Oct 31 2017

CMS Waiver Approval

Category: CMS,Questions and Answers,WaiversBKeyes @ 12:00 am

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.


Oct 10 2017

Power Strips

Category: CMS,Power Strips,Questions and AnswersBKeyes @ 12:00 am

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 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 (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.

Mar 07 2017

State Agency Validation Survey

Category: CMS,Questions and AnswersBKeyes @ 12:00 am

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”

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”

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 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 refers to Table for inspection frequencies. Table 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 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.

Aug 31 2016

Enforcement Date for the 2012 LSC

Category: CMS,Joint Commission,Questions and AnswersBKeyes @ 12:00 am

Q: Can you provide some clarification? The NFPA 101 2012 edition was adopted July 5th is that correct? Joint Commission and CMS will not be reviewing using this current edition until November 1, 2016 is this also correct? Wheeled equipment once being use for patient care can now remain in the corridor?

A: Yes… CMS adopted the 2012 Life Safety Code on May 4, 2016 with an effective date set for July 5, 2016. However, they soon issued a S&C memo on June 20, 2016, that said while the new 2012 LSC is still effective on July 5, 2016, they will not enforce the requirements of the new code until November 1, 2016. This extra 4 months is needed for the accreditation organizations (AO) to modify their standards to address the new 2012 LSC requirements, submit them to CMS for review and approval, and then train their surveyors and clients. So, a November 1, 2016 enforcement date seems appropriate. This additional 4 months also allows you the opportunity to become fully compliant with the new requirements of the 2012 LSC, so that is a break as well.

While the new 2012 LSC is effective July 5, you will not see the AOs or CMS enforcing any of the new requirements, such as quarterly fire hose valve inspections, annual fire doors inspections, and 5-year internal inspections of the sprinkler pipe until November 1. But during this 4 month period of leniency, healthcare organizations may take advantage of the breaks the new 2012 LSC offers, such as monthly fire pump testing rather than weekly, and semi-annual water-flow switch testing rather than quarterly.

Section (4) of the 2012 LSC does allow certain wheeled equipment to be left unattended in the corridor, provided it meets the following criteria:

  • The wheeled equipment does not reduce the clear width of the corridor to less than 5 feet
  • There must be a fire safety plan and training program to relocate the wheeled equipment during a fire or similar emergency
  • The wheeled equipment is limited to equipment in use; carts in use; medical emergency equipment not in use; patient lift equipment; and patient transport equipment.

In case you’re wondering, computers on wheels are not considered to be medical emergency equipment, so they do not qualify to be left unattended in the corridors for more than 30 minutes.

Oct 09 2015

FGI Standards on Ventilation

Category: CMS,Questions and Answers,VentilationBKeyes @ 12:00 am

Q: The Centers for Medicare & Medicaid Services (CMS) standard §482.41(c)(4) states in their Interpretative Guidelines that hospitals must comply with the Facilities Guidelines Institute (FGI) for ventilation in anesthetizing locations. The Joint Commission standard EC.02.06.05, EP 1 requires compliance with the same FGI standards on ventilation. Our operating rooms were designed more than 20 years ago when the AIA guidelines at the time had less air changes per hour than what the new 2010 FGI guidelines require. Am I supposed to modify my current ventilation equipment in order to comply with the new 2010 FGI guidelines for air changes per hour? 

A: This short answer is No; you do not have to modify your existing air handler to meet the new 2010 FGI guidelines on air changes per hour, unless you alter, renovate or remodel the rooms the ventilation equipment serves. The Interpretative Guidelines for the CMS standards are not part of the enforceable standards, and are considered references. CMS does not expect compliance with the new FGI guidelines on existing equipment; only on new construction. Also, CMS states “acceptable standards such as from the Association of Operating Room Nurses (AORN) or the FGI should be incorporated into hospital policy.” This means, the FGI guidelines are not the only standard you should consider when designing new construction or renovated areas.

In regards to the Joint Commission standard EC.02.06.05, EP 1, it clearly states in the standard: “When planning for new, altered, or renovated space…” This means the FGI guidelines only apply to new construction, and not to existing conditions. And the FGI guidelines are only one of a set of criteria that the organizations may choose to comply with. The others are state rules and regulations or other reputable standards and guidelines that provide equivalent design criteria.

Sep 11 2015

CMS Requirements on Ventilation Testing

Category: CMS,Questions and Answers,VentilationBKeyes @ 12:00 am

Q: What does CMS require as far as frequency of testing of air changes per hour (ACH) in hospitals? I see where we are supposed to test and know what ACH is required, but I have not seen at what frequency we are to test. 

A: You raise a very interesting point. CMS seems to have a different philosophy when it comes to writing standards, than say, The Joint Commission, HFAP or DNV. CMS does not write into their standards as much detail or specifics as the accreditors do. CMS does rely heavily on their written Interpretive Guidelines and Survey Procedures that they include with their standards. At times, these Interpretive Guidelines and Survey Procedures have very useful and detailed information.

In regards to ventilation requirements, CMS standard §482.41(c)(4) says “There must be proper ventilation, light, and temperature controls in pharmaceutical, food preparation, and other appropriate areas”. That’s all it says in the standard, which is not much to go on. But their Interpretive Guidelines for this standard says: Acceptable standards such as from the Association of Operating Room Nurses (AORN) or the Facilities Guidelines Institute (FGI) should be incorporated into hospital policy.”

So, CMS is saying in their Interpretive Guidelines that the FGI Guidelines must be followed for ventilation requirements. But it is important to understand that the FGI Guidelines are not retroactive to existing conditions, but are used for the design of new construction or renovated areas. For existing conditions, you need to be compliant with the laws, regulations and FGI Guidelines (or AIA Guidelines, if the area is that old) that were in affect at the time the area was designed or renovated.

If your existing area can meet the current FGI Guidelines, then that is great and you’re in good shape. If your existing area cannot meet the current FGI Guidelines, then you need to determine what regulations or guidelines were in effect at the time the area was constructed. If you meet those ventilation requirements, and you can document that, then you’re in good shape.

Now, to answer your direct question: “What does CMS require as far as frequency of testing of air changes per hour (ACH) in hospitals?” The answer is…CMS does not specify how frequent you need to check the ACH rates, and neither does the FGI Guidelines appear to specify how frequently you need to check your ACH rates. But that does not mean you do not have to perform periodic checks. The answer is… You get to decide how often you check the ACH rates, but it better be based on reasonable assumptions. The state agency surveyors who will survey your hospital on behalf of CMS will have expectations on how often you check the ACH. I could offer suggestions, but ultimately you need to know and follow what your state agency inspectors expect. I suggest you contact them and discuss this issue with them to understand what their expectation will be.