Emergency Management

Q: Regarding the new CMS rule on emergency preparedness, are they telling us that we must have full heating and cooling support for the entire hospital during a power outage up to and including adding more generators?

A: No… I don’t believe it is. Section 482.15 (b)(1)(ii)(A) says, “The hospital must develop and implement emergency preparedness policies and procedures … that must address temperatures to protect patient health and safety”. This does not say or mean that you need to add equipment to maintain temperatures (other than what the Life Safety code and NFPA 99 requires). It’s saying you must have a policy and a procedure that must address temperatures to protect the health and safety of patients.

So, your policies must reflect a plan on how you are going to accomplish this. If you lose fuel for the heating appliances, then what is your back-up plan? If you lose normal power and then emergency power, what is your back-up plan? Ultimately, your plan should recognize that you must evacuate the building if you can no longer maintain safe temperatures for your patients and staff.

Magnetic Locks

Q: Is there a code requirement for testing magnetic-locking devices, for a facility maintenance director?

A: There is a requirement in NFPA 72-2010, section 14.4.5 that all interface devices (i.e. relays, control modules) be tested once per year. Since the magnetic locks in access-control and delayed egress locks are connected to the fire alarm system via an interface relay, then the magnetic lock needs to be tested once per year to ensure it disconnects during a fire alarm signal. This test is required to be conducted by someone who is certified in accordance with NFPA 72.

If you are CMS certified or accredited by any of the major accreditation organizations then you would be expected to comply with the manufacturer’s recommendations on preventive maintenance. Most manufacturers of magnetic locks requires periodic maintenance to ensure they are functioning correctly.

Portable Space Heaters

Q: Could you please clear up a concern related to section 19.7.8 of the 2012 Life Safety Code, that addresses Portable Space-Heating Devices? Section 19.7.8 (1) states such devices are used only in non-sleeping staff and employee areas. Does this mean that the approved space heaters are allowed at nurse stations or offices that are located in the same smoke compartment as patient care rooms?

A: It really depends on the AHJ’s interpretation of the term “non-sleeping staff and employee areas”. I know Joint Commission interprets this to mean approved space heaters cannot be used in any smoke compartment that contains patient sleeping or treatment activities. Other AHJ’s may not be as definitive, and leave it up to the surveyor to decide.

Personally, I suggest you go with Joint Commission interpretation (see LS.02.01.70, EP 8) as that seems to me to be the more restrictive. You should be safe with most other AHJs if you follow that interpretation.

GFCI Receptacles on Ice Machines

Q: We had our Joint Commission inspection today and they cited us for water coolers and ice machines not being plugged into GFCI (ground-fault circuit interrupter) receptacles. One of our buildings was built in 1972 and the other was 2008. They cited NFPA 99-2012 Chapters 6 and 9, under EC 02.05.05 EP 8. Do you believe that was a correct finding? Thanks

A: Yes… that is a legitimate finding.

NFPA 99-2012, section 6.3.2.1 says the electrical installation must be in accordance with NFPA 70 National Electrical Code. Article 210.8(B) of NFPA 70-2011 says ground-fault circuit-interruption for personnel protection shall be provided as required in 210.8(A) through (C). The ground-fault circuit-interrupter shall be installed in a readily accessible location.

Sub-section (B) “Other Than Dwelling Units” says all 125-volt, single-phase, 15- and 20-ampere receptacles installed in the locations specified in 210.8(B)(1) through (8) shall have ground-fault circuit-interrupter protection for personnel:

(1) Bathrooms

(2) Kitchens

(3) Rooftops

(4) Outdoors

(5) Sinks — where receptacles are installed within 6 ft of the outside edge of the sink.

(6) Indoor wet locations

(7) Locker rooms with associated showering facilities

(8) Garages, service bays, and similar areas where electrical diagnostic equipment, electrical hand tools, or portable lighting equipment are to be used

So, item #6 ‘wet locations’ is the kicker on this issue. The AHJs are now interpreting anything that holds water to be a wet location, and therefore must have a GFCI receptacle. Another issue that you need to be aware of, is all GFCI receptacles need to be tested monthly. Ouch. More labor and documentation.

I don’t see where NFPA 99-2012 Chapter 9 (HVAC) applies in this issue, but it is a legitimate finding through chapter 6.

Non-Compliant Construction Type Above a Healthcare Occupancy

Q: I have an interesting one for you. We have an architect propose a construction type of Type V (111) for a 3-story building with the first-floor being Healthcare occupancy (a nursing home) and the upper 2 floors being Residential Board and Care occupancy (assisted living). There is a 2-hour floor ceiling assembly separating the nursing home and assisted living.

It is interesting to me because I am not aware that the LSC has ever allowed this in the past, but it appears to be allowed by the 2012 LSC in accordance with 18.1.3.5. The 2012 LSC Handbook also gives a good description. What I am worried about is CMS and accreditation surveys. This is against everything that has been engrained in our brains and it could be a major issue. Have you seen this or heard of this before?

A: Yes… this is a very interesting case. I cannot recall that I’ve seen this before, mainly because the 2000 LSC did not allow this arrangement. It was not until the 2009 edition of the LSC that this was clearly permitted. And I agree, the Handbook for the 2012 LSC explains this very well. I recall a conversation that I had with a representative from NFPA years ago on this very subject and he assured me it was not permitted (we were under the 2000 LSC at the time). So, I agree with you… It goes against what we’ve been taught. But times change, don’t they!

Unless you have other regulations preventing this arrangement, I would say that the NFPA codes and standards would permit it, but please check with your state and local authorities to see if they have any problems with it. I would not be too concerned about a nursing home being cited by a CMS surveyor or an accreditation surveyor since they follow NFPA rather rigidly (or are supposed to), and since the 2012 LSC does permit it, the nursing home may make the case that it is permitted if the surveyor is considering citing them.

Personally, I think it is poor insight by the healthcare organization to do this, as they will never be able to expand their healthcare occupancy beyond the 1st floor, and maintaining that 2-hour fire-rated barrier is a special challenge for anyone, let alone a typical maintenance staff of a nursing home that is often under-manned, and not trained well on technical issues. I suspect over a period of time the 2-hour fire-rated horizontal barrier will be compromised and not maintained properly due to a lack of understanding.

 

Which Edition of FGI?

Q: My understanding is we should be following the 2010 FGI Guidelines because that’s what is recognized by the 2012 LSC that was adopted by CMS. But I have read where CMS and Joint Commission would allow hospitals to comply with the most recent edition of the FGI Guidelines, which is the 2014 edition. To confuse the issue further, our state has adopted the 2010 FGI Guidelines. What this boils down to is Table 7-1 on ventilation and if we should follow the 2010 edition or a newer one. Is my understanding correct or are we to follow the latest FGI guideline?

A: For most hospitals, compliance with the FGI Guidelines is more of a suggestion, than a requirement. The FGI Guidelines are not standards, but are guidelines on how to design your facility. According to the Interpretive Guidelines for CMS Condition of Participation §482.41(c)(4), it is clear that the design of the hospital must be made in accordance with a select standard or guideline. CMS allows you to choose which standard or guideline you follow, and provides suggestions for temperature and ventilation as directed by AORN, FGI, CDC and the like. It is also expected that you would follow state or local regulations as well, even if they are more restrictive than the national regulations.

Once designed and constructed, the temperature and ventilation requirements do not change in your facility when a newer edition of a standard or guideline is adopted. If you designed your ORs to the 2010 edition of the FGI Guidelines, then you only have to comply with the requirements of the 2010 edition for the life of the building, or until you conduct major renovation. Your facility does not have to retroactively comply with newer editions of the FGI Guidelines.

If your state has adopted the 2010 edition of the FGI Guidelines, and they require compliance with that edition, then that is the edition you comply with, even though CMS would allow compliance with the 2014 edition. The state’s requirements are more restrictive than CMS’.

As far as I can see, the 2012 Life Safety Code does NOT reference any edition of the FGI Guidelines, but NFPA 99-2012 does reference the 2008 ASRAE 170 publication on ventilation, which is the basis for Table 7-1 in the FGI Guidelines.

Offsite Locations

Q: For clinics that are in a facility classified as business occupancy, is an ICRA required?

A: For Joint Commission accredited organizations, their hospital standards apply to all offsite locations that are considered hospital departments even if it is not classified as healthcare occupancy. For example, if a hospital has an offsite therapy unit in a local mall, the Environment of Care and Life Safety chapter requirements must apply to the offsite location, in accordance with the respective occupancy designation. This means, where the hospital is a healthcare occupancy, an offsite therapy unit would likely be a business occupancy, but the requirements found in the EC and LS chapters still apply at the therapy unit, but in accordance with business occupancy classification.

So, the requirement for an Infection Control Risk assessment (ICRA) is found in EC.02.06.05, EP 2 in the Hospital Accreditation Manual. The expectation is the hospital would conduct an ICRA at an offsite location when planning for construction as long as it is a hospital department. This concept of the Joint Commission standards applying at offsite locations is explained in the Overview to the EC and LS chapters.

Equivalencies for Exit Enclosures

Q: We have a hospital with a number of exit enclosures. These passageways have a large number of unrelated utilities running above the ceiling. Modification will not only be very expensive, but very difficult. Can we use NFPA 101A FSES equivalencies for alternate compliance?

A: Section 7.1.3.2.1 (10)(h) of the 2012 LSC does say “Existing penetrations protected in accordance with 8.3.5” as an exception regarding utility penetrations into an exit enclosure, so the undesirable utility penetrations in the exit enclosures may be acceptable if you can prove they are ‘existing’ conditions. According to CMS, anything designed or constructed prior to July 5, 2016 is considered existing conditions as far as the 2012 Life Safety Code goes, but not all other authorities agree with this concept entirely. Ever since the 1988 edition and all of the subsequent editions of the LSC, it has said that penetrations of ductwork, conduit, pipes, etc., that do not serve the exit enclosure are prohibited.

Many authorities having jurisdiction enforce this to present day…. Meaning if the utility was installed in 1992 in the exit enclosure but does not serve the exit enclosure, then it still can be cited today because it was not installed correctly ‘back then’. But the 1985 edition does not say that. So, any utility installed in an exit enclosure that does not serve the exit enclosure before the 1988 edition was adopted would be considered ‘existing’ and since it wasn’t prohibited when it was installed, it would be permitted to remain, provided it met the requirements of 8.3.5. For CMS, they were on the 1985 edition until March 11, 2003.

But Joint Commission had been adopting the new editions of the LSC shortly after they were published. So, they were on the 1991 edition back in 1992, which is as far as my memory goes. It’s all a crap-shoot…. Some surveyors will recognize the July 5, 2016 date as the only threshold between new and existing and will allow the existing utilities in the exit enclosure, and then some surveyors will be more scrutinizing and try to determine when the utilities were installed. But to answer your question, if you get cited, you could always go for an equivalency (NFPA 101A FSES) as part of your Plan of Correction, but you would have to prove a significant hardship in complying with the LSC.

One can assume it will be costly to install a 2-hour fire-rated ceiling in the exit enclosure to cover-up the utilities, but the CMS Regional Office is the entity to make the decision to approve the FSES equivalency or not, and you need to convince them whether or not it is a significant hardship. CMS does not accept equivalencies unless the deficiency is first cited, so you will have to wait to get cited by your accreditor or state agency surveying on behalf of CMS. And don’t forget to conduct an assessment for ILSMs now of the deficiency… most authorities will expect you to do so. But equivalencies are only valid until the next triennial survey, so it would be best to make long-range plans to resolve the issue, rather than continuously presenting equivalency requests.

New Forms on the ‘Tools’ Webpage

This is a special posting to let you know there are 6 new forms on the ‘Tools’ webpage for you to download for free:

  1. Advantages if the Building is Sprinklered – This form identifies all of the advantages that you can take  if your building is fully sprinklered.
  2. Building Tour by the Numbers – This form identifies many of the quantitative requirements for complying with the Life Safety Code.
  3. EC Document Review Form – This form identifies the documents you need to be compliant with The Joint Commission’s EC chapter.
  4. Fire Extinguisher Annual Maintenance Report – During the document review session, surveyors are often looking for documentation that identifies when the last 6-year inspection, or 12-year hydro test was conducted, and when the next one is due. This form helps you document that for each extinguisher.
  5. Cooking Hood Monthly Inspection – Did you know you are required to perform monthly inspections of the cooking hood fire suppression system? This form helps you document that.
  6. Sprinkler System Pressure Gauge Monthly inspection – All pressure gauges on the sprinkler system need to be inspected, and this form will track that for you.

Take a look at this re-defined webpage as there are over 35 forms and templates waiting for you to download… all at no cost.

Statement of Conditions PFI List

Q: We are expecting Joint Commission at our hospital soon. Since they will no longer look at the PFI lists, is it advisable to keep our current open PFIs open on their website? I was informed to close out the open PFIs and document under “Other” that they are closed since we are no longer required to report them to TJC. But, I do not want to close out open PFIs on the TJC website for this reason. Please advise.

A: It is totally up to you and your organization. It is true that Joint Commission has said the Statement of Conditions PFI section is no longer part of the survey process, and their surveyors will no longer look at the PFIs you have written. For the record, Joint Commission is encouraging hospitals to continue to use the PFI section in the SOC in order to manage their Life Safety Code deficiencies. In fact, the accreditor has recently said that they will even allow Environment of Care deficiencies to be placed on the SOC PFI section for you to manage. Joint Commission does not have any immediate plans to eliminate the PFI section from the SOC because they feel it is a useful tool for you to use to manage your deficiencies.

But if it were me, I would likely discontinue using the PFI section in the SOC because I think the computerized maintenance management system that most hospitals have would be a better tool to manage my deficiencies. And, I see no reason to leave Life Safety Code deficiencies listed on a Joint Commission document for their surveyors to look at, if I don’t have to. I know Joint Commission says their surveyors will not look at the PFIs you’ve written, but how do we know for sure that they won’t? In your case, I would not have a problem closing out the current PFIs using the “Other” choice.