Fire/Smoke Damper Drawings

Q: A California Life Safety Code surveyor enforcing the 2012 edition of the LSC asked for a map of all of the smoke and fire dampers in the building (skilled nursing home) and threatened a deficiency if one could not be produced. I have been searching for the 2012 LSC and cannot find any such reference to this specific requirement. I have not heard of this before. Can you shed any light on this matter?

A: Yes, I can understand the surveyor’s request, although threatening you with a citation seems a bit much.

The surveyor’s position is: How can you effectively maintain all of your fire/smoke dampers if you do not know where they are located? Having them documented on a drawing is logical in that you can then properly maintain the dampers. Without having them documented on a drawing, the chance is great that you would miss one or more dampers and they would not be tested.

But, to be sure, there is no standard that requires you to have drawings showing the locations of all fire/smoke dampers. But if you provide a test report that says you tested 25 dampers, how do you know where these 25 dampers are located, and you don’t have more than 25, and you got them all tested? I can see the surveyor could cite you with a finding that would read something like this: “The organization failed to provide evidence that all fire and smoke dampers were properly tested.”

But I don’t approve of surveyors making threats… that is just unprofessional.

Why ambulatory surgery centers need a compliance plan

According to the National Health Care Anti-Fraud Association (NHCAA), healthcare fraud financial losses are in the tens of billions of dollars each year. A conservative estimate is 3% of total health care expenditures, while some government and law enforcement agencies place the loss as high as 10% of our annual health outlay, which could mean more than $300 billion1.

Beginning in the mid-1990s, many healthcare providers were encouraged to develop and implement compliance plans. While many hospitals and large healthcare systems followed this guidance, many ambulatory surgery centers did not. As a result, those centers may unknowingly be at risk.

But the good news is that it’s never too late to implement a compliance plan. It doesn’t have to be expensive or time-consuming; in fact, there are simple and inexpensive steps that facilities can take to promote compliance and develop strategies2 that will keep your organization safe in the long run.

Choose who will develop the plan.

There are to options for establishing your plan: you can hire a consultant, like Compliance One Group, to develop it for you or you can prepare one yourself. The latter may be appropriate for smaller ASCs that have tighter operating budgets. If you choose to develop the plan yourself, you then have a couple of options: buying a ready-made, off-the-shelf product or starting from scratch. While a pre-developed plan may seem like a good idea at the time, keep in mind that your plan needs to be customized for your facility. Filling in the blanks of an off-the-shelf product will not be effective. 

Perform a facility audit. 

When it comes to audits, there are two that should be conducted: a standards and procedures audit to assess how well you are complying with regulatory requirements and a claims submission audit to examine the claims development and submission process from patient intake through to submission and payment of claims. 

However, these audits are not one-and-done; ASCs should re-audit annually to measure the success of the plan.

Write the plan.

Once you have performed your audits and have a thorough understanding of what your problem areas are, you can begin establishing your compliance plan. 

A standard compliance plan includes:

  • Overview of applicable federal and state laws
  • Duties and responsibilities of the Chief Compliance Officer
  • Acknowledgment form, signed by each owner and employee
  • Code of Conduct, applicable to owners, board members, and employees
  • Corporate compliance checklist
  • HIPAA compliance plan

If you would like to discuss how our team can assist you with effective compliance planning, leave me a message by clicking here.


Resources:

1 https://www.nhcaa.org/resources/health-care-anti-fraud-resources/the-challenge-of-health-care-fraud/

2 http://www.outpatientsurgery.net/issues/2002/05/why-ascs-need-a-compliance-plan

Direct Visual Observation Required in Emergency Department

Q: If an Emergency Department is greater than 7500 square feet but less than 10,000 square feet and is deemed to have “sleeping accommodations”, do the requirements of direct visual observation per 19.2.5.7.2.1(D)(1)(a) apply since only “sleeping accommodations” are provided and not a full “patient sleeping room”?

A: According to CMS, the answer is yes. They consider an Emergency Department that provides observation beds to be sleeping accommodations and must comply with healthcare occupancy sleeping suite requirements, and all that is required. They also consider the patient as ‘inpatients’, which seems to be contrary to the what the rest of the world believes.

See if you can do one of the following:

  • Eliminate the ‘observation beds’
  • Relocate those ‘observation beds’ to a regular inpatient unit
  • Divide your ED up into multiple suites to get around the direct observation requirement for sleeping suites over 7500 square feet.

Corridor Doors

Q: A deficiency was found by CMS on a recent survey that stated ‘staff failed to provide a safe and hazard free environment by not having all doors protecting corridor openings ready to close without impediments’. The finding was repeated three separate times as doors to a patient room could not be closed due to obstructions/impediments. In all three instances, the rooms were vacant, being used for storage, and had either a chair or waste basket blocking the door. Although we have regularly explained away this finding with Joint Commission surveyors as being an item we train our staff on (to move obstructions in patient room doorways in case of fire while closing all doors as directed by our fire plan) the CMS surveyor listed it as a deficiency and was not satisfied with our answer. Does this seem like a reasonable action to you? The rooms were vacant, and there were no patients in the rooms! Why would the CMS surveyor care if the doors closed or not? Do I have to attempt a zero-tolerance approach to this deficiency for all patient room doors (which would seem to be futile) or just enforce the regulation for vacant rooms only?

A: Corridor doors must close and latch at all times in the event of an emergency. Even corridor doors to vacant patient rooms used for storage. I believe by what you have described, that the CMS surveyor was correct and justified in citing any corridor door that could not close. If there was an impediment blocking the door, such as a chair or a waste receptacle preventing the door from closing, then that is a deficiency.

Here is the reason why… In an emergency, staff must quickly go through the unit and check rooms and close doors. If there is an impediment to quickly closing the doors, and the staff had to move a chair or a waste receptacle, then that slows down the process. The concept of the corridor door is to separate the room from smoke and fire in either the corridor, or the room. If an impediment prevents the door from closing, then smoke and fire can enter the patient room and then the patient is in serious trouble.

You must enforce maintaining the corridor doors free from impediments to close them throughout your entire hospital, on units that are occupied and units that are not. I do not agree with your comment that seeking a zero-tolerance on this issue would seem futile. On the contrary, nurses have a very keen respect for patient safety, and if you explain keeping corridor doors free of impediments is patient safety, then I’m sure they will buy into that and keep the doors clear.

I’m a bit concerned that you are using vacant patient rooms for storage. Be VERY careful with that. If there are any combustibles stored in those patient rooms, you have a big problem. The room would have to comply with section 43.7.1.2 (2) of the 2012 LSC on hazardous rooms. I would suggest you do not store any combustibles in vacant patient rooms.

ASC Waiting Area

Q: I am looking at a hospital facility with an Ambulatory Surgery Center in an existing building that is a Business Occupancy and construction type – II (222). We are working to separate the Ambulatory Surgery Center from the other business in the building with a two-hour fire rated partition. The waiting area, which is adjacent to the lobby/elevator area is enclosed by glass. Can we leave the waiting area out of the Ambulatory Surgery Center and make the separation behind the waiting area? This would be just separating the Ambulatory Surgery rooms and recovery area from the rest of the building (i.e. enclosed by a two-hour fire-rated wall).

A: No… I believe you are not permitted to do that. Actually, the LSC does not address this, but the CMS Conditions for Coverage (CfC) does address this. According to CMS Conditions for Coverage §416.44(a)(2), the ASC must have a separate recovery room and waiting area.

The Interpretive Guidelines for §416.44(a)(2) says this about waiting rooms:

The ASC is required to have both a waiting area and a recovery room, which must be separate from each other as well as other parts of the ASC. They may not be shared with another healthcare facility or physician office. (See the interpretive guidelines for §416.2 concerning sharing of physical space by an ASC and another entity.)

While the CfC does not specially say the waiting area must be inside the fire-barriers surrounding the ASC, if the waiting area was outside of these boundaries the surveyors could conclude that the waiting area is shared with other another healthcare facility or physician office.

I suggest you make sure the waiting area is inside the fire-rated barrier separating the ASC from the other entities.

New vs. Existing Construction

Q: How do we classify existing versus new construction? Do we look at the date of adoption of the current Life Safety Code as the cutoff? Anything constructed before that date is considered existing construction? The 2000 LSC required areas of major rehabilitation to be classified as new construction. The 2012 LSC appears to just require those areas be fully sprinklered. On our Life Safety plans all areas of the hospital were constructed prior to the adoption of the 2012 Code. Can the entire hospital now be considered existing and can we remove all notes on the plans referring to new construction?

A: According to the CMS Final Rule on adopting the 2012 Life Safety Code which was released in May, 2016, they identified July 5, 2016 as the threshold date to differentiate between new construction and existing conditions. However, the 2012 Life Safety Code says in section 4.6.12.1 that whenever a feature of life safety is required for compliance, it must be maintained as such for the life of the building. Section 4.6.12.2 continues to say that features of life safety shall not be removed or reduced where such features are required for new construction.

What this means, is you cannot down-grade a feature of life safety that was installed under new construction requirements, to meet existing condition requirements now that it is no longer considered new construction. It is true that something built prior to July 5, 2016 is now considered existing conditions, but you still are not permitted to down-grade the feature to meet existing condition requirements.

Smoke Door Testing?

Q: The Joint Commission standard for annual door testing states “The hospital has written documentation of annual inspection and testing of door assemblies by individuals who can demonstrate knowledge and understanding of the operating components of the door being tested”. The Joint Commission also references NFPA 105 (smoke doors). Would this include all smoke barrier doors?

A: It appears you have an older copy of the Joint Commission standards. In January, 2019, the standard in which you refer has been changed to specifically identify the need to inspect and test fire door assemblies. Their note to this standard says nonrated doors including smoke barrier doors are not subject to the annual inspection and testing requirements of either NFPA 80 or NFPA 105.

It is the position of CMS and all accreditation organizations that non-rated doors in smoke barriers (barriers that separate smoke compartments) do not have to be inspected on an annual basis.

Here is why: Even though section 7.2.1.15.2 of the 2012 LSC says (in part) smoke door assemblies need to be tested, that conflicts with the occupancy chapter for healthcare. Section 4.4.2.3 says when specific requirements in the occupancy chapters differ from the general requirements contained in the core chapters, the occupancy chapter shall govern. Section 19.3.7.8 says doors in smoke barriers shall comply with section 8.5.4. Section 8.5.4.2 says where required by chapters 11 -43 doors in smoke barriers that are required to be smoke leakaged-rated, must comply with section 8.2.2.4 (which requires testing).

Chapters 18 & 19 (healthcare occupancies) do not require smoke doors to be smoke leakaged-rated: Therefore, smoke barrier doors do not have to be tested in healthcare occupancies. Now… you may have an AHJ that believes differently. You may show them this code trail and perhaps they will allow you to not test your smoke doors, but ultimately they are an authority and if they say you have to test smoke doors, then you have to test smoke doors. But it is not required in healthcare occupancies according to the 2012 LSC.

NFPA 99 Risk Assessment

Q: A question came up concerning the NFPA 99 (2012) Risk Assessment. Does this only pertain to new construction or does it pertain to existing buildings also? Our company has never had an assessment done in the past but it is my understanding that it became a requirement in 2016. The CMS has established compliance requirements (K Tag) for risk assessment and its completion. Who would be the qualified personnel to perform this procedure and create a formal and documented risk assessment?

A: According to members of the Technical Committee who wrote the new Chapter 4 in NFPA 99-2012, the original intent was the risk assessment only applies to new construction. However, the way chapter 4 is written, it is not clear that the risk assessment is only applicable to new construction.

CMS has instructed the accreditation organizations and the state agencies who survey on the behalf of CMS to require all hospitals to have completed their NFPA 99 risk assessment for new as well as existing construction. Therefore, hospitals must conduct the risk assessment for new and existing conditions. These assessments are not difficult to do and only takes a few minutes.

There is no requirement to make a room-by-room assessment, but the intent is to assess the risk of the entire system if it were to fail and there were no back-up systems. It would stand to reason that most hospital systems would be Category 1 or Category 2. Anyone may conduct the assessment, but would have to have knowledge of the risk assessment process and knowledge of the facility.

Risk Assessments

Q: In regards to risk assessments, would you base a risk level to include having any additional controls in place for each item assessed, or do you place the risk level on the impact to patients/staff assuming the item being assessed would not be available or functional? We are performing a risk assessment on facility systems and medical equipment and are wondering what the standard is in the approach.

A: It sounds like you’re referring to the NFPA 99-2012 risk assessment for building system categories. If so, then the assessment is conducted with the assumption of the worst-case scenario, whereby the systems being evaluated fail and back-up systems (i.e. emergency power generators) fail as well. According to section A.4.1 of NFPA 99-2012, the category definitions apply to equipment operations and are not intended to consider intervention by caregivers or others. Also, the Introduction to Chapter 4 in the NFPA 99-2012 Handbook, the authors say:

“Each system must be evaluated for its impact on both the patients and the caregivers if the system should fail. Based on the worst-outcome scenario of a failure’s impact, the system is assigned a category. The chapter on that system the describes the requirements for the selected category.”

Be aware that the chairman of the Technical Committee who wrote this new chapter 4 for NFPA 99-2012 told me the intent was for the risk assessment to be on new equipment only, and existing equipment was exempted. However, chapter 4 of NFPA 99-2012 does not say that, and CMS is requiring all certified hospitals to have this risk assessment conducted on existing equipment as well as new. So, I recommend to my clients to do the assessment (it only takes a few minutes) on all existing and new equipment until such time CMS changes their minds.

Blanket Warmers

Q: Is there a code for blanket warmers, towel warmers and such equipment that is used in a medical setting? Since they have a heating element would it be the same as having a space heater?

A: No… Portable space heaters are regulated by section 19.7.8 of the 2012 LSC. Blanket warmers are not regulated by the LSC.

However, blanket warmers are unofficially regulated by the accreditation organization and by CMS. While there are not specific standards that address blanket warmers, surveyors will expect the hospital to regulate their blanket warmers via their own policies. The hospital is expected to have a policy that sets the maximum temperature that the blankets may be. Usually, the maximum temp is set at 130 degrees F. Anything over that will likely be scrutinized by a surveyor.

Blanket warmers are considered medical equipment and must be included in the medical equipment inventory, and they must be maintained in accordance with the manufacturer’s recommendations.