Clarifications Part 1

I’m going to post some clarifications of surveyor findings that I wrote recently for a client. Some were accepted by the accreditor and some were not. I thought you might be interested in the approach and outcome.

clarification[1]

Clarification for EC.02.03.01, EP 1

EC.02.03.01, EP 1: The hospital minimizes the potential for harm from fire, smoke and other products of combustion.

Surveyor finding:

In the Main Building near the utility room+ two open electrical junction boxes did not have covers.

In the Main Building near the elevator located on second floor an electrical junction box did not have a cover.

 Clarification:

Who: The Director of Facilities is responsible for the implementation and compliance of the safety management program at XYZ Hospital.

What: The Safety Management Plan clearly identifies the mission to provide a safe and secure environment for our patients, visitors and staff. The Facilities Department conducts routine and non-routine inspections and surveillance throughout the facility, identifying safety and security related issues that need to be resolved. These inspections are documented and reported to the health system’s Safety Committee for their review and consideration.

When: The Safety Management Plan is reviewed annually and presented to the health system’s Safety Committee for their approval. As recently as November 1, 2013 the Safety Management Plan was reviewed and approved by the Safety Committee along with the annual evaluation of the plan. The annual evaluation of the Safety Management Plan was found to be effective, based on quantitative criteria.

How: The Safety Management Plan is shared with all members of the health system through the intra-net, Safety Manuals and through direct conversations with key leaders in the organization.

Why: The element of performance in which the surveyor entered his finding is under the standard that requires the hospital to manage fire risks. The element of performance itself requires the hospital to minimize the potential for harm from fire, smoke and other products of combustion. The fact that a cover was missing from an electrical junction box does not constitute a “potential for harm from fire”. None of the electrical wires or their connections were bare or in any way capable of producing sparks which could lead to a fire situation. All of the wires were properly coated with insulation, and their connections were properly terminated with secure wiring methods. There was no potential for harm due to electrical shock.

All of the junction boxes identified by the surveyor are located above the ceiling and away from any contact with patients, staff and visitors. The wires were neatly tucked into the box and were not protruding out beyond the limitation of the electrical box, which could potentially cause a problem. In his finding the surveyor did not identify a “potential for harm from fire, smoke, and other products of combustion”. It is the position of XYZ Hospital that there was no “potential for harm from fire, smoke or other products of combustion” in regards to the electrical junction boxes observed by the surveyor at the time of the survey. Therefore, XYZ Hospital respectfully requests that The Joint Commission vacate this finding under EC.02.03.01, EP 1, and consider this standard to be ‘Compliant’.

 

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Result?  Clarification was not accepted. [Sometimes you just have to take your shot and hope.]

Keep track of the results with me: Accepted 0: Not Accepted 1

 

Risk Assessment

images[11]A surveyor recently cited an organization for having potential suicide hanging points in a behavioral health unit, in the form of door hinges and other hardware issues in the patient sleeping rooms. While I do not believe that anyone is questioning the reality of the potential suicide hanging points that door hardware may offer, a finding on this issue is not always warranted.

You can’t have a hospital without a certain amount of risk to the patient’s safety. It’s the nature of the beast. It has been said that the process of accreditation is the ability to reduce risk, but not necessarily to eliminate risk. In Joint Commission’s standard EC.02.01.01, EP 1, an organization has the responsibility to identify safety issues in the environment. The note after the EP says: “Risks are identified from internal sources such as ongoing monitoring of the environment, results of root cause analysis, results of annual proactive risk assessments of high-risk procedures, and from credible external sources such as Sentinel Event Alerts.”

This note states that risk assessments are “ongoing” and conducted at least annually. Therefore, in the case mentioned above about the door hardware being a potential suicide hanging point, before the surveyor decides to enter a finding in the survey report he/she should ask the organization if they have a Risk Assessment on that particular safety risk. If you do have a documented risk assessment, provide it for the surveyor to review. The surveyor will determine if the mitigation factors identified in your risk assessment are acceptable. This is one of those areas where the surveyor gets to make a judgment, and determines if your risk assessment mitigates the risk to the patient.

If the surveyor determines that your risk assessment does in fact mitigate the risk to the patient (remember: this is their judgment call) then no finding is scored in the survey report. However, if your organization does not have a risk assessment on that issue, or if your risk assessment does not mitigate the risk to the patient (in the surveyor’s opinion), then the surveyor will likely enter a finding under EC.02.01.01, EP 1 or EC.02.06.01, EP 1 for an unsafe environment.

Once your organization has conducted a risk assessment, it is not a “one and done” issue; meaning you need to review the safety risks to the patients periodically. The phrase “ongoing” in the note for EC.02.01.01, EP 1 means you need to do the risk assessment over and over on the same issue, because something in the physical environment may change and the factors that mitigated the risk to the patient may not be present anymore.

How often do you need to do a risk assessment? The note for EC.02.01.01, EP 1 says annually, but a surveyor may expect you to do one more often depending on the severity of the risk to the patient and the mitigating factors.

There is no specific form or template a risk assessment must be documented on. As long as the risk assessment is documented and dated, then it qualifies. Risk assessments can be in the form of a written narrative report of a special task force formed to review the risk; or they may be in the form of a template with specific discussion points. It doesn’t matter what format your organization chooses to use – just that you do assess the risk of a safety issue.[NOTE: To download a free copy of a Risk Assessment template, go to “Tools” and click on “Risk Assessment”.]

It is considered “best practice” that the risk assessment is conducted with a group of stakeholders, such as:

  • Manager of the unit
  • Safety officer
  • Risk manager
  • Facility manager
  • Security manager
  • Administrative representative
  • Environmental services manager
  • Infection control practitioner

The purpose of the multiple individuals is to get a rounded diversified opinion concerning the risk and the mitigation factors. While it is not a requirement, I would advise you to send the completed risk assessment to your Safety Committee for their review and approval, and get the results of the risk assessment entered into their minutes.

Changes to Joint Commission Standards for 2014: Part 1

calendar_quarterly[1]Joint Commission has announced a couple of subtle, yet far-reaching changes to their standards to become effective January 1, 2014. One of them has to do with how they define time, and the other…. well we will discuss that in a later posting.

Currently, Joint Commission defines the period of time between required activities, such as testing and inspecting, to be as follows:

  • Weekly, or ‘every 7 days’:   Anytime during the week
  • Monthly, or ‘every 30 days’:   Anytime during the month
  • Quarterly, or ‘every 3 months’:   Anytime during the quarter
  • Semi-annually, or ‘every 6 months’:   6 months from the previous activity, plus or minus 20 days
  • Annually, ‘every 12 months’:   12 months from the previous activity, plus or minus 30 days
  • 3-Years:   36 months from the previous activity, plus or minus 30 days

The change beginning in 2014 involves Quarterly and 3-Year intervals. Now, Joint Commission will define Quarterly as follows:

Quarterly, or ‘every 3 months’:   3 months from the previous activity, plus or minus 10 days.

This change has far-reaching consequences, especially for fire drills. When I was a safety officer at the hospital where I worked, I was responsible for fire drills. Now, I will tell you that I did not enjoy conducting fire drills, as most of the people that participated in the drill, complied only because they had to, and they considered it a major inconvenience to their daily routine. My staff and I understood the importance of doing fire drills, but we were pretty much the only ones. Therefore, since I didn’t enjoy doing fire drills, I tended to ‘put them off’ or procrastinate in doing them, until the last days of the quarter. I was not as organized in doing them as I should have been.

If other hospital safety officers are like me, then this new change in how Joint Commission defines “Quarterly” will be a serious issue. They will have to develop a specific schedule of doing the drills in accordance with the new description, and be disciplined enough to stick with it. This will require organization skills. Make note of this and if you are not the individual responsible for fire drills in your organization, then send this post to the person who is.

Also, this affects all other quarterly testing and inspection activities, such as:

  • Waterflow switches
  • Supervisory signal devices (not tamper switches)
  • Off-premises monitoring transmission equipment (usually conducted with the fire drill)
  • Fire department connections (FDC)

During a recent webinar sponsored by ASHE, George Mills of the Joint Commission explained that this change in how they defined “Quarterly” came from another department and he unsuccessfully argued against the change.

The other change in how Joint Commission defines time between testing and inspection activities is the 3-Year test. It will now read as follows:

3-Years: 36 months from the previous activity, plus or minus 45 days

This is a change from “plus or minus 30 days” and can only be considered a positive for the facility manager. What is strange about this issue, is I heard George Mills says “pus or minus 45 days” for 3-Year testing intervals a couple of years ago at an ASHE annual conference, so I advised my clients as such. Then, last year when one of my clients went 36 months, plus 40 days between the 3-Year generator load test, the surveyor cited them for non-compliance. We wrote a clarification on the finding saying plus or minus 45 days was acceptable, and Joint Commission denied it. So, I’m glad they finally made a decision and let’s hope they stick to it.

Next week’s posting: We will discuss the changes to the monthly generator load testing.

 

CMS Issues New Categorical Waivers for the LSC

CMS just issued another S&C memo describing the process for hospitals and nursing homes can take advantage of additional categorical waivers for some of the new 2012 Life Safety Code issues right away, instead of waiting another year or so when CMS finally adopts the new LSC. I have copied it word-for-word for you in this blog and it is rather lengthy, but I wanted you to know that it is available for you to use right away, and what it says.

Watch for future posts on the blog for specifics on each issue.

CMS Logo 2

 

 

 

 

 

Center for Clinical Standards and Quality /Survey & Certification Group

Ref: S&C: 13-58-LSC

DATE:           August 30, 2013

TO:                 State Survey Agency Directors

FROM:           Director, Survey and Certification Group

SUBJECT:    2000 Edition National Fire Protection Association (NFPA) 101® Life Safety Code (LSC) Waivers

Various regulations governing certain certified providers and suppliers require compliance with the 2000 edition of the NFPA 101: LSC.  The LSC establishes minimum requirements for the design, operation, and maintenance of buildings and structures to protect individuals from fire and related hazards.

As allowed by the regulations at §482.41(b)(2), §485.623(d)(3), §483.70(a)(2), §416.44(b)(2), and §418.110(d)(2), CMS may waive specific provisions of the 2000 edition of the LSC in hospitals, critical access hospitals, long-term care facilities, ambulatory surgical centers, and inpatient hospice, which, if rigidly applied, would result in unreasonable hardship upon a provider or supplier, but only if the waiver does not adversely affect the health and safety of patients or residents.  CMS has determined that the 2000 edition of the LSC contains several provisions that may result in unreasonable hardship for providers/suppliers, for which an adequate alternative level of protection may be achieved.  Accordingly, CMS is making available several categorical waivers to new and existing providers and suppliers subject to the LSC.

Waiver Process

Providers and suppliers that want to take advantage of one or more of the categorical waivers identified below must formally elect to use one or more of the waivers and must document their election decision.  If a provider/supplier conforms to the requirements identified for each categorical waiver elected, it will not need to apply specifically to CMS for the waiver, nor will it need to wait until being cited for a deficiency in order to use this waiver.  At the entrance conference for any survey assessing LSC compliance, a provider/supplier that has elected to use a categorical waiver must notify the survey team of this fact, and that it meets the applicable waiver provisions.  It is not acceptable for a healthcare facility to first notify surveyors of waiver election after a LSC citation has been issued.

The survey team will review the provider’s/supplier’s documentation electing to use one or more of the categorical waivers and confirm it is meeting all applicable categorical waiver provisions.  This will ensure an adequate level of protection is afforded.  The waiver(s) elected by the provider/supplier must be described under Tag K000.  Categorical waivers do not need to be cited as deficiencies nor do they require Regional Office approval.  Therefore the applicable field on the Form CMS-2786 should be marked as “Facility Meets, Based Upon, 3. Waivers.”  If the survey team determines that the waiver provisions are not being met, the provider/supplier will be cited as a deficiency under §482.41(b)(2), §485.623(d)(3), §483.70(a)(2), §416.44(b)(2), or §418.110(d)(2), as appropriate.

Categorical Waivers Available:

 1.      Medical Gas Master Alarms

The 1999 NFPA 99, Health Care Facilities Code is cross-referenced in the 2000 LSC and, as a result, it contains requirements applicable to providers and suppliers who must meet the 2000 edition of the LSC under our regulations.  The 1999 NFPA 99, sections 4-3.1.2.2(b)(2) requires medical gas master alarms to be located in two separate locations and section 4-3.1.2.2(a)(9) does not allow a centralized computer as a substitute for any medical gas alarm panel.  The use of computers to continuously monitor critical signals has increased in health care facilities and the use of computers to monitor medical gas can improve surveillance and shorten response time.  As a result, the 1999 NFPA 99 provision required under the 2000 LSC is not only outmoded and unduly burdensome to providers and suppliers, but also arguably less efficient in promoting fire safety.    As a result, in the 2005 edition of NFPA 99, the NFPA began to permit a centralized computer system to be substituted for one of the master alarms, and this policy is continued in section 5.1.9.4 of the 2012 NFPA 99.  Accordingly, we are permitting a waiver to allow a centralized computer system to substitute for one of the Category 1 medical gas master alarms, but only if the provider/supplier is in compliance with all other applicable 1999 NFPA medical gas master alarm provisions, as well as with section 5.1.9.4 of the 2012 NFPA 99.

2.      Openings in Exit Enclosures

 

The 2000 LSC limits opening in exit enclosures (e.g., stairwells) to doors from normally occupied spaces and corridor, and doors for egress from the enclosure, with a few exceptions.  Existing health care facilities often have unoccupied mechanical equipment spaces that have an exit access door to an exit enclosure.  Providing an alternative exit access to these areas is typically impractical and unduly burdensome with respect to the cost of the reconstruction that would be required.  With the 2003 LSC, the NFPA began to permit existing unoccupied openings to mechanical equipment spaces with fire-rated doors to open into exit enclosures, and continuation of this policy is reflected  in section 7.1.3.2(9)(c) of the 2012 LSC.  Accordingly, we are permitting a waiver to allow existing openings in exit enclosures to mechanical equipment spaces that are protected by fire-rated door assemblies.  These mechanical equipment spaces must be used only for non-fuel-fired mechanical equipment, must contain no storage of combustible materials, and must be located in sprinklered buildings.  This waiver allowance will be permitted only if the provider/supplier is in compliance with all other applicable 2000 LSC exit provisions, as well as with section 7.1.3.2.1(9)(c) of the 2012 LSC.

3.      Emergency Generators and Standby Power Systems

Section 9.1.3 of the 2000 LSC requires emergency generators and standby power systems to be installed, tested, and maintained in accordance with 1999 NFPA 110, Standard for Emergency and Standby Power Systems.  Section 6-4.2.2 of the 1999 NFPA 110 requires diesel-powered generators that do not meet the monthly testing requirements under section 6-4.2 to be run annually with various loads for a total of two (2) continuous hours.  Shorter generator run times will reduce undue cost burden and negative environmental impacts.  In the 2010 NFPA 110, the NFPA began to allow for total test duration of one hour and 30 minutes (1-1/2 continuous hours).  Accordingly, we are permitting a waiver to allow for a reduction in the annual diesel-powered generator exercising requirement from two (2) continuous hours to one hour and 30 minutes (1-1/2 continuous hours), but only if the provider/supplier is in compliance with all other applicable 1999 NFPA 110 operational inspection and testing provisions, as well as with section 8.4.2.3 of the 2010 NFPA 110.

4.      Doors

Section 18/19.2.2.2.2 through 18/19.2.2.2.5 of the 2000 LSC permits door locking arrangements where the clinical needs (e.g., psychiatric units, Alzheimer units, dementia units) of the patients require specialized security measures for their safety, provided adequate provisions are made for the rapid removal of occupants by means such as remote control locks or keys carried by staff at all times.  The need for door locking arrangements may extend to other circumstances, such as instances when patients pose a security risk (e.g., some patients in emergency departments) or when a patient requires specialized protective measures for safety (e.g., pediatric units, newborn nurseries).  In the 2009 LSC, the NFPA recognized this and began to allow for door locking arrangements when patients pose a security risk or when patients require specialized protective measures for safety, and continuation of this policy is reflected in the 2012 LSC, in sections 18/19.2.2.2.2 through 18/19.2.2.2.6.  Accordingly, we are permitting a waiver to allow door locking arrangements where there are clinical needs justifying them, patients pose a security risk, or where patients require specialized protective measures for their safety, but only if the provider/supplier is in compliance with all other applicable 2000 LSC door provisions, as well as with sections 18/19.2.2.2.2 through 18/19.2.2.2.6 of the 2012 LSC.

Section 19.2.2.2.4 of the 2000 LSC permits delayed-egress locks in the means of egress, provided not more than one such device is located in an egress path.  However, where the clinical needs (e.g., psychiatric units, Alzheimer units, dementia units) of the patients require specialized security measures for their safety, or where patients pose a security risk (e.g., some patients in emergency departments) or when a patient requires specialized protective measures for safety (e.g., pediatric units, newborn nurseries), more than one delayed egress lock may be required along the path of egress in order to accommodate the clinical, security, and other special needs of patients.  In the 2009 LSC, NFPA began to allow for more than one delayed-egress lock in an egress path, and continuation of this policy is reflected in sections 18/19.2.2.2.4 of the 2012 LSC, provided that the facility also employs the compensating safety measures specified in those sections which facilitate rapid removal of occupants.  Accordingly, we are permitting a waiver to allow more than one delayed-egress lock in the egress path, but only if the provider/supplier is in compliance with all other applicable 2000 LSC door provisions, as well as with sections 18/19.2.2.2.4 of the 2012 LSC.

5.      Suites

Sections 18/19.2.5 of the 2000 LSC requires every habitable room to have an exit access door leading directly to an exit access corridor; allows for exit access from a suite to include intervening rooms only under certain circumstances; requires suites of certain size to have two exit access doors remotely located from one another; and limits the size of sleeping room suites to 5,000 ft2.  Suites are used to create groupings of rooms and spaces that can function more efficiently than individual rooms located off of a corridor.  The specific limitations on suite size and design in the 2000 LSC limit their efficiency and the ability for facilities to accommodate suites in their building space, which results in undue burden.  In the 2006 LSC, NFPA began to include additional provisions to further accommodate the use of suites, and continue to be reflected in sections 18/19.2.5.7 of the 2012 LSC.  Accordingly, we are permitting a waiver to further accommodate the use of suites by allowing: (1) one of the required means of egress from sleeping and non-sleeping suites to be through another suite, provided adequate separation exists between suites; (2) one of the two required exit access doors from sleeping and non-sleeping suites to be into an exit stair, exit passageway, or exit door to the exterior; and (3) an increase in sleeping room suite size up to 10,000 ft2.  This waiver allowance will be permitted only if the provider/supplier is in compliance with all other applicable 2000 LSC suite provisions, as well as with sections 18/19.2.5.7 of the 2012 LSC.

6.      Extinguishing Requirements

Section 9.7.5 of the 2000 LSC requires all automatic sprinkler and standpipe systems to be inspected, tested, and maintained in accordance with the 1998 edition of NFPA 25, Standard for the Inspection, Testing, and Maintenance of Water-based Fire Protection Systems.  Sections 2-3.3 and 5-3.2 of the 1998 NFPA 25 require the quarterly testing of vane-type and pressure switch type waterflow alarm devices, and weekly testing of electric motor-driven pump assemblies.  Reducing the frequency of testing requirements will reduce cost burden.  In the 2011 NFPA 25, the NFPA began allowing for the testing of vane-type and pressure switch type waterflow alarm semiannually and electric motor-driven pump assemblies monthly.  Accordingly, we are permitting a waiver to allow for the reduction in the testing frequencies for sprinkler system vane-type and pressure switch type waterflow alarm devices to semiannual, and electric motor-driven pump assemblies to monthly.  This waiver allowance will be permitted only if the provider/supplier is in compliance with all other applicable 1998 NFPA 25 (as referenced in section 9.7.5 of the 2000 LSC) testing provisions, as well as with sections 5.3 and 8.3 of the 2011 NFPA 25.

7.      Clean Waste & Patient Record Recycling Containers

Sections 18/19.7.5.7 of the 2000 LSC limit the size of trash collection containers to 32-gallons when located outside of a hazardous storage area and not attended.  Recycling containers used for clean waste (e.g., bottles, cans, paper) pose a lower fire risk than trash containing grease, oil, or flammable liquids.  Allowing the size of container used for recycling to increase will reduce the number of trash receptacles and hazardous storage areas required, which will reduce undue cost burden.  In the 2012 LSC, the NFPA began allowing containers used solely for recycling clean waste or for patient records awaiting destruction outside a hazardous storage area to be a maximum capacity of 96-gallons.  Accordingly, we are permitting a waiver to allow the increase in size of containers used solely for recycling clean waste or for patient records awaiting destruction outside of a hazardous storage area to be a maximum of 96-gallons,but only if the provider/supplier is in compliance with sections 18/19.7.5.7.2 of the 2012 LSC.

8.      Clarification of Process for LSC Waivers permitted under S&C-12-21

CMS memorandum S&C-12-21-LSC, dated March 9, 2012, also provided for categorical waivers of several provisions of the 2000 LSC, but required each provider/supplier waiver to be evaluated separately before a survey was to be conducted, with final approval by the CMS Regional Office.  Providers/suppliers seeking to take advantage of these categorical waivers may now use the categorical waiver process described above, so long as they are in compliance with all other requirements identified in S&C-12-21-LSC.

Questions:  If you have questions regarding this memorandum please contact Lieutenant Commander Martin Casey at Martin.Casey@cms.hhs.gov.

Effective Date:  Immediately.  This policy should be communicated with all survey and certification staff, their managers and the State/Regional Office training coordinators within 30 days of this memorandum.

/s/

Thomas E. Hamilton

cc:  Survey and Certification Regional Office Management

 

 

Communication With Nurses

imagesCAATJSWMThe key to life safety compliance is education. Relating better to caregivers will open their eyes about the important of Life Safety Code® (LSC) requirements.

The situation with nurses not observing LSC provisions is near universal in hospitals. The solution has to start with safety and accreditation professionals because the nurse’s main focus is often on patient care. The LSC isn’t a regulation that nurses generally worry about—there are plenty of issues in their jobs that are more immediately pressing.

For example, nurses like to keep patient care items nearby (e.g., parking blood pressure cuff machines in corridors outside patient rooms) instead of having them stored 30 feet away in a utility room. Although items parked in corridors is generally a legitimate violation of the LSC and Joint Commission standards, if you voice your objection nurses may nonetheless feel you are policing them. Rather than taking a hard-line stand on compliance, a more open approach will get the desired results. 

Steps to Open Lines of Communication

Use the following tips to win over nurses:

  • Go onto the units and job-shadow nurses for a few hours. Tell them, “I want to get to know what you do better.” You’ll learn nurses may need to take all of their patients’ blood pressure every two hours, which is why they want the blood pressure cuff devices nearby.
  • Schedule times to sit down and talk to the nurses, either individually or in group meetings. This approach is time-consuming because the goal is to reach every nurse in the facility. Years ago, I carried out a similar effort as a safety officer at the hospital where I used to work, and it took a total of six months to talk to all the nurses. This involved coming to the hospital on weekends and at 2 a.m. on the overnight shift.
  • When you talk to nurses, don’t wear a suit. Appearance plays a large part in the success of the interaction. You don’t want to dress like you’re someone’s boss.
  • Avoid mentioning LSC terms and related jargon. Words such as “Life Safety Code,” “standards,” “laws,” and “rules” will drown out your message. Don’t use these buzzwords because caregivers will tune you out right away.
  • Relate life safety to nursing work. After learning what activities nurses undertake as part of patient care, explain that life safety compliance has a similar goal. Tell them, “I want you to consider other examples in the environment that keep your patients safe.”
  • Use visual examples to drive the point about life safety provisions home. For example, explain that an 8-foot corridor needs to remain clear because in a fire, nurses may need to push 40-inch-wide hospital beds down that corridor. Those beds almost never roll straight and could occupy up to 6 feet of the corridor, especially if IV pumps, heart monitors, and other equipment are attached to the patient. The remaining width of the corridor needs to stay clear for other nurses, security officers, and firefighters who are trying to get onto the unit to assist. As a nurse moves a bed, if he or she encounters an item blocking the corridor, that item will need to be moved out of the way and stored somewhere. This could take 30–60 seconds to accomplish and may mean the difference between life and death for the last person trying to get out.
  • Show nurses the closest locations of portable fire extinguishers and fire alarm pull stations. There’s a good chance caregivers will pass by the closest location for these items and delay response because they simply don’t realize the devices are there. Encourage nurses to talk to each other about the locations of extinguishers and pull stations to maintain awareness.
  • Confirm that nurses know where to relocate patients during an evacuation. Sure, most nurses understand that if an alarm goes off in their unit, they may need to move patients to the nearest safe smoke compartment, which begins after a double set of smoke barrier doors. But not all double doors that close on alarm are smoke barrier doors. Show nurses the exact locations of adjacent smoke compartments so they know where to relocate patients.
  • Ask nurses whether they’ve ever been involved with a fire. If you’re talking to a group of nurses and you encounter one who has responded to a blaze, that nurse’s recounting of the event will support your cause.

Time Is the Major Investment

The above approach will take time but shouldn’t cost you much money. Getting leadership support is important, particularly if you run into a nurse who butts heads with you about efforts such as keeping egress corridors clear. You can further convince nurses to help you with LSC compliance by assisting them with nagging projects, such as hanging a bulletin board that’s been lying around for weeks. By fixing little things, you can buy trust.

Oversized Suites of Rooms

Q: Can an FSES equivalency be written for an oversized ER suite? Our ER was constructed in 2005 and the designer made it 13,450 square feet, which is more than the maximum allowable amount.  We have exam rooms without doors and a surveyor said that was not allowed if the ER is not a suite.

 A: Yes, a Fire Safety Evaluation System (FSES) equivalency may be conducted and submitted to your authority having jurisdiction, but you have to make sure of a few issues. First, the deficiency for an over-sized ER suite has to address the fact that the exam rooms do not have doors. The surveyor is correct in saying that a room providing care or treatment to a patient has to be separated from the corridor by a door that latches.  Secondly, since you do not qualify for a suite (because you are 3,450 square feet over the limit), you have to assess the ER as if it has an exit access corridor, and all the exam rooms are open to the corridor. The FSES document is a NFPA 101A Guide on Alternative Approaches to Life Safety (2001 edition), and the worksheet to use is form 4.7.6. The value for Safety Parameter #5 has to be -10 points for no doors to the corridor. Make sure you travel distances are no more than 100 feet or 50 feet if through two intervening rooms. If the plans to construct the ER department were approved by the local authority on construction after March 11, 2003, then you must assess the area on the FSES worksheet as new construction, which makes it harder to get the numbers to work. The logic on that issue is a new building should not have any life safety deficiencies. If the numbers do not work out on the FSES equivalency, you can always consider cutting the ER into two, smaller suites by adding doors and walls in strategic areas. That may not be desirable, but it may be your only solution if the FSES does not work.

Using Certain Sections of the 2012 Edition of the Life Safety Code

What process should be used to take advantage of the recent CMS correspondence that deals with allowing mobile equipment, such as patient lifts and gurneys in the corridors? To refresh your memory, CMS S&C Letter 12-21 issued March 9, 2012 allows hospitals and nursing homes the opportunity to start using certain sections of the 2012 edition of the Life Safety Code, by considering requests for waivers to the current 2000 edition of the Life Safety Code, without the organization having to show an “unreasonable hardship”.

The sections that CMS will allow, are (references are to the 2012 edition of the LSC):

  • 18/19.2.3.4 which allows projections into the means of egress corridor width for wheeled equipment and fixed furniture
  • 18/19.3.2.5.2 though 18/19.3.2.5.5 which allows certain types of alternative kitchen cooking arrangements
  • 18/19.5.2.3(2), (3), and (4) which allows the installation of direct vent gas fireplaces in smoke compartments containing patient sleeping rooms and the installation of solid fuel burning fireplaces in areas other than patient sleeping areas
  • 18/19.7.5.6 which allows the installation of combustible decorations on walls, doors, and ceilings.

If you are Joint Commission (TJC) accredited, the process to follow, is to request a Traditional Equivalency from TJC to allow you to begin using the 2012 edition of the LSC on those 4 or 5 issues identified in the CMS S&C Letter 12-21. TJC requires that you have a written opinion from one of the following three individuals, who states that you meet the expectations in the 2012 edition of the LSC:

  • Local AHJ on fire safety
  • Registered architect
  • Fire safety engineer

You then write a cover letter requesting a Traditional Equivalency and submit it along with the written opinion from one of the above individuals. TJC should approve your Traditional Equivalency request, and then you may begin using the new 2012 references. The important thing to understand in this issue, is you do not request a waiver from CMS to use the 2012 edition until such time you are cited by a state agency representing the CMS. Then, as part of your Plan of Correction, you submit a waiver request through the state agency to the CMS Regional Office who will review and probably approve your request. For many of the organizations out there, you may never get cited by a state agency representing CMS before the new 2012 edition of the LSC is adopted, which is hopefully within the next 24 months.

Sprinklers in Existing Healthcare Occupancies

This may seem basic to some of you, but one of the problems in the healthcare facilities management industry is people don’t always have a good solid foundation of the basics. From time to time, I have a conversation with a client about challenges they are having in regards to installing sprinklers in their existing facilities. Frequently they ask me how they should enter their sprinkler project into the Joint Commission Statement of Conditions (SOC), Plan For Improvement (PFI) list. Eventually I get around to asking the question “Why are you installing sprinklers?” Now, don’t get me wrong, I’m a firm believer in sprinklers as they do save lives in the event of a fire, and I am all for hospitals and nursing homes retroactively installing them, but I want to make sure the client fully understands their options.

First of all, let’s make it very clear that the 2000 edition of the Life Safety Code (LSC) does not require existing healthcare occupancies to be protected with automatic sprinklers, unless the Construction Type or an approved equivalency requires it. Existing conditions is defined as the local authority having approved construction documents for new construction or renovation projects before March 11, 2003. Why March 11, 2003? Because that’s the date the Centers for Medicare & Medicaid Services (CMS) approved the 2000 edition of the LSC. There is a caveat to this issue, and that is the LSC has required new construction and renovation to be protected with automatic sprinklers since the 1991 edition, so if your organization was required to comply with the 1991 (and subsequent) edition(s), then new construction and renovation conducted since the time that edition was adopted by your authorities needs to be sprinklered. CMS went directly from the 1985 edition of the LSC to the 2000 edition on March 11, 2003. I know Joint Commission had adopted the 1994 and the 1997 editions prior to adopting the 2000 edition on March 1, 2003 (Yes, they adopted the 2000 edition 10 days earlier than CMS…), but I do not know if and when they ever adopted the 1991 edition.

Construction Type is a NFPA reference describing the general fire resistance of the construction materials used to build the facility, and the level of fire protection on key structural members of the building, as measured in hours. So, Construction Type II (222) which is the most common type  for hospitals, would be a building constructed with fire resistant materials (such as concrete, brick, stone, gypsum board, etc.) and has key structural members (such as load bearing walls, beams, joists, trusses, floor decks) with a 2-hour fire resistant rating. Generally speaking, the taller the building the greater the Construction Type must be. According to the existing healthcare occupancy chapter (19) in the LSC, some lessor Construction Types in existing constructions must be sprinklered. In some cases an equivalency will specify sprinklers in an existing condition in order to gain enough points to be successful. If you have any approved equivalencies, check them out to see if automatic sprinklers are a condition of their approval.

So, getting back to the client with the question about entering the sprinkler project into the SOC PFI list, I ask them “Why are you installing sprinklers?” If they say it is just a desire of theirs to have a fully sprinklered facility, then that is not a LSC deficiency, and they cannot enter that into their PFI list. The PFI list is reserved only for deficiencies with the Life Safety Code. Now, if they are installing sprinklers because they are renovating an area,or correcting a deficiency with their Construction Type, or need the points on an equivalency, then that is a life safety deficiency and the sprinkler project may be entered into the PFI list.

Confusing? That’s all-right, as it can be. Rome wasn’t built in a day, and everything a facility manager needs to know about the Life Safety Code is not learned by just reading a blog posting…. But it can help!

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P.S. Be prepared for changes when the 2012 edition of the Life Safety Code is finally adopted (probably in 2014 or 2015). The new edition will require existing nursing homes to be fully protected with automatic sprinklers, and existing hospitals that are considered high-rise facilities to be fully protected with automatic sprinklers. A high-rise building is greater than 75 feet in height where the building height is measured from the lowest level of fire department vehicle access to the floor of the highest occupiable story. A penthouse mechanical room would not typically be considered an occupiable story.

CMS Releases Memo Allowing Waivers for Certian References of the 2012 LSC

The Centers for Medicare & Medicaid Services (CMS) released a new memo (S&C-12-21-LSC) to their State Survey Agencies on Friday, March 9, 2012. In the memo was instructions on how healthcare facilities can apply for waivers to the 2000 edition of the NFPA 101 Life Safety Code (LSC), which will allow the healthcare organizations to take advantage of select references of the new 2012 edition of the LSC.

This memo describes the process that a healthcare organization can request a waiver from CMS on the following issues:

  • Increasing the amount of wall space that may be covered by combustible decorations
  • Permitting gas fire places in common areas
  • Permitting permanent seating groupings of furniture in corridors
  • Allowing kitchens which serve less than 30 residents, to be open to the corridor as long as they are contained inside a smoke compartment

CMS says the waivers will be applicable to both new and existing conditions, and organizations are not required to demonstrate ‘unreasonable hardship’ as they would with a normal waiver request. It is apparent that the intent of the change to allow waiver requests for these four items, is directed towards the nursing home industry, but it does apply to all healthcare occupancies, including hospitals. While it is not likely that an acute-care hospital would be interested in pursuing the waiver request procedure for just these 4 items, it is possible that a specialty hospital, such as rehab or facility based hospice, may be interested.

Some individuals in the healthcare industry are heralding this announcement as a step towards CMS adopting the 2012 edition of the LSC. This certainly looks favorable in this regard, but since there really isn’t any ‘meat’ on this bone for the majority of the hospitals in the nation, I wouldn’t get too worked up about this.

I’m often asked when will CMS finally adopt the 2012 edition of the LSC, and the honest answer is, no one knows  the precise date. However, last October CMS did announce that they are reviewing the 2012 edition for consideration of adopting it, which is their vernacular indicating they will. History tells us they will take anywhere from 18 months to 3 years to adopt it, as they must go through many stages of public review and comment. So, that puts us in 2013 or 2014 for the ‘best guess’.

 

Equivalencies

QUESTION: It has been stated that an organization is permitted to submit either a Traditional Equivalency or a Fire Safety Evaluation System for a deficiency to a life safety feature. How do we decide when to use which one and what is the difference between them?

ANSWER: A Traditional Equivalency is a basic three-step process:

  1. Identify the deficiency and reference the applicable NFPA 101 Life Safety Code paragraph.
  2. Propose an alternative solution to the problem; include drawings      showing existing conditions and the proposed solution; identify the total      cost of the solution, including the source and availability of the funds;      and identify when the solution will be implemented.
  3. One of the following individuals needs to state in writing that the      proposed solution meets the intent of the code, or creates an equivalent      level of safety:
  • A fire protection engineer
  • A registered architect
  • The local AHJ over enforcement of fire safety

A Fire Safety Evaluation System (commonly referred to as FSES) is a multiple page document that places numerical values to specific life safety features of your building. It is found in NFPA 101A, Guide on Alternative Approaches to Life Safety. This document provides alternative approaches to life safety based on the NFPA 101 Life Safety Code. It is intended to be used with the Life Safety Code, not as a substitute. The Life Safety Code permits alternative compliance with the Code under equivalency concepts where such equivalency is approved by the authority having jurisdiction.

After assigning a numerical value to specific life safety features based on questions in the FSES, a sore is derived in four basic equivalency functions:

  • Containment safety
  • Extinguishment safety
  • People movement
  • General safety

If the score equals 0 or greater in each of the basic functions, then the FSES demonstrates an acceptable level of safety, and the AHJ should approve it as an equivalency.

Anyone with intimate knowledge of your facility is permitted to conduct a FSES and special degrees and licenses are not required.