NFPA 99 Risk Assessment – PLEASE READ THIS

Q: I need to do the NFPA 99 risk assessment of my hospital. I was told by one of my consultants that I have do this risk assessment from a room-by-room perspective, and he provided me a form from ASHE that lists this assessment by room-by-room. Is this true…? Do I have to do this assessment for each room?

A: No… that’s not correct. Yes, ASHE does have a form that does imply a room-by-room assessment is needed for the Chapter 4 risk assessment, but that’s not required by Chapter 4. What is required is an assessment of building systems based on a defined risk assessment procedure. Chapter 4 does not define the risk assessment procedure that you should use, but the Annex section does identify three risk assessments that they suggest, and the ASHE room-by-room assessment form is not included in these three suggestions. To be sure, you may use the ASHE form if you wish, but then you can use any risk assessment form that you want.

The core of the risk assessment is to determine what level or category the following building systems falls under, in the event of a total catastrophic failure of that system:

  • Gas & Vacuum Systems
  • Electrical Systems
  • HVAC Systems
  • Electrical Equipment
  • Gas Equipment

There are 4 levels or categories:

  • Category 1:    Systems in which failure is likely to cause major injury or death of patients or staff
  • Category 2:    Systems in which failure is likely to cause minor injury to patients or staff
  • Category 3:    Systems in which failure is not likely to cause injury to patients or staff
  • Category 4:    Systems in which failure would have no impact on patient care or staff

The process in the assessment is to determine the level of risk to the patient or staff if there is a catastrophic failure of that particular system. Another way of saying this is “Worst case scenario”.

As an example, let’s take the hospital’s electrical system: The risk assessment must assume a catastrophic failure of the entire system. The normal power system fails, and then the emergency power system from the generators fail. In other words, you have no power whatsoever in the building. Now, what is the level of risk to your patients? It will probably be Category 1, right?

You then do that type of catastrophic failure risk assessment for each of the above listed systems. If you want, you can break this down into different assessments of systems that are the same type. Such as HVAC systems: If the HVAC system fails in patient care areas, then that would be a certain high-level of risk to the patients. But if the HVAC system fails in the Administration wing, it would not be a risk to your patients, and it would be a low risk to your staff.

For hospitals, the expectation would be all of the above systems would be assessed as a Category 1 or Category 2. But for a medical building that only has physician offices and administrative support areas, the expectation is the above systems would be assessed as a Category 3 or Category 4. All healthcare facilities must be assessed for the risk level to patients and/or staff.

You have to document your assessment using a defined process. You can down-load a simple one-page risk assessment from my website and see if that meets your expectations.

The ironic thing is, the NFPA 99-2012 Technical Committee on Chapter 4 did not intend for this risk assessment to be conducted on existing systems. I talked with two members of that committee and they said the committee believed it was obvious the way it is written that this risk assessment is only required for new construction, since most (not all) of NFPA 99 is for new construction.

But CMS did not get that message and they require all of their state agencies and accreditation organizations to evaluate the risk assessment during all surveys. In other words; They fully expect all CMS certified healthcare organizations to have the Chapter 4 risk assessments completed by now.

In my opinion, this risk assessment does not require a lot of time to conduct. As I said, CMS expects all hospitals to have Category 1 or Category 2 systems. This is something you and your staff can do.

Just last week I received a call from a friend of mine who is a facility manager in the Midwest. He returned from a regional ASHE meeting where one of his fellow facility managers was recently surveyed by a leading accreditation organization (AO). The surveyor for the AO cited them for not doing their NFPA 99 risk assessment in accordance with the ASHE form, and do a room-by-room assessment. Please understand that this surveyor was incorrect to make that citation.

There is no NFPA requirement, no CMS requirement, and no AO requirement for healthcare organizations to do a room-by-room assessment to be in compliance with Chapter 4 of NFPA 99-2012. As mentioned above, you can use whatever risk assessment format you wish. The only requirement is the risk assessment must be documented and the surveyors will expect it to be reasonable (meaning all systems in a hospital are Category 1 or Category 2 systems).

Eye-Wash Risk Assessment

Q: Your articles on eye-wash station refers to the need to conduct a risk assessment. Where can I find such a document?

A: There is no set form to use for risk assessments. You can just get a group of stakeholders together and discuss the issue and the proposed solution and then write down what you discussed.

If you want a form that is based on the seven (7) steps recommended by The Joint Commission, go to my website, click on “Tools” and download the risk assessment form.

Environmental Tours

Q: I have read, or thought I read, that the environmental tours were no longer required with the adoption of the life safety code. Is this correct?

A: No… The NFPA codes and standards referenced by the Life Safety Code never did require environmental tours. When the 2012 Life Safety Code was adopted by CMS (and the accreditation organizations) last year, it made no changes regarding environmental tours because the 2012 LSC does not require it. The 2000 LSC did not require it either. Environmental tours are required… by the accreditation organizations (at least some of them). Joint Commission, HFAP and DNV all require that you evaluate your physical environment on a periodic basis. Some require semi-annually, and some only require annually. CMS does not have any Condition of Participation or standard that specifically requires a periodic tour of the physical environment, although they do require that your physical environment be maintained in a safe manner, which implies a routine inspection would be required to achieve that. So, if you’re accredited by one of the major accreditation organizations, you need to continue to perform environmental tours.

 

Immediate Jeopardy Decision?

Q: Our hospital has a room that is used for seclusion in a Behavioral Health unit. The door to this room is locked and it does not allow the patient to leave the room; only staff may release the door lock. Is this in any way an Immediate Jeopardy situation?

A: Not necessarily… Section 19.2.2.2.5.1 of the 2012 Life Safety Code allows doors to be locked in the path of egress where the clinical needs of the patients require specialized security measures or where the patients pose a security threat, provided staff can unlock the doors at all times. Clinical needs locks are permitted for use for psychiatric patients, dementia patients, Alzheimer’s patients and substance abuse patients. A seclusion room in a Behavioral Health unit would likely meet the definition for clinical needs locks, provided staff was watching the patient 24 hours/day.

Clarification on Emergency Department Occupancy Classification

If you’ve been reading my blog postings over the past few months ( see http://keyeslife.wpengine.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.

CMS Interprets Emergency Departments to be Healthcare Occupancies

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.”

Emergency Departments: Healthcare Occupancy Only

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.

Bronchoscopy Procedure Rooms

Q: Are Bronchoscopy procedures to be performed in negative pressure rooms under all circumstances, or can they be performed in OR suites? Does the negative pressure rule only apply to new construction, or does it apply universally to all facilities old and new?

A: According to the 2010 FGI Guidelines for Design and Construction of Health Care Facilities, ventilation requirements for a Bronchoscopy procedure room requires negative air pressure relationship to the surrounding area, and a minimum of 2 outdoor air exchanges per hour and a total of 12 air exchanges per hour. This ventilation requirement must be met regardless where the Bronchoscopy procedure is conducted, which includes the operating rooms. So, to answer your first question: Yes, this requirement applies to all circumstances.

The ventilation requirements found in the 2010 FGI guidelines applies to new construction or renovated areas. It is not a standard, and it does not apply to existing conditions. However, the ventilation requirements for Bronchoscopy procedures have been consistent since the 1996-1997 edition of the guidelines, and perhaps even before that (I only have records back to the 1996-1997 edition). So, if you have constructed or renovated the Bronchoscopy procedure room since 1996-1997, then these ventilation requirements must be complied with.

Some authorities will allow deviance from the FGI guidelines as they are guidelines and not standards. So, if you have extenuating circumstances that requires you to deviate from the FGI guidelines, then contact your AHJ to determine what their expectations are.

Which Edition of FGI Guidelines Do We Use?

Q: We were using the 2006 edition of the FGI Guidelines for Design and Construction of Health Care Facilities but we have both the 2006 and the 2010 version of this document. The guidelines are different related to air pressures in Endoscopy and Bronchoscopy procedure rooms. We are trying to determine if air flow should be positive or negative. Can you tell us which edition of this book we are to be using as the current guideline?

A: The ventilation requirements for Bronchoscopy procedure rooms have stayed consistent through the many recent editions of the Facility Guidelines Institute (FGI) Guidelines for Design and Construction of Health Care Facilities. There have been no changes in the requirement for negative air pressure in relationship to the surrounding areas, and a minimum of 2 outdoor air changes per hour with an overall total of 12 air changes per hour.

However, the same cannot be said for Endoscopy procedure rooms. From the 1996-1997 edition to the 2014 edition, the ventilation requirements seemed to change every edition:

Edition Air-Pressure Requirement Outdoor Air Changes

per Hour

Total Air Changes

per hour

1996-1997 No Requirement 2 6
2001 Negative 2 6
2006 No Requirement 2 6
2010 Positive 2 15
2014 No Requirement 2 6
[It is noted that the 1996 – 1997 edition was written and published by the American Institute of Architects (AIA), and the 2001 and 2006 editions were written by the FGI and AIA together. All subsequent editions are written by FGI and published by the American Society for Healthcare Engineers (ASHE).]

So, depending on when the Endoscopy room was designed, the ventilation requirements fluctuated. You authorities having jurisdiction usually state which edition of the FGI guidelines they are using as a guide. The interpretive guidelines for the Centers for Medicare & Medicaid Services (CMS) standard 482.41(c)(4) says acceptable standards such as the FGI guidelines should be incorporated into the hospital’s policy, but the standard does not say which edition. Likewise, the HFAP standard 11.07.03 says virtually the same thing, but The Joint Commission standard EC.02.06.05, EP 1 does reference the 2010 edition of the FGI guidelines.

For CMS and HFAP purposes, the assumption is clear that they would require the most recent edition, which would be the 2014 edition. For Joint Commission purposes, George Mills, Engineering Director for the accreditor recently stated during a regional ASHE meeting they would allow a health care organization to use the more recent 2014 edition.

The current edition of the FGI guidelines is the 2014 edition, which has no requirement for air pressure relationship to surrounding areas, and requires 2 outdoor air changes per hour and 6 total air changes per hour. But please check with you state and local authorities to determine what their requirements are.

CMS Enforces Different Time-Description

I received the following comment from a reader:

During a recent CMS life safety survey a surveyor stated that my kitchen hood suppression testing intervals were out of compliant even though they’re we’re clearly within The Joint Commision’s plus or minus 20 day window for semi-annual testing. He said CMS goes by the NFPA code (not JC) and that, that window is not in the code so therefore the testing must be completed before the 6 month anniversary. However, he stated that the quarterly inspections and testing can be done in a calendar basis and not by the revised quarterly interval parameters that JC has implemented (every 3 months, plus or minus 10 days).

This is an example where the accreditation organization has developed a thoughtful and practical interpretation of the NFPA standards regarding frequency of inspections and tests. Then CMS comes along and denies the practicality of the interpretation because it is not permitted in the NFPA codes or standards. That’s one of the problems with the NFPA standards is they don’t define time, such as what “semi-annual” or “every 6 months” means.

I’ve heard some state agencies surveying on behalf of CMS actually require the annual inspection or testing activity to occur exactly on the same date as the previous activity, one year later. So if it was last tested on April 15, it had to be next tested on April 15 of the next year, regardless what day of the week that landed on. That was extreme and I hope responsible people came to their senses.

But part of the problem is the people who are interpreting these rules have never worked in a hospital. They seem to not understand that hospitals need a reasonable window of opportunity to schedule these inspections and tests. Facility departments have decreasing resources available to them and it would sure be helpful if the government would just give them a little help now and then by interpreting issues with a little kinder attitude.

Wouldn’t it be nice if all of the authorities having jurisdiction (i.e. CMS, accreditation organizations, state fire marshals, etc.) were on the same page for critical issues like this?