Feb 06 2018

Keyes Life Safety Boot Camp – April 24 & 25, 2018

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 24 & 25, 2018

Location: Embassy Suites Centennial Olympic Park, 267 Marietta St., Atlanta, GA 30313  404-223-2300

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; and former Joint Commission LS surveyor.

Alise Howlett, Assoc. AIA, CFPE, CHFM, owner of Codenity, LLC; current advisor to HFAP, and a plan reviewer for multiple municipalities.

Cost: $889.00 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.

Embassy Suites at Centennial Olympic Park, 267 Marietta Street, Atlanta, GA 30313, phone (404) 223-2300

To receive special event hotel room pricing of $179/night, book your room prior to March 24 at: http://embassysuites.hilton.com/en/es/groups/personalized/A/ATLESES-KLS-20180423/index.jhtml

Register Early: Seating is limited to 50 individuals – Previous boot camps have sold out.  Registration will close on April 2. Go to https://www.eventbrite.com and search “Keyes Life Safety Boot Camp-Atlanta”

Registration is not confirmed until payment is received. Registration closes when all seats are filled, or April 2, 2018

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 05 2018

Trash Cans

Category: BlogBKeyes @ 12:00 am
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Q: Can you tell me where to find the code reference for trash cans in healthcare, ambulatory, and business occupancies? I have reviewed the respective chapters in the 2012 LSC and there does not appear to be any requirements for a rating or type of trash container to be used. I was thinking that they all had to be UL listed?

A: You are correct in that there is no mention of trash can ratings in the Life Safety Code… That is because there are none. Years ago (perhaps 25 years ago) there used to be, but the requirements for a trash can to have a specific rating has since been deleted.

Now, there is a requirement for containers holding clean waste and documents waiting for shredding to be FM Approval 6921 (See 19.7.5.7.2 of the 2012 Life Safety Code), but other than that there are no requirements.

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Feb 02 2018

Patient Room Decorations

Category: BlogBKeyes @ 12:00 am
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Q: Where does “Homelike Environment” end and fire safety begin? We have a resident who likes to push-pin everything she makes in activities to her wall. On a recent Life/Safety visit, the surveyor noted that she had “too much stuff” on her walls and that it was a “fire hazard”. We are supposed to encourage “homelike” and “Individualized Care”, then we are told that we have to tell the resident that they cannot decorate their “home” as they desire. I know there has to be a balance, but the items do not impede entrance nor egress to the room and, while there are a lot of items, high and low, they are not on top of one another nor sticking out more than 3 or 4 inches from the wall. One might consider them to be “cluttered”, however, they are not on the floor. Also, he said that everything from pictures to wreaths to whatever has to be “flame retardant”. Are we to spray everything that a family brings in from home?

A: By the sound of your comments, it appears to me that you are referring to a nursing home environment. I am very empathetic to your problem as I understand that CMS state agencies want you to create a “home-like” environment for long-term care patients, but yet, you are required to comply with the 2012 edition of the Life Safety Code.

However, there is some relief available to you on this subject. Since CMS adopted the 2012 edition of the Life Safety Code effective July 5, 2016, section 19.7.5.6 changes how decorations may be displayed in the patient’s room:

  • Combustible decorations are permitted to be attached to walls, ceiling and non-fire rated doors as long as the decorations do not interfere with the operation of the doors
  • Combustible decorations may not exceed 20 percent of the wall, door and ceiling areas inside any room or space of a smoke compartment that is not fully protected by sprinklers
  • Combustible decorations may not exceed 30 percent of the wall, door and ceiling areas inside any room or space of a smoke compartment that is fully protected by sprinklers
  • Combustible decorations may not exceed 50 percent of the wall, door and ceiling areas inside patient sleeping rooms having a capacity of no more than 4 patients, in a smoke compartment that is fully protected by sprinklers

I don’t know if the decorations covering the walls that the surveyor saw were within the above limitations, but I would think your organization could calculate the square footage of the decorations and ensure it stays within the limits.

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Feb 01 2018

Strange Observations – Part 11

Category: BlogBKeyes @ 12:00 am
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Continuing in a series of strange things that I have seen when consulting at hospitals…

This may be hard to see but there is an ‘Exit’ sign over the door at the end of this corridor. Storing combustibles in the corridor is creating a hazardous area and the path of egress may not enter a hazardous area to get to the exit.

This scene is probably familiar to many hospitals across the country, but you’ve got to take action to eliminate it before it becomes a tragedy.


Jan 31 2018

Oxygen in Use Around Hair Dryers

Category: BlogBKeyes @ 12:00 am
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Q: Can you tell me what the rules are for oxygen usage around hair dryers might be?

A: As you can imagine, the codes and standards cannot have rules for every possible scenario. The NFPA codes and standards primarily deal with the storage of oxygen cylinders, and installation of piped oxygen systems. The NFPA codes and standards do not deal much with the use of oxygen… those standards would likely come from Respiratory Care regulations. To give you an idea, NFPA 99-2012, section 5.1.3.3.1.6 says indoor locations for oxygen shall not communicate with locations storing flammables, kitchens, and areas with open flames. Now, I presume there would not be any open flames around a hair dryer, but you get the idea that a heat source (i.e. a hair dryer) around oxygen is not a good idea. But, there is one standard in NFPA 99-2012 that could be of some help for you. Section 11.5.1.1.4 says: “Nonmedical appliances that have hot surfaces or sparking mechanisms shall not be permitted within oxygen delivery equipment or within the site of intentional expulsion.” Hair dryers are definitely ‘nonmedical’ and they do have hot surfaces, so you could use this section of NFPA 99-2012 to prohibit the use of medical oxygen therapy in close proximity to hair dryers.

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Jan 30 2018

Category: Blogcreekside @ 10:21 am
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Jan 30 2018

GFCI Receptacle Testing

Category: BlogBKeyes @ 12:00 am
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Do you ever have the feeling for every step forward, you take two steps backward? Regulatory compliance in the healthcare industry is getting tougher and tougher each year with new interpretations by the authorities. Just when you learn about the latest new requirement, and make the necessary adjustments so you are in compliance, along comes a new interpretation that throws a wrench into your process and you have to re-boot again.

Take the example that a reader sent me last December: Their hospital was having an inspection by their state agency representing CMS and the surveyor for the state said they were going to cite the hospital for not testing their GFCI receptacles on a monthly basis. She wrote me an email and asked me if testing the GFCI receptacles on a monthly basis was a requirement. I looked it up in the NFPA 99-2012 code and could not find any requirement to test GFCI receptacles. I did find a requirement in NFPA 70-2011, Article 517.17 (D) that does require the GFCI receptacles to be tested upon the initial installation, but nothing was mentioned about monthly testing requirements.

The state agency eventually submitted their report and the hospital was cited under K-914 for not providing any documentation that monthly testing was conducted on the Ground Fault Circuit Interrupter (GFCI) receptacles at various locations in the hospital, in accordance with the manufacturer’s instructions on testing.

Even though NFPA does not require monthly testing of the GFCI receptacles, the manufacturer does recommend it, and the CMS surveyor cited the hospital for not following the manufacturer’s recommendations. The reader sent me a copy of the survey report and asked if this made sense to me. I replied that yes, it is a legitimate finding, because the hospital was not following the manufacturer’s recommendation for testing the GCFI receptacles. CMS Condition of Participation CFR §482.41 (c)(2) Interpretive Guidelines is clear that hospitals must follow the manufacturer’s recommendations for maintenance activities, or they must comply with the Alternate Equipment Management (AEM) program. But, in a larger picture, it does not make sense to me to start citing healthcare organizations for a little-known requirement without first providing some warning.

Why can’t CMS make an announcement and say they will start holding certified healthcare organizations accountable for monthly testing of their GFCI receptacles and provide a year’s moratorium until they begin enforcement? When I was a surveyor for Joint Commission, the accreditor used to do that. They would make an announcement that they would begin holding hospitals accountable for a new requirement, but would give the healthcare organization at least 6-months, and sometimes a year, to become compliant before that issue was enforced.

So… for now, the lesson we all need to learn from this, is to begin a monthly testing program of all your GFCI receptacles. Do your own survey of your facility and inventory the location where each GFCI receptacle is at. Purchase one of the GFCI testing devices (~$10) in the picture and have your technicians do the test on a monthly basis. Document each monthly test with the date, location, a “Pass” or “Fail” decision of the test, and a signature by the technician. There is a report template on my “Tools” webpage that you can down-load and use for free.

But that takes care of the this ‘flavor-of-the-month’. What will be the next surprise by the CMS surveyors that will catch most healthcare organizations off-guard? The way CMS is putting pressure on their state agency surveyors to find deficiencies that the accreditation organizations over-look, it makes the survey process more of an enforcement interrogation rather than a collaborative and educational event.

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Jan 29 2018

What’s the Standard?

Category: BlogBKeyes @ 12:00 am
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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.

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Jan 26 2018

Staff Sleeping Rooms

Category: BlogBKeyes @ 12:00 am
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Q: During a recent survey, we were cited for not having a single-station smoke alarm in our hospital on-call staff sleeping rooms. Since this was cited, I have learned that these staff sleeping rooms are required to have single-station smoke alarms since they are considered a different occupancy (Lodging & Rooming House) and must meet section 26.3.4.5.1 of the 2012 LSC. But can I use the hospital smoke detector system in lieu of installing a battery operated smoke alarm in these rooms?

A: Yes… Section 9.6.2.10 does allow the use of the smoke detectors connected to the building’s NFPA 72-2010 approved fire alarm system, instead of installing the battery-operated smoke alarms.

However, section 9.6.2.10.1.4 does say these system smoke detectors must be arranged to function in the same manner as single-station or multiple-station smoke alarms. The typical building system smoke detectors are detectors only and do not provide any occupant notification. But the single-station smoke alarms provide both functions: Detection and occupant notification. Therefore, on a technical standpoint, the basic fire alarm system smoke detectors are not enough and some sort of occupant notification system must be provided.

Now, having said that, I do know that some accreditation organizations are simply accepting a smoke detector in the on-call sleeping room without the inclusion of an occupant notification device. But, I am aware that some state agencies surveying on behalf of CMS do enforce the letter of the code and will cite you if you do not have an occupant notification device in the room.

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Jan 25 2018

Strange Observations – Part 10

Category: BlogBKeyes @ 12:00 am
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Continuing in a series of strange things that I have seen when consulting at hospitals…

Access to this electrical panel was obstructed. Staff that was with me did not understand that 36 inches clearance needed to be maintained.

What was the person thinking when they built the shelves?


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