Sep 04 2017

Waiver and Equivalency Validation

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

Q: During a recent webinar, the presenter said waivers and equivalencies are only valid until the next triennial survey.   Does that really mean if CMS approved a waiver or an equivalency we need to go through that same process again even if things have not changed in 3yrs and get this reapproved?

A: Yes it does. Once a waiver or equivalency request is approved by CMS, it is only valid until the next survey, regardless if the next survey is the triennial survey by your accreditation organization, or a validation survey by your state agency. At that time, the waiver or equivalency is no longer valid, and the surveyor will inspect the area to determine if the deficiency still exists, and if it does, the deficiency will be cited again. Then the hospital has the choice to either resolve the deficiency or submit a waiver (or equivalency) request again.

According to a statement from CMS, this process of having waivers and equivalencies valid until the next survey is a checks-and-balance system to ensure that the conditions in the hospital that allowed the waiver to be approved in the first place have not changed in the time since the waiver (or equivalency) was granted. It makes sense, in that CMS is ensuring that the conditions are still acceptable for a waiver or an equivalency.

However, the expense of submitting waivers or equivalencies every 3 years may be a real burden to some organizations, and there is no guarantee that CMS will approve a waiver (or equivalency) request for the same deficiency a second time. It is a very subjective process. That is why hospitals need to seriously consider resolving the deficiency instead.

Feb 28 2013

Oversized Suites of Rooms

Category: Equivalencies,Questions and Answers,SuitesBKeyes @ 5:00 am

Q: Can an FSES equivalency be written for an oversized ER suite? Our ER was constructed in 2005 and the designer made it 13,450 square feet, which is more than the maximum allowable amount.  We have exam rooms without doors and a surveyor said that was not allowed if the ER is not a suite.

 A: Yes, a Fire Safety Evaluation System (FSES) equivalency may be conducted and submitted to your authority having jurisdiction, but you have to make sure of a few issues. First, the deficiency for an over-sized ER suite has to address the fact that the exam rooms do not have doors. The surveyor is correct in saying that a room providing care or treatment to a patient has to be separated from the corridor by a door that latches.  Secondly, since you do not qualify for a suite (because you are 3,450 square feet over the limit), you have to assess the ER as if it has an exit access corridor, and all the exam rooms are open to the corridor. The FSES document is a NFPA 101A Guide on Alternative Approaches to Life Safety (2001 edition), and the worksheet to use is form 4.7.6. The value for Safety Parameter #5 has to be -10 points for no doors to the corridor. Make sure you travel distances are no more than 100 feet or 50 feet if through two intervening rooms. If the plans to construct the ER department were approved by the local authority on construction after March 11, 2003, then you must assess the area on the FSES worksheet as new construction, which makes it harder to get the numbers to work. The logic on that issue is a new building should not have any life safety deficiencies. If the numbers do not work out on the FSES equivalency, you can always consider cutting the ER into two, smaller suites by adding doors and walls in strategic areas. That may not be desirable, but it may be your only solution if the FSES does not work.

Mar 17 2009


Category: Equivalencies,Questions and AnswersBKeyes @ 9:06 pm

QUESTION: It has been stated that an organization is permitted to submit either a Traditional Equivalency or a Fire Safety Evaluation System for a deficiency to a life safety feature. How do we decide when to use which one and what is the difference between them?

ANSWER: A Traditional Equivalency is a basic three-step process:

  1. Identify the deficiency and reference the applicable NFPA 101 Life Safety Code paragraph.
  2. Propose an alternative solution to the problem; include drawings      showing existing conditions and the proposed solution; identify the total      cost of the solution, including the source and availability of the funds;      and identify when the solution will be implemented.
  3. One of the following individuals needs to state in writing that the      proposed solution meets the intent of the code, or creates an equivalent      level of safety:
  • A fire protection engineer
  • A registered architect
  • The local AHJ over enforcement of fire safety

A Fire Safety Evaluation System (commonly referred to as FSES) is a multiple page document that places numerical values to specific life safety features of your building. It is found in NFPA 101A, Guide on Alternative Approaches to Life Safety. This document provides alternative approaches to life safety based on the NFPA 101 Life Safety Code. It is intended to be used with the Life Safety Code, not as a substitute. The Life Safety Code permits alternative compliance with the Code under equivalency concepts where such equivalency is approved by the authority having jurisdiction.

After assigning a numerical value to specific life safety features based on questions in the FSES, a sore is derived in four basic equivalency functions:

  • Containment safety
  • Extinguishment safety
  • People movement
  • General safety

If the score equals 0 or greater in each of the basic functions, then the FSES demonstrates an acceptable level of safety, and the AHJ should approve it as an equivalency.

Anyone with intimate knowledge of your facility is permitted to conduct a FSES and special degrees and licenses are not required.