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.


Medical Equipment Contractor

 Q: When I came into this new position the medical equipment program was run by a third party managing our own Bio-med technicians. We changed the 3rd party contractor and we still have a problem as far as the PM’s not being done by the new contractor (huge back log). We think with good reason that the hospital is at risk.   We put pressure on the contractor by mentioning our concerns regarding an upcoming accreditation survey, or the state public health department survey, and CMS (which could happen at any time), not to mention the safety of our patients. The contractor’s answer is we should not be concerned since the accreditation organization and CMS will accept the fact that we are “in transition” and that it is commonly accepted to experience a backlog in this type of situation. We asked them to provide documentation to support their position, but we have not heard anything yet. What are your thoughts?

A: I think that is faulty logic. There is nothing in the accreditation standards or the CMS CoPs that allows non-compliance based on a change in contractors. Either you are or you are not compliant. Most surveyors will not care why you’re not compliant.

It is likely that the contractor who told you this was provided misleading information. Perhaps they were part of a survey where the surveyor was benevolent said something like that. If so, then that is an individual surveyor’s preference and is not the policy of the accreditor or the CMS. The chances are you will have a surveyor in your upcoming survey who may be sympathetic, but still cite you if you’re not compliant.

Get cracking on that contractor… You’re the boss, not them.  If they fail to perform, withhold payment and find a new contractor, or better yet, use this situation as a validation to your leadership that you need to manage this important process in-house, and no longer have outside contractors manage your Bio-med services.

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.

Testing Requirements

Q: On annual testing requirements, how many days do you have on either side of the test date?

A: If the NFPA standard simply says the test is required ‘annually’, then that can be interpreted differently depending on the many different authorities having jurisdiction. I do know that CMS is okay with an ‘annual’ test requirement to happen once per calendar year, as long as you do not exceed 12 months. This means if you tested something on July 1, the next test may occur anytime between January 1 and June 30 the following year. You just cannot exceed 12 months between tests. But not all accreditation organizations (AOs) agree with that. They typically have a more restrictive requirement, such as ‘annual’ means 12 months from the previous test, and must be conducted during the 12th month. So, if you did the test on July 1, then you must do the next test between June 1 and June 30. Some AOs even have said 12 months from the previous test, plus or minus 30 days. But CMS has told them that they do not like the “plus 30 days” because that exceeds 12 months between tests. So that pretty much limits the test to 12 months from the previous test, minus 30 days.

But CMS has said in informal communications with the AOs that they will honor the NFPA 72-2010 3.3.106 definition of annual testing for fire alarm system components, which is no sooner than 9 months and no later than 15 months from the previous annual inspection/test. But there is no guarantee that the AOs will honor this. And, this only applies to fire alarm system testing… not any other feature of life safety.

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.

Changes to the 2018 Life Safety Chapter

A lot has been said and written concerning the changes that Joint Commission has made in regards to their Life Safety chapter for acute-care hospitals, and for good reason. CMS has been working with the accreditor to make changes and additions to bring the LS chapter up to their expectations. So far, it has been a long and arduous project, but we now have the results of Joint Commission’s hard work: The Life Safety chapter of the 2018 Comprehensive Accreditation Manual for Hospitals.

Nearly every standard in the new LS chapter has received some change or addition with their elements of performances (EPs). We have compared the new chapter to last year’s version and summarized all of the changes and additions found in the new 2018 chapter.

If you are interested in reading about all of the changes in a summary format, go to “Tools” on this website, and look for the “Changes to the 2018 Joint Commission Life Safety Chapter” subheading and down-load the free 9-page .pdf document that describes all of the changes that you need to know for 2018.


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.

Fully Sprinklered Buildings

Q: Our facility is a four story facility, and is a combination of different structures built in different years. All of the different structures are protected with sprinklers except for our power plant. Our power plant is 24 hours manned and has Fire Alarm System devices installed or equipped. Do we need to ask for a waiver as per the new NFPA 101 2012 edition that is to be implemented this year?

A: Existing healthcare occupancy buildings are not required to be fully protected with sprinklers. There is no requirement with the new 2012 LSC to install sprinklers in existing buildings (unless the building is a high-rise) so there is no need to ask for waivers.

Now, it is very desirable for healthcare occupancy buildings to be fully sprinklered because if they are, it allows you to do many terrific things. Take a look at the following 2012 Life Safety Code references, which describes the many advantages of having a fully sprinklered building:

  • – Delayed egress locks are allowed only if the entire building is protected with sprinklers or smoke detectors
  • – Capacity factors for egress components improve if entire building is sprinklered
  • 7.7.2 – No more than 50% of required exits may discharge through the level of exit discharge if area is sprinklered
  • – A hazardous area may not have to have 1-hour fire rated walls if protected with sprinklers (Note: This does not supersede section 18/
  • – Class C interior finishes are permitted in locations where Class B is permitted, and Class B interior finishes are permitted in locations where Class A is permitted, provided the area is protected with sprinklers. (Note: This does not supersede section 18/
  • – Class II interior floor finish is permitted in locations where Class I is permitted providing the area is protected with sprinklers.
  • 10.3.3 – Upholstered furniture must meet the requirements in accordance with NFPA 260 and NFPA 261, unless the furniture is located in rooms protected by sprinklers.
  • 10.3.4 – Mattresses must meet the requirements in accordance with Part 1632 of the CFR 16, and NFPA 267, unless the mattresses are located in a room that is protected with sprinklers.
  • – Lesser levels of Construction Types are permitted if the entire building is protected with automatic sprinklers.
  • Travel distances between any point in a room and the exit increases by 50 feet if the entire building is protected with automatic sprinklers
  • Hazardous areas are not required to be 1-hour fire rated if the walls are smoke resistant and area is protected with automatic sprinklers
  • – No interior floor finish requirements apply in smoke compartment protected with automatic sprinklers
  • – Areas open to the corridor are afforded exceptions if the smoke compartment is protected with automatic sprinklers
  • – Corridor walls are not required to be ½ hour fire rated provided they resist the passage of smoke and the smoke compartment is protected with automatic sprinklers.
  • – Corridor doors do not have to be 1 ¾ inch thick, solid-bonded wood core or of construction that resists fire for not less than 20 minutes provided they resist the passage of smoke and the smoke compartment is protected with automatic sprinklers.
  • – Smoke dampers are not required in fully ducted penetrations of smoke barriers provided both smoke compartments served by the barrier is protected with automatic sprinklers.

By the way, CMS will not consider a waiver request until such time the Life Safety Code deficiency has been cited in a report. So, don’t plan on submitting a waiver request until after you have been cited.

Decontamination Activation

Q: Is there a specific time-limit required by the accreditation organizations for decontamination purposes, from activation of a drill to being able to put victims through a decontamination tent?

A: While there is no specific standard which spells out the amount of time required to set-up a decontamination tent, the time-frame must be evaluated to determine its effectiveness.

The emergency management standards require an effective disaster plan which must be written and educated to the staff of the organization. These same standards require disaster drills that are evaluated by observers for effectiveness. The results of the drill observations must be relayed to the Safety Team which uses the information to improve the hospital’s capacity to respond to disasters. The whole disaster response process includes an on-going evaluation to determine the effectiveness of the organization’s emergency response efforts.

So, while the amount of time to set-up a decontamination tent and run your first patient through is not specified, the catch-all is it must be effective. You may ask who judges whether or not the amount of time is effective? First, the hospital makes that determination but ultimately, the surveyor may make a judgment on that as well. If a surveyor decides that the amount of time to set-up a decontamination tent is too long, then that can lead to a finding.

The bottom line: Run a disaster drill which includes setting up the decontamination tent, and make an evaluation of the time it took from the start of the drill to when a patient can first use the tent. Report that process to your safety committee, and have them decide if it is an adequate amount of time. If the safety committee decides it is adequate, then there is a good chance the surveyor will view it the same.