Response to a Recent Post

The following is a response I received from a reader after my posting on April 3, 2018 titled Lawmakers Want More Oversight on AOs. This reader put into words the feelings and emotions of hundreds (if not thousands) of concerned healthcare workers on the subject of over-regulation by the government.

Today’s message makes retirement look sweeter and sweeter. I love my job and for 35 years I have loved taking care of patients and staff from the Plant Ops seat. The last 5-10 years has been harder as the Code enforcement has gotten pickier and more involved in minutia. Your posting today is a virtual death knoll for attracting good qualified younger engineers and mechanics into our business, why would someone want to come into an industry where common sense is treated with absolute disrespect? We’ve taken smoking out of buildings, sprinkled most everything, you can’t find hospital fires in the literature yet we still treat +1/8″ gaps as death traps. Sprinkler piping is designed to support weight well in excess of the piping and water yet one cable on a pipe is a finding? The 1/4″ extra distance on the projection will result in more money being spent with no added value. Even your recent post about data closets and gaps around the conduit through the ceiling tile stretches the imagination about how much smoke or heat will bypass a detector or sprinkler head.

 I looked at the ASHE agenda for Seattle and I didn’t see anything there where we as a group are ready to say either “I’m mad as hell and I’m not going to take it anymore” or “Calling BS” on this. Thanks for the opportunity to rant, this is the most discouraged that I have ever been about what we do.

Lawmakers Want More Oversight on AOs

In a letter to CMS Administrator Seema Verma, the committee on Energy and Commerce is asking for what could be reams of information from the agency about patient harm and incidents of misconduct at acute care hospitals. The committee has also asked for similar information from each of the four hospital accrediting organizations (AOs).

The committee was particularly concerned about information in a report to Congress published last summer that indicated AOs “conducting hospital surveys did not report 39% of ‘condition level’ deficiencies that were subsequently reported following validation surveys conducted by [CMS] State Survey Agencies no later than 60 days following the AO survey.”

“Although CMS has worked to strengthen its oversight of AOs, the committee is concerned about the adequacy of CMS’ oversight as well as the rigor of the accrediting organization survey process,” wrote the committee leaders.

Noting that the Department of Health and Human Services, through CMS, must provide oversight of accrediting organizations, including CMS’ own survey agencies, “the Committee is concerned about the adequacy of CMS’ oversight as well as the rigor of the AO survey process,” read the letter to Verma.

You can view a copy of this letter at this link: https://energycommerce.house.gov/wp-content/uploads/2018/03/20180309CMS.pdf

In 2017, approximately 67% of the surveys performed by HFAP and The Joint Commission received a Condition Level Deficiency in the Life Safety or Environment of Care chapters. This percentage of Condition Level Findings was up in 2017 compared to 2016. How much more does the committee expect the AOs to cite Condition Level Findings?

What does all of this mean for the future…? From my point of view, I believe you will see CMS tighten their reigns on the hospital AOs such as Joint Commission, HFAP, DNV-GL and CIHQ…. especially on issues of Life Safety, Environment of Care, and Emergency Management. The reason for this is based on the high disparity rates that most of the AOs have when compared to state agency validation surveys in the area of Life Safety.

Many observers have said that the method CMS uses to compare the efficiency of findings between the AOs and the state agencies is unfair based on the state agencies allowed to have more LS surveyors for more days on their surveys than the AOs.

I also claim that not all surveyors are the same: Most AOs hire current or former hospital facility managers who are operation minded. So they will focus on Life Safety issues pertaining to operations, such as corridor clutter, obstructions to doors and medical gas valves, etc. On the contrary, most state agencies surveying on behalf of CMS hire architects and engineers as LS surveyors, who focus on design issues (such as construction type and egress capacity) and mechanical systems (such as fire alarm systems and sprinkler systems).

Just because the surveyors have different backgrounds does not make them right or wrong: But it does make them different. So naturally, state agency surveyors will gravitate to cite deficiencies that are more along their specialty. And AO surveyors will do likewise. There will always be a disparity when the survey teams are different. To prove that point, the high disparity rate of AO findings compared to state agencies findings, is just as high when you make the comparison the opposite way: When you compare state agency findings to AO findings. The point is…. it is normal to have a high disparity rate when there are so many variables in the mix.

I don’t see this ever being fixed in my lifetime… The people in power seem to be too stubborn to acknowledge this issue and take appropriate action to resolve it. In the mean-time, I foresee CMS cracking down even harder on the AOs to cite even more findings, which will result in tougher Life Safety surveys.

What’s the Standard?

Q: In regards to your answer last week requiring plastic coffee pots to be inspected, is this a code requirement or just a ‘best practice’? I’m not talking about equipment patients touch or are treated with… would computers be a part of electrical safety test?

A: This is not a standard. This is an interpretation by CMS. According to the CoP for acute-care hospitals, §482.41(c)(2) says:

“Facilities, supplies, and equipment must be maintained to ensure an acceptable level of safety and quality.”

The Interpretive Guidelines for this section says:

“The hospital must ensure that the condition of the physical plant and overall hospital environment is developed and maintained in a manner that provides an acceptable level of safety and well-being of patients, staff and visitors.”

The way CMS has interpreted this in the field in the past, is they expect all electrical devices, including computers, to be electrically checked first before placed into service. CMS does not expect all consumer items to be placed in the plant inventory, but they do expect the facility to be maintained to ensure an acceptable level of safety. While some accreditation organizations do not enforce this level of scrutiny, I have observed many state agencies who survey on behalf of CMS do enforce this level.

It’s up to you…. If you choose not to do this, you probably will not be cited for a finding under an accreditation survey. But you would take your chances with a CMS validation survey.

Hazardous ER Department

Q: In a hospital emergency department, can the corridors be 6 feet wide? Can the hospital install an 18-inch deep lockable computer cabinet in the 8 foot ED corridor?

A: Well… It depends.

If you claim the ER is a suite, then there would be no problem with a cabinet in the 8-foot wide hallway…. Because there are no corridors in a suite. What looks like a corridor in a suite is a communicating space and you would only have to maintain 36-inches clearance for aisles.

But if the ER is not a designated as a suite, then you must maintain corridor widths. But the required width of the corridor is different depending on the occupancy classification of the ER. CMS has said that Emergency Departments must be classified as healthcare occupancies (HCO) if the ER has patient observation beds. CMS’s logic on this is if patients are under observation in the ED, then they consider this patient sleeping accommodations. In this logic, then all areas providing patient sleeping accommodations must be healthcare occupancies, and the required width of the corridor must be 8-feet.

However, CMS does permit the Emergency Department to be classified as an ambulatory health care occupancy (AHCO) if the ER does not contain any patient observation beds. Then the corridor width is only required to be 44-inches wide.

But keep in mind, the maximum corridor projection permitted by CMS is 4-inches. If your ER is not designated as a suite, then you must maintain corridor widths (either HCO widths of 8-feet, or AHCO widths of 44-inches) and you cannot have corridor projections more than 4-inches, and the cabinet would not be permitted.

CMS Waiver Approval

Q: If a building changes ownership, do waivers stay active with their 1-year window or do the new owners have to resubmit if the building is cited the same deficiency?

A: Interesting question… I’ve never had this issue come up before.

My guess would be the waivers would be valid only to the organization for which they were approved. The way that CMS writes their approval letters is the approval of the waiver is addressed to the healthcare organization, and not to the building owner. In other words, CMS grants approval to the healthcare organization to not have to comply with a particular section of the Life Safety Code. This approval would not appear to be transferrable, since it is addressed to the healthcare organization.

But if the ownership of the healthcare organization changes hands, then I could see where the waiver approval would follow the healthcare organization. CMS tracks the waiver requests and the subsequent approvals via their own CMS Certification Number (CCN), which is assigned to healthcare organizations, not their owners.

To answer your question, if a deficiency is cited and the healthcare organization chooses to submit a waiver request rather than resolve the deficiency, then yes, a new waiver request would have to be submitted.

 

Power Strips

Q: There is so much discussion on the proper use of power strips that it can cause confusion amongst even the seasoned facility managers. There is absolutely no guarantee that the different power strips will remain in their ‘designated areas’. The OR is much easier to control, but as technology quickly progresses, the space between patient care vicinities and non-patient care vicinities quickly losing the defined lines. What’s your thoughts on the power strip issue?

A: I do see your point that power strips may be difficult to control as they may move around the hospital, in and out of patient care vicinities. And I respect your comment that there is confusion on the proper use of power strips. But I find CMS’ explanation regarding power strips under their K-Tag 920 to be refreshingly simple:

  • Power strips in a patient care vicinity are only used on movable patient-care related electrical equipment and are permanently attached to the equipment, and are UL 1363A or UL 60601-1.
  • Power strips in a patient care vicinity may not be used for non-patient-care related electrical equipment, such as personal electronics, except in long-term care resident rooms that do not use patient-care related electrical equipment.
  • Power strips for patient-care related electrical equipment must meet UL 1363A or UL 60601-1.
  • Power strips for non-patient-care related electrical equipment in the patient care rooms, but outside of the patient care vicinity, must meet UL 1363.
  • In non-patient care rooms, power strips meet other UL standards.

Section 3.3.139 defines “patient care vicinity” as a space, within a location intended for the examination and treatment of patients, extending 6 feet beyond the normal location of the bed, chair, table, treadmill, or other device that supports the patient during examination and treatment and extending vertically to 7-foot 6-inches above the floor.

It appears K-Tag 920 is permitting qualified personnel to permanently attach UL 1363A or UL 60601-1 power strips to movable patient-care related electrical equipment, provided it meets section 10.2.3.6 of NFPA 99-2012, which is:

  • The power strip is permanently attached to the equipment assembly;
  • The sum of the ampacity of all appliances connected to the outlets does not exceed 75% of the ampacity of the flexible cord supplying the outlets;
  • The ampacity of the flexible cord is in accordance with NFPA 70-2011, National Electrical Code.
  • The electrical and mechanical integrity of the assembly is regularly verified and documented.

This section does not explain what makes one “qualified”, so that determination should be left to the AHJ and the healthcare facility. While NFPA 99-2012 does not specify how frequent “regularly verified” means, the general consensus is annually, based on annual receptacle inspection requirements in Chapter 6.

You will note that section 10.2.3.6. (5) was deleted per Tentative Interim Amendment (TIA) 12-5.

K-Tag 920 is also clear that outside of a non-patient care room (i.e. OR, PACU, procedure room, patient sleeping room, etc.) CMS no longer regulates which UL power strip to use on non-patient-care related electrical equipment, other than it must be UL listed. That means a power strip used at a nurse station on office equipment, or in an office environment does not have to be UL 1363, UL 1363A, or UL 60601-1; it just has to be UL listed.

Changes to Smoke Barrier Door Testing

The following article was published in HCPro’s Hospital Safety Insider, on August 3, 2017:

More than three weeks after a well-publicized compliance deadline passed, CMS announced Friday that the deadline would be pushed back nearly six months, giving facilities until New Year’s Day 2018 to comply with an annual testing requirement for certain doors.

David Wright, director of the CMS Survey and Certification Group, made the announcement in a memo to state survey agency directors. He acknowledged that there had been a fair amount of confusion concerning the change, and he offered some pretty consequential clarifications that could affect whether the new requirement applies to your facility at all.

“[C]onsidering the level of reported misunderstanding of this requirement, CMS has extended the compliance date for this requirement by six months,” Wright wrote.

Within the National Fire Protection Association’s (NFPA) 2012 Life Safety Code® (LSC), which CMS adopted last year, there is a requirement that fire doors and smoke barrier doors be tested annually. Officials with CMS had taken the position that the new requirement applies to healthcare occupancies; that position, however, was met with pushback.

A petition objecting to the CMS position was discussed at length in June by members of the NFPA Healthcare Interpretations Task Force (HITF), says Brad Keyes, CHSP, owner of Keyes Life Safety Compliance. That petition objected to the notion that the LSC specifically requires annual inspections of smoke barrier doors in healthcare occupancies.

“The HITF members did discuss the issue and agreed that healthcare occupancies were exempt from complying with section 7.2.1.15.2 … because the healthcare occupancies did not specifically require compliance with that section,” Keyes says in an email.

The committee decided to table its decision on the matter to give CMS an opportunity to review its position, as it did, Keyes says.

“I am pleased that the system worked in favor for the many hospitals that are certified by the Federal agency,” he adds.

Although the LSC does include provisions requiring annual inspections of smoke barrier doors and fire doors alike, section 7.2.1.15.1 states that these standards apply only where required by Chapters 11–43. Since the chapters governing healthcare occupancies make no direct reference to Section 7.2.1.15.1, the door inspection provisions do not apply to healthcare occupancies, Wright acknowledged in his memo.

Based on that conclusion, Wright spells out a few key takeaways:

  1. Fire doors. In healthcare occupancies, all fire door assemblies must be inspected and tested annually in healthcare occupancies, based on section 8.3.3.1 of the 2012 LSC, which applies to all occupancies.
  2. Smoke barrier doors. Non-rated doors (including smoke barrier doors and corridor doors to patient care rooms) aren’t subject to the annual inspection and testing requirements, but they “should be routinely inspected as part of the facility maintenance program.”
  3. Deadline. The compliance deadline has been pushed back from July 6, 2017, to January 1, 2018.
  4. Citations. Any LSC deficiencies related to annual fire door inspections should be cited under K211—Means of Egress—General.

But what if a healthcare organization was already cited at some point during the three-week gap between the original compliance date and the clarifying memo (July 6–28) for a failure to conduct an annual test of its smoke doors? Multiple CMS representatives did not respond to requests for an answer. Keyes says CMS has been a stickler in the past, holding that a finding cannot be removed once it is written on a survey report.

“There was an accreditation organization [AO] that used to allow findings to be removed from their survey report if the hospital could demonstrate compliance at the time of the survey,” Keyes says. “CMS has said that the AOs may no longer remove findings, even if the hospital was compliant at the time of the survey.”

The Joint Commission stated in the July edition of Perspectives that it requires annual testing for fire door and smoke door assemblies alike, despite acknowledging that the healthcare occupancy chapters don’t cite section 7.2.1.15 specifically. (To support the requirement, The Joint Commission noted that Section 18/19.2.2.2.1 references section 7.2.1, and cited a belief that the annual tests are beneficial.)

Keyes adds a word of caution: “The AOs are not locked into complying with everything CMS says or does. The AOs may have standards that exceed what CMS requires.”

That means the guidance in Wright’s memo might not trickle down to the AOs and state agencies that conduct surveys at your facilities, especially considering how widely advertised the original compliance date has been.

“So, I suspect many of the AOs will keep the start date at July 5, 2017, since they are already enforcing that,” Keyes says.

With that in mind, he recommends that all healthcare facilities have their fire doors tested as soon as possible, rather than waiting until the new deadline—because another authority having jurisdiction might keep to the stricter timeline.

 

Follow-Up From an Earlier Post….

I recently posted on documentation retention, and how long you should keep test/inspection records. A reader contacted me and said they attended a recent ASHE regional event where the speaker said the CMS K-Tags require some records to be kept for the life of the building, and the reader wanted to know if I was familiar with this requirement.

I said no, I was not, but I decided to get an answer direct from CMS themselves. I did receive a reply from CMS which is considered an informal non-public response, and here is a summary of what they said:

  • CMS has not issued any formal policy on retention of records for LS test/inspections.
  • Surveyors typically look back one (1) year to establish compliance.
  • However, the extent of the record review would consider the frequency of a particular test/inspection requirement.
  • If the test/inspection requirement was a monthly requirement, the surveyor may review 12-months’ worth of documentation to confirm compliance.
  • If the test/inspection requirement was an annual requirement, then the surveyor may review 3-years’ worth of documentation to confirm compliance.
  • In addition, retention of records would consider any NFPA, State, or manufacturer requirements.

It’s important to point out that there is a special requirement in NFPA 99-2012, section 5.1.14.4.1 that does require ‘permanent’ records of certain medical gas tests. Permanent would mean retention for the life of the building (or system), but section 5.1.14.4.1 only refers to initial system verification test records… not routine annual inspections. And it only applies to medical gas and vacuum systems, not other mechanical or electrical systems identified in NFPA 99.

CMS K-Tags 907 and 908 refer to a routine maintenance program and a test/inspection program for medical gas systems. These K-Tags says records are to be maintained as required. Since the K-Tags are a CMS product, they are obviously saying maintenance records and routine test/inspection records are to be kept long enough to establish a pattern of compliance. For annual test/inspection records, that would mean you must retain the records for 3-years, not necessarily for the life of the building.

Similarly, K-Tag 921 discusses a testing and maintenance program for electrical equipment, and it says records are maintained for a period of time to demonstrate compliance. This is consistent with the CMS informal comment that a ‘period of time’ would be 1-year for monthly requirements and 3-years for annual requirements.

Since accreditation organizations operate with the authority granted to them by CMS, it would be expected that the accreditation organizations would comply with the same requirements and informal policies as CMS.

But, I will fallback on what I believe: You should never throw away any records that demonstrate compliance with a regulatory requirement. That’s Brads opinion.

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.

State Agency Validation Survey

Q: I recently had a state validation inspection and wanted to get some clarification on a few their findings:

“K 353: The facility failed to provide complete visual observation checklist during the weekly churn test. Not in accordance with NFPA 25, 2011 edition Section 8.3.2.8.”

I have been doing a weekly churn test for the past two years (now it will be monthly) the information on the form includes discharge pressure and how long it took for the pump to kick on after the main drain was open. My question is what else is required and what does a visual observation checklist include. I thought we were in compliance with what we were doing. What is the checklist he is referring to?

“K 353: Maintenance record review revealed that the facility failed to provide record of weekly inspection of the fire pump assembly operating and physical condition. Not in accordance with NFPA 25, 2011 edition Section 8.2.1, 8.2.2.”

What does a weekly inspection of the fire pump assembly operating and physical condition entail?

“K293: Facility failed to provide record of monthly (interval not to exceed 30 days) visual inspection of the operation of illumination source of emergency exit signs installed in the facility. Not in accordance with NFPA 101 2012 edition Section 7.10.9.1”

Currently we have had the practice of conducting a monthly load bank test of the generator. During this test, checking and logging the exit lights is part of the test. Need clarification of what the visual inspection includes. Thought we were in compliance.

A: Do you have a copy of NFPA 25-2011? If not, I suggest you obtain a copy.

NFPA 25-2011, section 8.3.2.8 requires the following visual observations while the pump is operating:

(1) Pump system procedure as follows:

(a) Record the system suction and discharge pressure gauge readings

(b) Check the pump packing glands for slight discharge

(c) Adjust gland nuts if necessary

(d) Check for unusual noise or vibration

(e) Check packing boxes, bearings, or pump casing for overheating

(f) Record the pump starting pressure

(2) Electrical system procedure as follows:

(a) Observe the time for motor to accelerate to full speed

(b) Record the time controller is on first step (for reduced voltage or reduced current starting)

(c) Record the time pump runs after starting (for automatic stop controllers)

(3) Diesel engine system procedure as follows:

(a) Observe the time for engine to crank

(b) Observe the time for engine to reach running speed

(c) Observe the engine oil pressure gauge, speed indicator, water, and oil temperature indicators periodically while engine is running

(d) Record any abnormalities

(e) Check the heat exchanger for cooling waterflow

 

NFPA 25-2011, section 8.1.1.2 refers to Table 8.1.1.2 for inspection frequencies. Table 8.1.1.2 says the fire pump house and fire pump system must be inspected weekly. Sections 8.2.1 and 8.2.2 require the following inspections to verify that the pump assembly appears to be in operating condition and is free from physical damage:

(1) Pump house conditions as follows:

(a) Heat is adequate, not less than 40°F (5°C) for pump room with diesel pumps without engine heaters.

(b) Ventilating louvers are free to operate.

(2) Pump system conditions as follows:

(a) Pump suction and discharge and bypass valves are fully open.

(b) Piping is free of leaks.

(c) Suction line pressure gauge reading is within acceptable range.

(d) System line pressure gauge reading is within acceptable range.

(e) Suction reservoir is full.

(f) Wet pit suction screens are unobstructed and in place.

(g) Waterflow test valves are in the closed position.

(3) Electrical system conditions as follows:

(a) Controller pilot light (power on) is illuminated.

(b) Transfer switch normal pilot light is illuminated.

(c) Isolating switch is closed — standby (emergency) source.

(d) Reverse phase alarm pilot light is off, or normal phase rotation pilot light is on.

(e) Oil level in vertical motor sight glass is within acceptable range.

(f) Power to pressure maintenance (jockey) pump is provided.

(4) Diesel engine system conditions as follows:

(a) Fuel tank is at least two-thirds full.

(b) Controller selector switch is in auto position.

(c) Batteries’ (2) voltage readings are within acceptable range.

(d) Batteries’ (2) charging current readings are within acceptable range.

(e) Batteries’ (2) pilot lights are on or battery failure (2) pilot lights are off.

(f) All alarm pilot lights are off.

(g) Engine running time meter is reading.

(h) Oil level in right angle gear drive is within acceptable range.

(i) Crankcase oil level is within acceptable range.

(j) Cooling water level is within acceptable range.

(k) Electrolyte level in batteries is within acceptable range.

(l) Battery terminals are free from corrosion.

(m) Water-jacket heater is operating.

 

I don’t know what your current inspection logs say regarding the ‘Exit’ sign inspections, but apparently, the surveyor did not feel it met the requirement of section 7.10.9.1 of the 2012 LSC. ‘Exit’ signs must be inspected monthly (at intervals not exceeding 30 days) to verify that the illumination sources are operating. This means the ‘Exit’ signs must be illuminated. Your inspection logs for this monthly requirement must specifically state your staff confirmed the ‘Exit’ sign is illuminated for each inspection. If the inspection log does not say that, then you did not perform the proper inspection.

If you are thinking the surveyor really hit you hard on the inspection and testing requirements described above, you’re right. But don’t blame the surveyor… he/she is only doing their job. CMS is systematically holding healthcare providers accountable for compliance with the 2012 Life Safety Code, and the referenced standards. CMS is insisting their state agencies who do validation and complaint surveys on their behalf, hold all healthcare providers accountable to every large and little NFPA requirement. If this results in the surveyor being ‘picky’, then so be it, according to CMS.

You can expect the accreditation organizations to follow suit. CMS is cracking down on them as well, and making the AOs enforce little-known NFPA requirements that were never enforced before.