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.

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.

Response to a Recent Post

The following is a response I received from a reader after my posting on April 3, 2018 titled Lawmakers Want More Oversight on AOs. This reader put into words the feelings and emotions of hundreds (if not thousands) of concerned healthcare workers on the subject of over-regulation by the government.

Today’s message makes retirement look sweeter and sweeter. I love my job and for 35 years I have loved taking care of patients and staff from the Plant Ops seat. The last 5-10 years has been harder as the Code enforcement has gotten pickier and more involved in minutia. Your posting today is a virtual death knoll for attracting good qualified younger engineers and mechanics into our business, why would someone want to come into an industry where common sense is treated with absolute disrespect? We’ve taken smoking out of buildings, sprinkled most everything, you can’t find hospital fires in the literature yet we still treat +1/8″ gaps as death traps. Sprinkler piping is designed to support weight well in excess of the piping and water yet one cable on a pipe is a finding? The 1/4″ extra distance on the projection will result in more money being spent with no added value. Even your recent post about data closets and gaps around the conduit through the ceiling tile stretches the imagination about how much smoke or heat will bypass a detector or sprinkler head.

 I looked at the ASHE agenda for Seattle and I didn’t see anything there where we as a group are ready to say either “I’m mad as hell and I’m not going to take it anymore” or “Calling BS” on this. Thanks for the opportunity to rant, this is the most discouraged that I have ever been about what we do.

Lawmakers Want More Oversight on AOs

In a letter to CMS Administrator Seema Verma, the committee on Energy and Commerce is asking for what could be reams of information from the agency about patient harm and incidents of misconduct at acute care hospitals. The committee has also asked for similar information from each of the four hospital accrediting organizations (AOs).

The committee was particularly concerned about information in a report to Congress published last summer that indicated AOs “conducting hospital surveys did not report 39% of ‘condition level’ deficiencies that were subsequently reported following validation surveys conducted by [CMS] State Survey Agencies no later than 60 days following the AO survey.”

“Although CMS has worked to strengthen its oversight of AOs, the committee is concerned about the adequacy of CMS’ oversight as well as the rigor of the accrediting organization survey process,” wrote the committee leaders.

Noting that the Department of Health and Human Services, through CMS, must provide oversight of accrediting organizations, including CMS’ own survey agencies, “the Committee is concerned about the adequacy of CMS’ oversight as well as the rigor of the AO survey process,” read the letter to Verma.

You can view a copy of this letter at this link: https://energycommerce.house.gov/wp-content/uploads/2018/03/20180309CMS.pdf

In 2017, approximately 67% of the surveys performed by HFAP and The Joint Commission received a Condition Level Deficiency in the Life Safety or Environment of Care chapters. This percentage of Condition Level Findings was up in 2017 compared to 2016. How much more does the committee expect the AOs to cite Condition Level Findings?

What does all of this mean for the future…? From my point of view, I believe you will see CMS tighten their reigns on the hospital AOs such as Joint Commission, HFAP, DNV-GL and CIHQ…. especially on issues of Life Safety, Environment of Care, and Emergency Management. The reason for this is based on the high disparity rates that most of the AOs have when compared to state agency validation surveys in the area of Life Safety.

Many observers have said that the method CMS uses to compare the efficiency of findings between the AOs and the state agencies is unfair based on the state agencies allowed to have more LS surveyors for more days on their surveys than the AOs.

I also claim that not all surveyors are the same: Most AOs hire current or former hospital facility managers who are operation minded. So they will focus on Life Safety issues pertaining to operations, such as corridor clutter, obstructions to doors and medical gas valves, etc. On the contrary, most state agencies surveying on behalf of CMS hire architects and engineers as LS surveyors, who focus on design issues (such as construction type and egress capacity) and mechanical systems (such as fire alarm systems and sprinkler systems).

Just because the surveyors have different backgrounds does not make them right or wrong: But it does make them different. So naturally, state agency surveyors will gravitate to cite deficiencies that are more along their specialty. And AO surveyors will do likewise. There will always be a disparity when the survey teams are different. To prove that point, the high disparity rate of AO findings compared to state agencies findings, is just as high when you make the comparison the opposite way: When you compare state agency findings to AO findings. The point is…. it is normal to have a high disparity rate when there are so many variables in the mix.

I don’t see this ever being fixed in my lifetime… The people in power seem to be too stubborn to acknowledge this issue and take appropriate action to resolve it. In the mean-time, I foresee CMS cracking down even harder on the AOs to cite even more findings, which will result in tougher Life Safety surveys.

What’s the Standard?

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.

Hazardous ER Department

Q: In a hospital emergency department, can the corridors be 6 feet wide? Can the hospital install an 18-inch deep lockable computer cabinet in the 8 foot ED corridor?

A: Well… It depends.

If you claim the ER is a suite, then there would be no problem with a cabinet in the 8-foot wide hallway…. Because there are no corridors in a suite. What looks like a corridor in a suite is a communicating space and you would only have to maintain 36-inches clearance for aisles.

But if the ER is not a designated as a suite, then you must maintain corridor widths. But the required width of the corridor is different depending on the occupancy classification of the ER. CMS has said that Emergency Departments must be classified as healthcare occupancies (HCO) if the ER has patient observation beds. CMS’s logic on this is if patients are under observation in the ED, then they consider this patient sleeping accommodations. In this logic, then all areas providing patient sleeping accommodations must be healthcare occupancies, and the required width of the corridor must be 8-feet.

However, CMS does permit the Emergency Department to be classified as an ambulatory health care occupancy (AHCO) if the ER does not contain any patient observation beds. Then the corridor width is only required to be 44-inches wide.

But keep in mind, the maximum corridor projection permitted by CMS is 4-inches. If your ER is not designated as a suite, then you must maintain corridor widths (either HCO widths of 8-feet, or AHCO widths of 44-inches) and you cannot have corridor projections more than 4-inches, and the cabinet would not be permitted.

CMS Waiver Approval

Q: If a building changes ownership, do waivers stay active with their 1-year window or do the new owners have to resubmit if the building is cited the same deficiency?

A: Interesting question… I’ve never had this issue come up before.

My guess would be the waivers would be valid only to the organization for which they were approved. The way that CMS writes their approval letters is the approval of the waiver is addressed to the healthcare organization, and not to the building owner. In other words, CMS grants approval to the healthcare organization to not have to comply with a particular section of the Life Safety Code. This approval would not appear to be transferrable, since it is addressed to the healthcare organization.

But if the ownership of the healthcare organization changes hands, then I could see where the waiver approval would follow the healthcare organization. CMS tracks the waiver requests and the subsequent approvals via their own CMS Certification Number (CCN), which is assigned to healthcare organizations, not their owners.

To answer your question, if a deficiency is cited and the healthcare organization chooses to submit a waiver request rather than resolve the deficiency, then yes, a new waiver request would have to be submitted.

 

Power Strips

Q: There is so much discussion on the proper use of power strips that it can cause confusion amongst even the seasoned facility managers. There is absolutely no guarantee that the different power strips will remain in their ‘designated areas’. The OR is much easier to control, but as technology quickly progresses, the space between patient care vicinities and non-patient care vicinities quickly losing the defined lines. What’s your thoughts on the power strip issue?

A: I do see your point that power strips may be difficult to control as they may move around the hospital, in and out of patient care vicinities. And I respect your comment that there is confusion on the proper use of power strips. But I find CMS’ explanation regarding power strips under their K-Tag 920 to be refreshingly simple:

  • Power strips in a patient care vicinity are only used on movable patient-care related electrical equipment and are permanently attached to the equipment, and are UL 1363A or UL 60601-1.
  • Power strips in a patient care vicinity may not be used for non-patient-care related electrical equipment, such as personal electronics, except in long-term care resident rooms that do not use patient-care related electrical equipment.
  • Power strips for patient-care related electrical equipment must meet UL 1363A or UL 60601-1.
  • Power strips for non-patient-care related electrical equipment in the patient care rooms, but outside of the patient care vicinity, must meet UL 1363.
  • In non-patient care rooms, power strips meet other UL standards.

Section 3.3.139 defines “patient care vicinity” as a space, within a location intended for the examination and treatment of patients, extending 6 feet beyond the normal location of the bed, chair, table, treadmill, or other device that supports the patient during examination and treatment and extending vertically to 7-foot 6-inches above the floor.

It appears K-Tag 920 is permitting qualified personnel to permanently attach UL 1363A or UL 60601-1 power strips to movable patient-care related electrical equipment, provided it meets section 10.2.3.6 of NFPA 99-2012, which is:

  • The power strip is permanently attached to the equipment assembly;
  • The sum of the ampacity of all appliances connected to the outlets does not exceed 75% of the ampacity of the flexible cord supplying the outlets;
  • The ampacity of the flexible cord is in accordance with NFPA 70-2011, National Electrical Code.
  • The electrical and mechanical integrity of the assembly is regularly verified and documented.

This section does not explain what makes one “qualified”, so that determination should be left to the AHJ and the healthcare facility. While NFPA 99-2012 does not specify how frequent “regularly verified” means, the general consensus is annually, based on annual receptacle inspection requirements in Chapter 6.

You will note that section 10.2.3.6. (5) was deleted per Tentative Interim Amendment (TIA) 12-5.

K-Tag 920 is also clear that outside of a non-patient care room (i.e. OR, PACU, procedure room, patient sleeping room, etc.) CMS no longer regulates which UL power strip to use on non-patient-care related electrical equipment, other than it must be UL listed. That means a power strip used at a nurse station on office equipment, or in an office environment does not have to be UL 1363, UL 1363A, or UL 60601-1; it just has to be UL listed.