Clinical Needs Locks

Q: For clinical needs locks, can occupants pass through four locked doors (patient room door, a cross-corridor door, another cross-corridor door, and a door at exit discharge) in a required single path of egress? (All options have 4 locked doors in the path.)

A: The 2012 Life Safety Code does not address any restrictions on how many doors in the path of egress may be equipped with Clinical Needs locks. Therefore, if the LSC does not prohibit it, then it is permitted.

However, not all AHJs permit it. For example; I am told that the IBC prohibits more than one Clinical Need lock in the path of egress (or, at least they used to). When I worked at the hospital, I tried to get the state to allow two locked doors in the path of egress from the Psychiatric unit but they would not allow it.

But in my travels, I have seen multiple doors in the path of egress equipped with Clinical Needs locks where permitted in various states around the country. The most common use of multiple Clinical Needs locks create a ‘Sally Port’ or ‘airlock’ that allows one locked door to open but the other locked door must be closed. This is an added security to prevent anyone from eloping.

So, the LSC does not prohibit it, but the IBC and some AHJs do.

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.

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.

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.

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.

NFPA 99 Risk Assessment – PLEASE READ THIS

Q: I need to do the NFPA 99 risk assessment of my hospital. I was told by one of my consultants that I have do this risk assessment from a room-by-room perspective, and he provided me a form from ASHE that lists this assessment by room-by-room. Is this true…? Do I have to do this assessment for each room?

A: No… that’s not correct. Yes, ASHE does have a form that does imply a room-by-room assessment is needed for the Chapter 4 risk assessment, but that’s not required by Chapter 4. What is required is an assessment of building systems based on a defined risk assessment procedure. Chapter 4 does not define the risk assessment procedure that you should use, but the Annex section does identify three risk assessments that they suggest, and the ASHE room-by-room assessment form is not included in these three suggestions. To be sure, you may use the ASHE form if you wish, but then you can use any risk assessment form that you want.

The core of the risk assessment is to determine what level or category the following building systems falls under, in the event of a total catastrophic failure of that system:

  • Gas & Vacuum Systems
  • Electrical Systems
  • HVAC Systems
  • Electrical Equipment
  • Gas Equipment

There are 4 levels or categories:

  • Category 1:    Systems in which failure is likely to cause major injury or death of patients or staff
  • Category 2:    Systems in which failure is likely to cause minor injury to patients or staff
  • Category 3:    Systems in which failure is not likely to cause injury to patients or staff
  • Category 4:    Systems in which failure would have no impact on patient care or staff

The process in the assessment is to determine the level of risk to the patient or staff if there is a catastrophic failure of that particular system. Another way of saying this is “Worst case scenario”.

As an example, let’s take the hospital’s electrical system: The risk assessment must assume a catastrophic failure of the entire system. The normal power system fails, and then the emergency power system from the generators fail. In other words, you have no power whatsoever in the building. Now, what is the level of risk to your patients? It will probably be Category 1, right?

You then do that type of catastrophic failure risk assessment for each of the above listed systems. If you want, you can break this down into different assessments of systems that are the same type. Such as HVAC systems: If the HVAC system fails in patient care areas, then that would be a certain high-level of risk to the patients. But if the HVAC system fails in the Administration wing, it would not be a risk to your patients, and it would be a low risk to your staff.

For hospitals, the expectation would be all of the above systems would be assessed as a Category 1 or Category 2. But for a medical building that only has physician offices and administrative support areas, the expectation is the above systems would be assessed as a Category 3 or Category 4. All healthcare facilities must be assessed for the risk level to patients and/or staff.

You have to document your assessment using a defined process. You can down-load a simple one-page risk assessment from my website and see if that meets your expectations.

The ironic thing is, the NFPA 99-2012 Technical Committee on Chapter 4 did not intend for this risk assessment to be conducted on existing systems. I talked with two members of that committee and they said the committee believed it was obvious the way it is written that this risk assessment is only required for new construction, since most (not all) of NFPA 99 is for new construction.

But CMS did not get that message and they require all of their state agencies and accreditation organizations to evaluate the risk assessment during all surveys. In other words; They fully expect all CMS certified healthcare organizations to have the Chapter 4 risk assessments completed by now.

In my opinion, this risk assessment does not require a lot of time to conduct. As I said, CMS expects all hospitals to have Category 1 or Category 2 systems. This is something you and your staff can do.

Just last week I received a call from a friend of mine who is a facility manager in the Midwest. He returned from a regional ASHE meeting where one of his fellow facility managers was recently surveyed by a leading accreditation organization (AO). The surveyor for the AO cited them for not doing their NFPA 99 risk assessment in accordance with the ASHE form, and do a room-by-room assessment. Please understand that this surveyor was incorrect to make that citation.

There is no NFPA requirement, no CMS requirement, and no AO requirement for healthcare organizations to do a room-by-room assessment to be in compliance with Chapter 4 of NFPA 99-2012. As mentioned above, you can use whatever risk assessment format you wish. The only requirement is the risk assessment must be documented and the surveyors will expect it to be reasonable (meaning all systems in a hospital are Category 1 or Category 2 systems).

Eye-Wash Risk Assessment

Q: Your articles on eye-wash station refers to the need to conduct a risk assessment. Where can I find such a document?

A: There is no set form to use for risk assessments. You can just get a group of stakeholders together and discuss the issue and the proposed solution and then write down what you discussed.

If you want a form that is based on the seven (7) steps recommended by The Joint Commission, go to my website, click on “Tools” and download the risk assessment form.

Environmental Tours

Q: I have read, or thought I read, that the environmental tours were no longer required with the adoption of the life safety code. Is this correct?

A: No… The NFPA codes and standards referenced by the Life Safety Code never did require environmental tours. When the 2012 Life Safety Code was adopted by CMS (and the accreditation organizations) last year, it made no changes regarding environmental tours because the 2012 LSC does not require it. The 2000 LSC did not require it either. Environmental tours are required… by the accreditation organizations (at least some of them). Joint Commission, HFAP and DNV all require that you evaluate your physical environment on a periodic basis. Some require semi-annually, and some only require annually. CMS does not have any Condition of Participation or standard that specifically requires a periodic tour of the physical environment, although they do require that your physical environment be maintained in a safe manner, which implies a routine inspection would be required to achieve that. So, if you’re accredited by one of the major accreditation organizations, you need to continue to perform environmental tours.

 

Immediate Jeopardy Decision?

Q: Our hospital has a room that is used for seclusion in a Behavioral Health unit. The door to this room is locked and it does not allow the patient to leave the room; only staff may release the door lock. Is this in any way an Immediate Jeopardy situation?

A: Not necessarily… Section 19.2.2.2.5.1 of the 2012 Life Safety Code allows doors to be locked in the path of egress where the clinical needs of the patients require specialized security measures or where the patients pose a security threat, provided staff can unlock the doors at all times. Clinical needs locks are permitted for use for psychiatric patients, dementia patients, Alzheimer’s patients and substance abuse patients. A seclusion room in a Behavioral Health unit would likely meet the definition for clinical needs locks, provided staff was watching the patient 24 hours/day.