Clarifications Part 5

I continue my series on clarifications of surveyor findings that I have written for a client.

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Clarification for LS.02.01.10, EP 9

LS.02.01.10, EP 9: The spaces around pipes, conduits, bus ducts, cables, wires, air ducts, or pneumatic tubes that penetrate fire-rated walls and floors are protected with an approved fire-rated material.

Surveyor finding:

In the 6th floor utility room the 4 inch vertical wiring conduit and a one inch wall conduit were not sealed with fireproofing material.

In the Main Building there was a conduit penetration in the hallway by room xxxxx.

In the Main Building there was a conduit penetration by room xxxx.

 Clarification:

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

What: Compliance with the NFPA 101 Life Safety Code (2000 edition) is the objective and mission of the Facilities Department. The Safety Management Plan clearly identifies the mission to provide a safe and secure environment, which includes compliance with the Life Safety Code. 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, and the statement that the facility will be maintained in accordance with the Life Safety Code, is shared with all members of the health system through the intra-net, Safety Manuals [is this true?], and through direct conversations with key leaders in the organization.

Why: As an organization that has thousands of feet of fire & smoke rated barriers and corridor walls, we feel that 4 situations of unsealed conduit penetrations is not a true reflection of our overall compliance rate. Since this element of performance is designated as a ‘C’ element, we conducted an audit on all of our fire & smoke rated barriers, and our corridor walls in our facility prior to the survey. The sample size chosen for this audit is 2,954 wall-units for fire & smoke rated barriers, and 2,750 wall-units for corridor walls. This represents 100% of all the fire & smoke rated barriers and 100% of all the corridor walls in the hospital.

A wall-unit is an inspection of the fire & smoke rated barrier, or the corridor wall, whereby the maintenance technician lifts a ceiling panel and examines the wall to the left and to the right for unsealed penetrations. This represents the barrier (or wall) being inspected approximately every six (6) feet.

The audit on the fire & smoke rated barriers was conducted in May, 2013, and the audit on the corridor walls conducted in September, 2013. These audits were conducted as part of our ongoing Building Maintenance Program (BMP), which were no more than 6 months prior to the survey. The walls and barriers were inspected for:

  • Unsealed penetrations
  • Conduit sleeves      penetrating the wall but were not sealed
  • Gaps and holes
  • Completion of construction      to the deck above

The results of these two audits found 2,930 compliant fire & smoke rated wall-units (out of 2,954 total fire & smoke rated wall units), which represents a 99.18% compliance rate, and 2,737 compliant corridor wall-units (out of 2,750 total corridor wall units) which represents a 99.52% compliance rate.

Therefore, since our audit of this ‘C’ element demonstrates a compliance rate greater than 90% prior to the survey, XYZ Hospital respectfully requests that The Joint Commission vacate this finding under LS.02.01.10, EP 9, and consider this standard to be ‘Compliant’.

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Result? The accreditor accepted this clarification. The success of this clarification is based on an audit that the hospital had done prior to the survey, that demonstrated more than 90% compliance. The audit option for clarifications is only allowed to be used on ‘C’ category EPs.

If you’re keeping track, the score is:   Accepted 2: Not Accepted 3

Clarifications Part 4

I continue my series on clarifications of surveyor findings that I have written for a client.

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Clarification for EC.02.06.01, EP 13

EC.02.06.01, EP 13: The hospital maintains ventilation, temperature, and humidity levels suitable for the care, treatment and services provided.

Surveyor finding:

During a tour of the operating rooms it was noted that the temperature in a recently used operating room was 59 degrees. Nursing and medical staff noted that there were occasions when physicians asked that the temperature in a room be lowered below 68 degrees for personal comfort rather than patient care.

The Soiled Utility room number 6630 has airflow coming out of the room instead of flowing into the room.

Clarification:

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

What: The ventilation requirements for the operating rooms are based on design recommendations from the Guidelines for Design and Construction of Health Care Facilities, as written by The Facilities Guidelines Institute (FGI), and published by the American Society for Healthcare Engineering. These guidelines are not regulatory requirements, as stated in the preface of the FGI document, and as indicated in the Joint Commission standard EC.02.06.05, EP 1. Another Joint Commission standard, EC.02.05.01, EP 1, specifically states: “The hospital designs and installs utility systems that meet patient care and operational needs.”  While the FGI Guidelines were used during the design of the operating rooms, it was fully understood and planned by the hospital with careful input from the medical staff for ventilation settings outside the range that the FGI Guidelines recommended. There are legitimate reasons to have the air temperature lower than the minimum FGI recommendations, such as the operational needs during the surgery. (See “Why” below).

When: Ventilation settings in operating rooms are carefully monitored by Surgery and Plant Operations staff. Normal temperature ranges are adhered to, with the exception when a surgeon makes a request to have the operating room temperature set outside of the recommended range.

How: Operating room staff is educated in the normal ventilation requirements of surgical procedures. New-hires are orientated on all policies and procedures in the Surgery department, and any changes or updates to policies or procedures are communicated to all staff in the Surgery unit.

Why: The request to have the temperature setting in the operating room lower than what is recommend by the FGI Guidelines is not just for surgeon personal comfort, as the surveyor wrote in his finding. This is an operational need for a successful surgical procedure based on the many layers of surgical attire worn by the surgeon and the procedures required during surgery. The layers of attire worn by the surgeon during the procedure include:

  • Undergarments;
  • Surgical scrubs;
  • Sterile surgical gowns;
  • A hooded mask.

The hooded mask is similar to a Hazmat hood and has little air flow. The procedure is performed underneath high wattage intense surgical lights which produce heat, and the procedure requires physical manipulation of the patient’s limbs during prosthetic replacements. The many layers of attire, the heat from the surgical lights, and the physical assertion required during the surgery ultimately requires a lower air temperature in the operating room in order to have a successful surgery, which ultimately is the mission of the organization to provide excellent patient care. Without the lower temperature setting, the surgeon would suffer from physical exhaustion and fatigue, which would jeopardize the success of the surgery and the care provided to the patient.

The decision to set the operating room temperature below a recommended range is not taken lightly, and only done so under the direction of the attending surgeon. Surgery Department policy #12375-2.30 specifically allows for the operating room temperature to be set lower than the 68° to 73°F range at the request of the surgeon for certain surgical procedures.

Therefore, since the 68 degree temperature range is based on guidelines and recommendations and not regulations; since Joint Commission standards permits the operation of utility systems that meets operational needs; and since the air temperature setting that the surveyor observed was permitted in accordance with hospital policy; XYZ Hospital respectfully requests that The Joint Commission vacate this finding under EC.02.06.01, EP 13, and consider this standard to be ‘Compliant’.

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Result? The accreditor did not accept this clarification…. and I think I know why. We made a very good argument that the temperature settings are recommendations only and not regulations, and the hospital had a great reason to have air temperature set lower than recommended. Had that been the only finding the surveyor wrote under this standard I think the accreditor would have accepted the clarification. But there were two findings: the other was improper air pressure relationship for a soiled utility room. We had nothing for that finding. So we decided to argue on the OR temperature setting issue and hope that they would overlook the soiled utility finding.

They didn’t. Oh well… It is what it is.

If you’re keeping track, the score is:   Accepted 1: Not Accepted 3

CMS Issues New Proposed Rule on Disaster Preparedness

CMS Logo 2The Centers for Medicare & Medicaid Services (CMS) has issued a new proposed rule in the Federal Register on Friday, December 27, 2013. This is a Notice of Proposed Rulemaking and is not a Final Rule. CMS is soliciting comments on this proposed rule concerning healthcare facility disaster preparedness, and the general public has 60 days to respond.

Being a Federal Agency, CMS must follow the Administrative Procedure Act of 1946 whenever they want to add, remove or change a rule or regulation, and they must issue a public notice in the Federal Register that they are proposing a new rule. Then there is a 60-day window for the public to respond with comments to the proposed rule. After the 60-day window is over, CMS will take the time to review the comments made and will respond to them when they issue a final rule, in about 6 months or so (my guess of time- not theirs). The changes that CMS is proposing are to the respective Conditions of Participation or Conditions for Coverage to 17 different sets of rules (or laws) for healthcare organizations.

I have started an initial review of the proposed rule and I like what I see. CMS  identified four core elements that they believe are central to an effective emergency preparedness system and must be addressed by healthcare organizations to offer a more comprehensive framework of emergency preparedness requirements for the various Medicare- and Medicaid-participating providers and suppliers. The four elements are—(1) risk assessment and planning; (2) policies and procedures; (3) communication; and (4) training and testing.

CMS admits that they took into consideration the existing standards and regulation of national agencies, such as The Joint Commission and AOA/HFAP. The current CMS Conditions of Participation (CoP) for acute care hospitals are light on specific requirements for emergency management, and most experts agree that The Joint Commission Emergency Management chapter provided better guidance for healthcare facilities than any other standard.

Below is the link to the proposed disaster preparedness rule that was published today.

https://federalregister.gov/a/2013-30724

I encourage you to review the proposed new rule and if you have a comment, please follow the directions and submit it to the CMS. They will appreciate your insight and considerations.

After you have reviewed the proposed new rule, please let me know what you think of it.

 

Clarifications Part 3

I continue my series on clarifications of surveyor findings that I have written for a client.

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Clarification for EC.02.05.01, EP 8

 EC.02.05.01, EP 8: The hospital labels utility system controls to facilitate partial or complete emergency shutdowns.

 Surveyor finding:

In the D-Wing electrical room breaker panel 7HEB did not have breakers labeled and the panel was blocked.

In Surgery operating room 9 the breaker panel 1B/OR9 did not have all breakers labeled.

 Clarification:

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

What: The Utility Management Plan clearly identifies the mission to provide and maintain safe and reliable plant equipment. Plant equipment will be installed, maintained and operated in such a way as to provide a safe, clean, comfortable and efficient environment for our patients, visitors and staff.

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

How: The Utility 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 unmarked breakers that the surveyor observed in electrical panel 7HEB, are spares. When the electrical panel was installed by the electrical contractor, it is a requirement for the contractor to provide a full ‘stable’ of breakers, regardless whether all of them are immediately utilized. The remaining unused breakers are considered spares and are available for future use. The breakers that are connected to electrical circuits in panel 7HEB are marked. Only the spare breakers which the surveyor referred to are unmarked.

Contrary to what the surveyor wrote in his finding, all of the breakers in electrical panel 1B/OR9 are marked and were marked at the time of the survey. We are not sure why the surveyor wrote that the breakers were not marked, other than the fact that all of the breakers are two-pole breakers, and perhaps the surveyor did not realize that a description was only needed to be written in one slot on the panel legend for the two-pole breaker.

Therefore, since the unmarked breakers in panel 7HEB are spares, and since we believe these circuit breakers in the electrical panel 1B/OR9 were properly labeled at the time of the survey, XYZ Hospital respectfully requests that The Joint Commission vacate this finding under EC.02.05.01, EP 8, and consider this standard to be ‘Compliant’.

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Result? The accreditor did not accept this clarification. Which just shows that they are serious on having all electrical breakers labeled.

If you are keeping track, the score is:  Accepted 1: Not Accepted 2

PFIs on Inaccessible Fire Dampers

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There seems to be much discussion lately on how to manage the Joint Commission Statement of Conditions Plans For Improvement (PFI) on inaccessible dampers. Joint Commission has instructed healthcare organizations to write a PFI for inaccessible fire or smoke dampers, and place a projected completion date of 6 years on them.

I have been telling my clients to close the PFI out at the end of the 6-year cycle; examine the fire dampers again to see if anything has changed that now allows them to be accessible (and then test them); and if they are still inaccessible, write up a new PFI with a new 6-year projected completion date. I vaguely remember that Joint Commission initially wanted hospital to request another 6-year extension on PFIs for inaccessible fire dampers, but I think they soon realized their error as they would be over-whelmed with extension requests. Also, they typically only allow one extension per PFI, so after the first 12 years, would they grant another extension? I also remember them saying to just close out the PFI and write a new one.

I don’t have a copy of the 2007 EOC article on the PFIs for inaccessible fire dampers, but 7-year old information seems a bit old for me to trust. People and organizations change their mind in 7-years. If anyone has any doubt, they should contact the Standards Interpretation Group at Joint Commission directly and ask them. Their number is (630) 792-5900, select option 6.

 

Clarifications Part 2

I continue my series on clarifications of surveyor findings that I recently wrote for a client:

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Clarification for EC.02.05.01, EP 4

EC.02.05.01, EP 4: The hospital identifies, in writing, the intervals for inspecting, testing, and maintaining all operating components of the utility systems on the inventory, based on criteria such as manufacturers’ recommendations, risk levels, or hospital experience.

 Surveyor finding: The battery powered lights in the Surgery operating rooms did not have an interval for testing. At Emergency Generator 5 there was no required interval for testing of the battery powered lights.

Clarification:

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

What: The requirement for testing and inspection intervals of the battery powered lights in the hospital is located in the Facilities Department policy #xxxx-x. This policy specifies that battery powered lights will have a functional test at 30-day intervals for at least 30 seconds, and an annual test for 90 minutes.

When: This Facilities Department policy #xxxx-x was written by the Facility Director on July 31, 2006, and approved by the Safety Committee thereafter. This policy has been periodically reviewed by the Facility Director, most recently on January 11, 2013.

How: All new-hires into the Facilities Department are educated on all departmental policies and procedures. All Facilities Department staff is aware of departmental policies and procedures and is provided training and education when changes or updates are made.

Why: The surveyor did not request to see our policy on the intervals for testing the battery powered light, at the time of the survey. It is unknown why the surveyor did not ask to see our policies, but the surveyor did cite us under EC.02.05.01, EP 4 for not having “intervals for testing”, when in fact we did have these “intervals for testing” in written form of the policy for over seven (7) years prior to the survey. Therefore, XYZ Hospital respectfully requests that The Joint Commission vacates this finding under EC.02.05.01, EP 4, and considers this standard to be ‘Compliant’.

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Result? The clarification was accepted by the accreditor. The clarification clearly implies that the surveyor screwed up and scored his finding under the wrong standard. When I write clarifications for findings scored under the wrong standard, I do not point out the obvious, that the surveyor made a mistake. I take the tact that the finding does not fit the standard. Same difference…

If you are keeping track, the score is:   Accepted 1: Not Accepted 1

 

 

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.

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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.

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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