that is not the end of the story. The LSC requires hospitals to be compliant with NFPA 72 National Fire Alarm Code, (1999 edition) and section 3-9.7.3 of NFPA 72 says all exits connected with a locking device shall unlock upon loss of the primary power to the fire alarm system, and the secondary power supply shall not be used to maintain these doors in the locked condition. The Annex portion of 3-9.7.3 explains that the LSC refers to batteries in the fire alarm control panel as the secondary power supply, but the Annex portion is not part of the enforceable code, just an explanatory section. Since the LSC is silent as to whether the locks can or cannot be connected to emergency power, it is up to the authorities having jurisdiction (AHJ) to make this interpretation. It appears to me that The Joint Commission does not have a problem with delayed egress or access control locks being connected to emergency power, but I know of some state AHJs that do not allow this. I suggest you contact your state and local AHJs for their interpretations.


Jan 30 2017

Exiting Through Other Occupancies

Category: Exits,Occupancies,Questions and AnswersBKeyes @ 12:00 am
Share

Q: If I want to classify my building as a healthcare occupancy, even though I have a business or ambulatory healthcare occupancy in it, I know I need to meet the most restrictive occupancy, which would be healthcare. I know that I need to meet construction type, fire protection, and allowable floors for the healthcare occupancy, but what about exiting requirements?

A: Where inpatients are expected to exit through any other occupancy, you need to maintain the exiting requirements for healthcare occupancy even if the occupancy is something else. As an example, if an Emergency Department is classified as an ambulatory healthcare occupancy, the required width of corridors for exiting is 44 inches. However, if inpatients are expected to use the path of egress from the healthcare occupancy into and through the ambulatory healthcare occupancy, then the required width must be maintained for healthcare occupancy (which is 8 feet) even in the ambulatory healthcare occupancy.


Jun 04 2014

Comments on CMS Proposed Rule to Adopt 2012 LSC – #5

Category: Blog,Life Safety Code UpdateBKeyes @ 6:00 am
Share

CMS Logo 2

The following is one of many comments that I will make in response to CMS’s proposed rule to adopt the 2012 Life Safety Code.

CMS statement: “We also propose to add a new requirement at §482.41(b) (10) that would retain the majority of the 36 inch window sill requirement that was in the 2000 edition of the LSC. Newborn nurseries and rooms intended for occupancy for less than 24 hours, such as those housing obstetrical labor beds, and recovery beds would be exempt from the window sill height. The 2000 edition of the LSC allowed for observation beds in the emergency department to be exempt from the 36 inch window sill requirement. However, we do not propose to incorporate an exemption for observation beds, because they are frequently occupied for greater than 24 hours. Therefore, observation beds would be required to meet the 36 inch window sill requirement.”

Brad’s comment:  The physical environment of the ER consists of as many exam rooms and treatment rooms as the space would allow, and still meet applicable codes and standards. Many ERs extend into the interior areas of the facility since windows to the outdoors are not required in exam and treatment rooms. However, if CMS does not allow an exemption for window sill height in rooms containing observation beds, then healthcare facilities will have difficulty in finding space in the emergency department on outside walls for observation beds that will allow a window to the exterior.

Therefore, I will encourage CMS to reconsider their position and include rooms containing observation beds in the exemption for window sill height.

The following comment is not based on any one specific CMS statement:

Existing Non-High-Rise Health Care Occupancies

Brad’s comment:  While the 2012 LSC does not require existing non-high-rise healthcare occupancies to become fully protected with automatic sprinklers, I will encourage CMS to consider making this a requirement for participation in the Medicare & Medicaid program under this proposed rule, or perhaps future proposed rules.

As mentioned earlier, automatic sprinklers are the most effective fire safety system that can be installed for patient safety. Reports provided by NFPA show a significant reduction in the potential for loss of life when a hospital is equipped with automatic sprinklers, as indicated by this excerpt from a NFPA report:

“On January 24, 1993, an incendiary fire occurred at a hospital in Weymouth, Massachusetts.  One sprinkler operated in the room of fire origin, extinguishing the flames before firefighters arrived.  The damage from flame and heat was limited to the room of origin; however, water and smoke spread into the corridor and resulted in some damage.  Six staff were treated and released for smoke-related injuries.  Compliance with fire safety code requirements, training of staff, and the use of automatic sprinklers significantly reduced the potential for loss of life and large property loss during this incident.”

Based on this and other NFPA reports that indicate sprinklers saves lives in health care facilities, I believe mandating existing non-high-rise healthcare occupancies to become fully sprinklered within 6 to 8 years will provide a significant level of safety for patients in those facilities.

Submit your comments to http://www.regulations.gov  by June 16th, 2014.

Tags:


Next Page »