Mar 02 2016

CMS Enforces Different Time-Description

Category: BlogBKeyes @ 12:00 am

I received the following comment from a reader:

During a recent CMS life safety survey a surveyor stated that my kitchen hood suppression testing intervals were out of compliant even though they’re we’re clearly within The Joint Commision’s plus or minus 20 day window for semi-annual testing. He said CMS goes by the NFPA code (not JC) and that, that window is not in the code so therefore the testing must be completed before the 6 month anniversary. However, he stated that the quarterly inspections and testing can be done in a calendar basis and not by the revised quarterly interval parameters that JC has implemented (every 3 months, plus or minus 10 days).

This is an example where the accreditation organization has developed a thoughtful and practical interpretation of the NFPA standards regarding frequency of inspections and tests. Then CMS comes along and denies the practicality of the interpretation because it is not permitted in the NFPA codes or standards. That’s one of the problems with the NFPA standards is they don’t define time, such as what “semi-annual” or “every 6 months” means.

I’ve heard some state agencies surveying on behalf of CMS actually require the annual inspection or testing activity to occur exactly on the same date as the previous activity, one year later. So if it was last tested on April 15, it had to be next tested on April 15 of the next year, regardless what day of the week that landed on. That was extreme and I hope responsible people came to their senses.

But part of the problem is the people who are interpreting these rules have never worked in a hospital. They seem to not understand that hospitals need a reasonable window of opportunity to schedule these inspections and tests. Facility departments have decreasing resources available to them and it would sure be helpful if the government would just give them a little help now and then by interpreting issues with a little kinder attitude.

Wouldn’t it be nice if all of the authorities having jurisdiction (i.e. CMS, accreditation organizations, state fire marshals, etc.) were on the same page for critical issues like this?


Tags: , ,

Oct 31 2013

Changes to Joint Commission Standards for 2014: Part 1

Category: BlogBKeyes @ 6:00 am

calendar_quarterly[1]Joint Commission has announced a couple of subtle, yet far-reaching changes to their standards to become effective January 1, 2014. One of them has to do with how they define time, and the other…. well we will discuss that in a later posting.

Currently, Joint Commission defines the period of time between required activities, such as testing and inspecting, to be as follows:

  • Weekly, or ‘every 7 days’:   Anytime during the week
  • Monthly, or ‘every 30 days’:   Anytime during the month
  • Quarterly, or ‘every 3 months’:   Anytime during the quarter
  • Semi-annually, or ‘every 6 months’:   6 months from the previous activity, plus or minus 20 days
  • Annually, ‘every 12 months’:   12 months from the previous activity, plus or minus 30 days
  • 3-Years:   36 months from the previous activity, plus or minus 30 days

The change beginning in 2014 involves Quarterly and 3-Year intervals. Now, Joint Commission will define Quarterly as follows:

Quarterly, or ‘every 3 months’:   3 months from the previous activity, plus or minus 10 days.

This change has far-reaching consequences, especially for fire drills. When I was a safety officer at the hospital where I worked, I was responsible for fire drills. Now, I will tell you that I did not enjoy conducting fire drills, as most of the people that participated in the drill, complied only because they had to, and they considered it a major inconvenience to their daily routine. My staff and I understood the importance of doing fire drills, but we were pretty much the only ones. Therefore, since I didn’t enjoy doing fire drills, I tended to ‘put them off’ or procrastinate in doing them, until the last days of the quarter. I was not as organized in doing them as I should have been.

If other hospital safety officers are like me, then this new change in how Joint Commission defines “Quarterly” will be a serious issue. They will have to develop a specific schedule of doing the drills in accordance with the new description, and be disciplined enough to stick with it. This will require organization skills. Make note of this and if you are not the individual responsible for fire drills in your organization, then send this post to the person who is.

Also, this affects all other quarterly testing and inspection activities, such as:

  • Waterflow switches
  • Supervisory signal devices (not tamper switches)
  • Off-premises monitoring transmission equipment (usually conducted with the fire drill)
  • Fire department connections (FDC)

During a recent webinar sponsored by ASHE, George Mills of the Joint Commission explained that this change in how they defined “Quarterly” came from another department and he unsuccessfully argued against the change.

The other change in how Joint Commission defines time between testing and inspection activities is the 3-Year test. It will now read as follows:

3-Years: 36 months from the previous activity, plus or minus 45 days

This is a change from “plus or minus 30 days” and can only be considered a positive for the facility manager. What is strange about this issue, is I heard George Mills says “pus or minus 45 days” for 3-Year testing intervals a couple of years ago at an ASHE annual conference, so I advised my clients as such. Then, last year when one of my clients went 36 months, plus 40 days between the 3-Year generator load test, the surveyor cited them for non-compliance. We wrote a clarification on the finding saying plus or minus 45 days was acceptable, and Joint Commission denied it. So, I’m glad they finally made a decision and let’s hope they stick to it.

Next week’s posting: We will discuss the changes to the monthly generator load testing.


Tags: , ,