Jul 01 2017

Clarification on Emergency Department Occupancy Classification

Category: BlogBKeyes @ 12:00 am
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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.

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Jun 30 2017

Fire Drill Response

Category: BlogBKeyes @ 12:00 am
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A recent question by a reader asked if fire-rated doors and smoke compartment barrier doors that close on a fire alarm could be opened before the fire alarm is considered ‘all clear’. 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 2012 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 codes 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 the reader was 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 the reader was 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 18/19.7.1.2 of the 2012 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 standard (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. Business must continue even during a fire alarm, so some staff must continue with their assigned responsibilities.

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 an ‘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 the reader with his 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 the reader is 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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Jun 27 2017

Keyes Life Safety Boot Camp – September 19 & 20, 2017

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Understand 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: September 19 & 20, 2017

Location: Embassy Suites Hotel – Denver In’t Airport, 7001 Yampa Street, Denver, CO  80249-6411   303-574-3000

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
• Challenges in Implementing the New Requirements of the 2012 LSC • 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: $879.00 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.

For special hotel rates, mention Keyes Life Safety Boot Camp when calling 303-574-3000

Register: Online at www.Eventbrite.com and search “Keyes Life Safety Boot Camp” or go to: https://www.eventbrite.com/e/keyes-life-safety-boot-camp-denver-co-registration-35653000083

Seating is limited to 50 individuals. Registration is not confirmed until payment is received. Registration closes when all seats are filled, or August 25, 2017

Bring your own copy of the 2012 Life Safety Code!

Questions? Call Alise Howlett at 815-713-8144

Exclusively sponsored by:

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Apr 21 2017

Eyewash Stations

Category: BlogBKeyes @ 12:00 am
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When and where are eyewash stations required in a healthcare facility? That is one of the more frequent issues that healthcare professionals struggle with. There is a tendency to place them nearly everywhere, but in reality there aren’t as many locations that require eyewash stations than one may think.

Eyewash stations are required wherever there is a possibility that caustic or corrosive chemicals could splash into the eye of an individual. It is important to note that blood and body fluids are not considered to be caustic or corrosive. It is also important to note that the use of Personal Protective Equipment (face shields, glasses, goggles) does not exempt the need for an eyewash station.

Most accreditation organization’s position on whether or not an eyewash station (or an emergency shower) is required is based on the healthcare organization conducting a risk assessment of the situation. Working with corrosive and caustic chemicals does not necessarily require an eyewash station (or emergency shower) unless the possibility is present that the chemicals could be splashed into the eyes (or onto the skin).

For example: If an environmental services worker opens a 1 gallon container of a liquid cleaner that is considered caustic or corrosive, and inserts a suction tube for a mixer, that doesn’t really present much of a splash hazard and a risk assessment could state an eyewash station is not warranted. However, if the employee pours the same chemical from its original container to another container, now the risk of splash is much greater and a risk assessment would likely require an eyewash station. All risk assessments are conducted with the presumption that staff will not be wearing any personal protective equipment.

If there are no corrosive or caustic chemicals present, then there is no need to conduct a risk assessment and there is no need for an eyewash station. Whether the term “corrosive” or the term “injurious corrosive” is used to describe a chemical, it’s all the same. Both would cause an injury.

A portable squeeze bottle is not prohibited, but it is not a substitute for a plumbed ANSI Z358.1-2014 approved eyewash station. Portable squeeze bottles are a potential problem for healthcare organizations, since they are usually placed around an area where a potential hazard can or may occur. In other words, somebody decided there is some sort of risk of splash present, that a portable bottle would be of some use.

That can lead to an incorrect assumption that the portable bottles are an approved eyewash station. Also, they need to have their water changed every two years (or so) and that can also be overlooked at times which can lead to a citation. Also, be aware that they are a huge flag to a surveyor who would likely conduct a tracer once he/she sees the portable bottle.

If the possibility of a corrosive or caustic material can be splashed onto the skin then an emergency shower would be required. But if a risk assessment determines there is no possibility of the chemicals splashing onto the skin through normal use, then there would not be a requirement for an emergency shower. The risk assessment should also consider emergency spills as well.

In regards to the ANSI Z358.1-2014 standard for eyewash stations, this standard is based on recommendations from OSHA letters of interpretation. OSHA requires the employer to provide suitable facilities for quick drenching or flushing of the eyes and body when employees may be exposed to injurious corrosive materials. ANSI standards become mandatory OSHA standards only when, and if, they are adopted by OSHA. ANSI Z358.1 has not been adopted by OSHA; however, ANSI Z358.1 provides detailed information regarding the installation and operation of emergency eyewash and shower equipment. OSHA, therefore, has often referred employers to ANSI Z358.1 as a source of guidance for protecting employees who may be exposed to injurious corrosive materials. Accreditation organizations seem to have latched onto the ANSI Z358.1 standard as the standard to comply with.

The organization is expected to conduct a risk assessment (or survey) of their facility’s operation and process areas to determine if and where eye wash stations are needed. If the facility has determined that an eye wash station is needed, then it needs to conform to the ANSI standard Z358.1-2014, which has the following specifications:

  • Only eye wash stations that are capable of providing a flow of clean potable water at a rate of 0.4 gallons per minute at 30 psi for 15 minutes are permitted. It is possible that some self-contained eye was stations may provide this flow requirement, but normally only plumbed eye wash stations do.
  • The flow nozzles of the eye wash station must be mounted a minimum of 33 inches and a maximum of 45 inches above the floor, and a minimum of 6 inches from any wall, post or other barrier.
  • Activation of the eye wash station must occur in one (1) second or less of operating the control valve, so this typically eliminates the faucet mounted eye wash stations that require the operation of three (3) levers to obtain a balanced flow of water. The control valve must remain open on its own until it is intentionally turned off.
  • Approved eye wash stations are required to be located within 10 seconds travel time (or 55 feet) of the hazard and the path to get to an eye wash station must not be hindered or obstructed. The ANSI Z358.1-2014 standard has changed to allow one (1) door in the path to get to an eye wash station, provided the door cannot be locked and the door swings in the direction to the eye wash station.
  • While there is no standard that prohibits the small supplemental personal squeeze bottles, they cannot meet the flow rate requirements for a 15-minute flush, and therefore are not a substitute for a plumbed eye wash station. They can serve as a supplemental aid but the plumbed eye wash station needs to be located within 10 seconds travel time (or 55 feet) of the hazard. The presence of the small supplemental personal wash bottles may indicate a need for a plumbed eye wash station.
  • The temperature of the water is required to be tepid. The ANSI standard defines tepid water as being between 60°F and 100°F. In order to achieve this temperature range, the organization may have to install mixing valves. Water temperatures outside of the 60°F and 100°F range may be permitted provide a risk assessment is conducted by qualified individuals which analyzes the hazard and the temperature of the water to flush the hazard. Qualifying individuals must include an individual with clinical or medical training.
  • Weekly activation of the eye wash stations is required to clear any sediment or bacteria. There is no specified time that the water must flow. An annual inspection of the eye wash station is required to determine conformances with the installation requirements are maintained.

Here are some recommendations on evaluating your existing eyewash stations for compliance:

  1. In a healthcare setting, eye wash stations are typically found where cleaning chemicals are mixed (such as housekeeping areas), plant operations, kitchens, generator rooms, environmental services storage room for battery powered floor scrubbers, in-house laundries, dialysis mixing rooms and laboratories. Determine if a risk assessment has been conducted to conclude the need for eye wash stations.
  2. All required eye wash stations must be the plumbed type, which can operate in one (1) second or less. This means the faucet mounted type that requires turning the hot water lever and the cold water lever and then pulling a center lever is not permitted.
  3. Access to the eye wash station must be within 10 seconds (or 55 feet) of the hazard. The individual seeking an eye wash station may travel through one (1) door to get to an eye wash station, provided the door does not have a lock on it, and swings in the direction to the eye wash station.
  4. If an eye wash station is observed outside of an area where they are typically needed, ask the staff who works in the area why it is there. See if they have a risk assessment that requires it to be there. Advise them if there is no valid reason for the eye wash station to be there, it can be removed and may save them time and resources in maintaining it.
  5. Eye wash stations may need to have a mixing valve to maintain a flow of water in the 60°F and 100°F range. Ask to see the risk assessment to determine if a mixing valve is required.
  6. Every eye wash station needs to be tested weekly by flowing water to clear any sediment and bacteria. There is no requirement how long the water must flow. Every eye wash station must be inspected annually to determine the eye wash station still conforms to the installation parameters. The weekly test and annual inspections must be documented.
  7. The presence of eye wash bottles indicates someone in the organization decided it was needed. Investigate and ask why the bottles are located there. Determine if they need a plumbed eye wash station within 10 seconds travel time (or 55 feet) of the perceived hazard. Check the expiration date on the bottles.

Always check with your state and local authorities to determine if they have any additional requirements.

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Apr 10 2017

Addressing Common Misconceptions Regarding Waivers and Equivalencies

Category: BlogBKeyes @ 12:00 am
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There has been much confusion and differing of opinions regarding the process to submit waiver and equivalency requests, and once they have been approved, how long they are valid. The Centers for Medicare & Medicaid Services (CMS) recently implemented new procedures that resulted in changes on how the accreditation organizations processed waiver and equivalency requests.

Up until a couple of years ago, CMS always said that approved waivers are only valid for 1-year. After the 1-year cycle, the federal agency wanted hospitals to resubmit their waiver request for another 1-year cycle. When Det Norske Vertitas (DNV) came on the scene in 2008 or so, CMS told them straight out-of-the-box that DNV cannot approve waivers or equivalencies. DNV would be required to send them to the appropriate CMS Regional Office for approval. DNV was okay with that because they wanted deeming authority, so they complied. The odd thing though, CMS did not inform Healthcare Facilities Accreditation Program (HFAP) or The Joint Commission of the same policy at that time.

Joint Commission and HFAP always recognized that CMS was the only entity that could approve waivers, but these two accreditors always considered equivalencies as different animals and were not considered to be waivers. It was always understood that the difference between a waiver and an equivalency is a waiver is requesting a specific Life Safety Code requirement to be ‘waived’ and the hospital would not have to comply with it due to significant hardships. An equivalency does not ‘waive’ any Life Safety Code requirements, but instead analyzes surrounding features of fire-safety and assigns numerical values. The numerical values are run through a formula and if the result is a positive number then that confirms there is a equivalent level of safety even with the Life Safety Code deficiency. This concept is supported by section 1.4.3 of the 2012 Life Safety Code. But CMS never saw it the same way and decided an equivalency is similar to a waiver, and needs to be processed the same. Therefore, only they (CMS) could approve equivalencies.

In 2012 CMS notified HFAP that they can no longer approve equivalencies, and CMS wanted HFAP to submit the waiver/equivalency requests to the appropriate CMS Regional Office for approval, just like DNV. But, for reasons known only to them, it wasn’t until July, 2014, that CMS got around to telling Joint Commission the same rules. Joint Commission agreed to discontinue approving equivalencies and would forward them on to the appropriate CMS Regional Office. So, for the first time since 2008, the big three accreditors for hospitals (Joint Commission, DNV and HFAP) were all on the same page and on a level playing ground regarding the approval process for equivalencies. But immediately, there was confusion; not the least of which the CMS Regional Offices were not prepared to handle the influx of the paper requests for waivers and equivalencies. Some of the busier Regional Offices started to misplace the equivalency requests, which meant the hospitals would have to resubmit them. Most of the accreditors required the equivalencies to be submitted on paper rather than electronically because the equivalencies required drawings of the facility, and at that time electronic files of drawings were not easily read without CAD software. That led to large, bulky paper submissions, which were easily misplaced.

By 2015, CMS took action to resolve the serious problem concerning misplaced copies of waiver and equivalency requests, so they contracted with Healthcare Management Solutions (HMS), a vendor, to create an electronic process to accept waiver and equivalency requests and track their progress through the approval process. In May, 2015 HMS unveiled a rather slick and easy process to the accreditors called Sharepoint, whereby the accreditors can submit waiver and equivalency requests electronically from their clients to HMS. Representatives from HMS will review the submissions to ensure that significant information is included, and once they consider it to be an acceptable submission, they will then send it electronically to the appropriate CMS Regional Office for review and approval. At this time (in May, 2015), they submitted a 6-page document to the AOs explaining the process for waivers and equivalencies to be submitted and approved. Highlights of this document says:

  1. Only CMS Regional Offices can approve waivers and equivalencies.
  2. Waiver and equivalency requests will only be considered for existing Life Safety code deficiencies; they will not consider a request if the deficiency has not been cited by the accreditor. (This is contrary to the way that Joint Commission and HFAP operated, as they would approve equivalencies prior to the Life Safety Code deficiency being cited.)
  3. The hospital will submit their waiver or equivalency request directly to their accreditation organization as part of their Plan of Correction to resolve a deficiency cited during a survey.
  4. If the AO agrees with the hospital’s request for a waiver or an equivalency, then they submit the request electronically along with a cover letter recommending approval to the HMS Sharepoint. If the AO does not agree with the request made by the hospital, then they simply do not submit the request to HMS Sharepoint, and the request is effectively denied. This allows the AOs a right of first-denial.
  5. Once the request submission meets the requirements, then HMS sends it on to the appropriate CMS Regional Office. Originally, CMS said they expected the Regional Offices to approve or disapprove requests within 30 days, but that has not always been the case as the influx of waiver and equivalency requests has created a back-log.
  6. The CMS Regional Office decides whether or not to approve the waiver/equivalency request and they make their decision in writing and inform the hospital and the AO of their decision. If they approve the request, it is only valid until the next triennial survey whereby if the deficiency is not resolved at that time, it will be cited again. If they deny the request, the hospital must submit an alternative Plan of Correction to resolve the deficiency.

In addition, when the CMS Regional Office sends a letter of approval to the hospital, they include language that says: “If you are not in compliance with the above requirements at the time of your next survey, you will be required to either submit a plan to correct deficiencies or renew your request for waiver, in order to continue your participation on the Medicare program.” This reinforces the CMS position that waivers and equivalencies are only valid until the next survey.

Since an approved waiver or equivalency is only valid until the next survey, that implies the waiver or equivalency is a short-term, temporary process. This is different than what used to be considered in the past. CMS now allows waiver requests to extend up to 3 years, rather than 1-year; and approved equivalencies are now limited to no more than 3 years, rather than indefinitely or until there is renovation in the area as Joint Commission and HFAP used to allow. Hospitals started to change their strategy and submitted more waiver request rather than equivalencies since equivalencies cost more resources to prepare.

CMS will allow a time-limited waiver request which is essentially the hospital requesting permission to continue to operate the facility with the cited Life Safety Code deficiency for a short-period of time until the hospital can either resolve the deficiency or implement other measures to qualify for an equivalency. CMS has stated that if a hospital cannot resolve a Life Safety deficiency within 60 days of the end of the survey, then they would expect the hospital to submit a time-limited waiver request.

You may wonder why CMS has not issued a public notice explaining the changes with the waiver and equivalency requests. I don’t know for sure, but I suspect it may be that they really don’t see that there have been any significant changes on their part to explain. Other than the HMS Sharepoint process which is really a private conversation between the CMS and the AOs, the statement that the waivers and equivalencies are only valid until the next survey has always been the case with CMS. It really was the Joint Commission and HFAP that had different procedures and allowed equivalencies to be valid indefinitely or until there was renovation in the area. Once CMS got those two AOs to stop approving equivalencies, then everything else fell into place.

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Mar 21 2017

Windows in Patient Sleeping Rooms

Category: BlogBKeyes @ 12:00 am
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Q: In the 2000 edition of the Life Safety Code, under section 18.3.8 “Special Protection Features -Outside Window or Door”, they have requirements for windows or doors to the outside in patient sleeping rooms. However, in the 2012 edition of LSC, under section 18.3.8 “Special Protection Features (Reserved)”, it does not list any requirements for windows or doors to the outside in patient sleeping rooms. Does this mean that outside windows or doors are no longer required?

A: You have touched on an issue that is not often discussed. Yes, you are correct: The 2000 LSC did require a window or door to the outside in patient sleeping rooms. Up until the 1994 edition, the LSC required those windows and doors to operate, to allow venting during a fire emergency. In the 1994 edition, the LSC changed to stop requiring the windows to operate, but the requirement for the windows or doors remained. In the 2009 edition, the LSC deleted the requirement for windows or doors to the outside in patient sleeping rooms all-together, because the technical committee feels the total concept approach in section 18/19.1.1.3 covers the issue of evacuation, and no longer requires such an opening.

However… that does not mean you can design new hospitals without windows in patient sleeping rooms. Many local building codes, and state agencies with authority over hospital construction, still require windows in patient sleeping rooms in hospitals. There is a psychological need for the patient to see the outside light of day in the recovery process. The problem is, the LSC does not deal in the psychological needs of patients… at least not on this issue.

I also reviewed the Final Rule that CMS issued last May when they adopted the new 2012 LSC. Sometimes, CMS will retain a requirement in an older version of the LSC even though the newer version no longer requires it. In this case though, CMS did not say anything about keeping the requirement for windows in patient sleeping rooms.

But I suggest you check with your state and local authorities to determine if they have any regulations on this issue.

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Mar 02 2017

CMS Interprets Emergency Departments to be Healthcare Occupancies

Category: BlogBKeyes @ 12:00 am
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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.”

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Feb 28 2017

Keyes Life Safety Boot Camp – Last Chance to Register

Category: BlogBKeyes @ 12:00 am
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Understand 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: April 3 & 4, 2017

Location: Hilton Garden Inn, 45 Lockwood Drive, Charleston, SC (843) 637-4074

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
• Challenges in Implementing the New Requirements of the 2012 LSC • 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: $879.00 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 / AIA CEU’s pending.

For special hotel rates, mention Keyes Life Safety Boot Camp when calling 843-637-4074

Register: Online at www.Eventbrite.com and search “Keyes Life Safety Boot Camp” or go to: https://www.eventbrite.com/e/keyes-life-safety-boot-camp-charleston-sc-registration-29783435056

Seating is limited to 50 individuals. Registration is not confirmed until payment is received. Registration closes when all seats are filled, or March 6, 2017

Bring your own copy of the 2012 Life Safety Code!

Questions? Call Alise Howlett at 815-713-8144

Exclusively sponsored by:

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Feb 24 2017

Correction to Yesterday’s Posting

Category: BlogBKeyes @ 12:00 am
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Hello readers…

I did it again. I made a mistake in my answer to yesterday’s posting, which asked the question if signs are required on doors to storage rooms where there is less than 300 cubic feet of oxidizing gases stored. Initially I said yes, citing NFPA 99-2012, sections 11.3.4.1 and 11.3.4.2 which identifies the need for signs on doors to rooms that store oxidizing gases.

But, thanks to my good friend Marge McFarlane of Superior Performance, LLC, she spotted the error and sent me an email identifying it.

If you want the details… here is where I made my mistake: Sections 11.3.4.1 and 11.3.4.2 of NFPA 99-2012 are under the heading of 11.3 “Cylinder and Container Storage Requirements”. Only rooms that store 300 cubic feet of gas or more are required to meet requirements for storage rooms. Since sections 11.3.4.1 and 11.3.4.2 are sub-sections of 11.3, they only apply to conditions identified under 11.3.

So, I took sections 11.3.4.1 and 11.3.4.2 out of context and thought it applied to all rooms storing oxidizing gases, which was incorrect. It only applies to rooms storing oxidizing gases in quantities of 300 cubic feet or more.

I’ve corrected the posting so the mistake is gone, but if you read it and thought you need to add signs on all the doors where oxygen cylinders are stored, please understand the signs are only required if the room contains 300 cubic feet or more.

Sorry… I apologize to my readers. I hope you will forgive me. I strive to be accurate and not make mistakes, but as you can see, understanding and interpreting the standards can be tricky.

Thanks, Marge.

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Feb 21 2017

Medical Office Building Occupancy Classification

Category: Blog,Occupancies,Questions and AnswersBKeyes @ 12:00 am
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Q: A Hospital System that I do work for is in the process of constructing a Medical Office Building off-campus (over 250 yards from the Hospital). The building will house exam rooms, treatment rooms, and procedure rooms for a Provider Based Physician. In the past, we would consider this a Business Occupancy. We have heard that for an off-campus Provider Based Physician we will need to use a more restrictive code. Is this true, and if so, do we use the Healthcare Occupancy or the Ambulatory Healthcare Occupancy for this building type?

A: On June 30, 2016, CMS issued a correction to their Final Rule to adopt the 2012 Life Safety Code. This correction specifies that all ‘hospital outpatient surgical departments’ have to meet Ambulatory Health Care Occupancy (AHCO) requirements regardless how many outpatients are incapable of taking action for self-preservation.

One of the confusing issues in this CMS communication is the phrase ‘hospital outpatient surgical departments’. Initially, most people would think that phrase describes Ambulatory Surgical Centers (ASC) because the word ‘surgical’ is used. But in follow-up communications with CMS, they described this phrase ‘hospital outpatient surgical departments’ to mean any service that qualifies under the definition of AHCO.

Section 3.3.188.1 of the 2012 LSC describes AHCO as:

  • Outpatient treatment for patients that renders the patient incapable of taking action for self-preservation under emergency conditions without the assistance of others;
  • Anesthesia that renders the patients incapable of taking action for self-preservation under emergency conditions without the assistance of others;
  • Emergency or urgent care for patients who, due to the nature of the injury or illness are incapable of taking action for self-preservation under emergency conditions without the assistance of others.

This description is beyond just ASC; it includes all sorts of procedures, such as:

  • Endoscopy
  • Bronchoscopy
  • Colonoscopy
  • MRI / CT Scan
  • Cath Labs
  • Some therapy units, such as Aqua-Therapy
  • Etc.

Since the 2012 LSC says four or more outpatients in order to qualify for AHCO, CMS felt the need to issue a correction to their Final Rule to say now it is 1 or more outpatients to qualify as an AHCO.

What this means, if the physician’s office was doing a minor procedure and it only involves one outpatient at a time, and that minor procedure qualifies under 3.3.188.1 as being an AHCO, then the building (or story) must meet AHCO occupancy requirements even if there is only one outpatient involved in the entire facility. Under the 2012 LSC definition, that physician office would qualify as being a Business Occupancy, but with the new CMS correction to the Final Rule, it now must be AHCO.

And this is retroactive to existing conditions.


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