Sunday, November 29, 2009

Compliance News: Combustible Decorations

By Dean Samet, CHSP

It’s that time of the year again when there is a propensity to cover walls, doors and hang decorations from ceilings in celebration of the particular holiday season. Typically these decorations are not flame retardant; therefore they could contribute to the development or spread of a fire. Per Section 19.7.5.4 of the 2000 NFPA 101® Life Safety Code®, “Combustible decorations shall be prohibited in any health care occupancy unless they are flame-retardant. Exception: Combustible decorations, such as photographs and paintings, in such limited quantities that a hazard of fire development or spread is not present.”

It is a judgment call when determining if the hazard for fire development or spread is present; however, newer editions of the Life Safety Code do state that, “…consideration should be given to whether the building or area being evaluated is sprinklered.”

Policies and procedures (P&Ps) that prohibit and strictly limit the use of any combustible decorations should be in place and enforced. Send memos to each department, especially nursing units, and follow up with a safety/security personnel visit to discuss and answer questions regarding the P&Ps.

Just a reminder, fire safety is each and every staff member’s responsibility.

Compliance News: Fireplaces in Hospitals

By Robert Trotter, CBO, CFM

Prescriptive requirements for fireplaces in new and existing healthcare occupancies are found in the NFPA 101®, Life Safety Code®. Likewise the 2009 Hospital Accreditation Standards of The Joint Commission has three Elements of Performance in the Life Safety Chapter relative to fireplaces. They are:

• LS.02.01.50 EP 1. Fireplaces are not permitted in patient sleeping areas. Where allowed, fireplaces are separated from patient sleeping spaces by one-hour or more fire-rated construction.
• LS.02.01.50 EP 2. Fireplaces are equipped with a fireplace enclosure guaranteed against breakage up to a temperature of 650° F and constructed of heat-tempered glass or other approved material.
• LS.02.01.50 EP 3. The hearth of newly installed fireplaces is raised at least four inches above the floor.

Compliance News: CMS Clarifies LSC Application for Off-Site Buildings

By Dean Samet, CHSP

There are many instances when hospitals have off-site spaces or on-campus buildings physically separated or separated by rated construction where they provide ambulatory surgery or a variety of outpatient services. There are occasions when inpatients are transported to one of these buildings for services or treatment not available in the hospital. Does the occupancy designation change because some inpatients are being treated? What chapter(s) of the Life Safety Code® should be applied? In a July 30, 2008 e-mail to CMS regional personnel, the Centers for Medicare & Medicaid Services (CMS) Life Safety Code Specialist, James Merrill, P.E., provided the “Survey Process” criteria below that summarize the Life Safety Code® chapters to be applied to off-site buildings owned or leased by hospitals for outpatient department services, ambulatory surgical services, nursing homes, etc. This reconfirms and updates a Health Care Finance Administration (HCFA) directive written in March of 1993. This criteria may be used as a first step in determining appropriate LSC application for those instances when hospitals have off-site spaces or those separated by one-hour or two-hour construction between occupancies where they provide ambulatory surgical or other outpatient services.

Survey Process:
1. If inpatients receive treatment or services routinely, on a 24-hour basis (sleeping in the building), then Chapter 18/19 (Health Care Facilities) should be applied.
2. If outpatients (and/or inpatients, but the inpatients do not sleep in the building overnight) receive treatment or services in the outpatient building (a separate building), and if they are incapable or are rendered incapable, of self-preservation or receive general anesthesia, then Chapter 20/21 (Ambulatory Health Care) should be applied.
3. If outpatients receive treatment (and/or inpatients, but only on an occasional basis and they do 3. not sleep in the building overnight), and if they are capable of self-preservation and do not receive general anesthesia, then Chapter 38/39 (Business Occupancies) should be applied.
4. If there is more than one occupancy in a building without a two-hour separation between occupancies, the most stringent occupancy chapter applies.

While the above-listed CMS survey process for occupancies outside of a healthcare occupancy is summarized, the nature of the medical services provided and to whom they are rendered must be considered as should the LSC definitions provided in the 2000 NFPA 101® Life Safety Code®.

Compliance News: CMS Categorical Waiver for Damper Testing Cycle

By Dean Samet, CHSP

On October 30, 2009, the Centers for Medicare & Medicaid Services (CMS) issued a “categorical waiver” whereby hospitals may apply the 2007 NFPA 80 and NFPA 105 six-year testing interval for fire and smoke dampers in heating and ventilating systems in hospitals without special application to CMS. This action brings CMS in line with The Joint Commission and other state agencies and authorities having jurisdiction (AHJs) across the country.

The CMS Survey and Certification Group October 30, 2009 memorandum states: “After due consideration of State survey agency findings and conclusions of the National Fire Protection Association (NFPA), we are issuing a categorical waiver pursuant to 42 CFR 482.41(b)(2) to permit a testing interval of six years rather than four years for the maintenance testing of fire and smoke dampers in hospital heating and ventilating systems, so long as the hospital’s testing system conforms to the requirements under 2007 edition of NFPA 80: Standard for Fire Doors and Other Opening Protectives and the 2007 edition of NFPA 105: Standard for the Installation of Smoke Door Assemblies. The six-year testing interval shall commence on the date of the last documented damper test.

“While the 1999 edition of NFPA 80: Standard for the Installation of Air-Conditioning and Ventilating Systems specified a four-year testing cycle, the NFPA more recently determined that an increase to a six-year interval did not lower the fire protection of hospitals but could instead lower the incidence of infections that may be spread when the ventilation system was shut down and restarted at shorter time intervals. There is also some indication of cost savings to institutions when maintaining these dampers on a longer time interval.

“Under this categorical waiver, a hospital that conforms to the above requirements will not need to apply in advance for a waiver nor will it need to wait until being cited for a deficiency in order to apply for a waiver. At the time of a CMS onsite life-safety code survey, the hospital must notify the survey team that it has elected to operate under this categorical waiver and is in conformance with the testing requirements of the above-cited 2007 NFPA edition. The survey team will note this attestation in its records and apply the 2007 testing cycle requirements in the course of its survey.”

Compliance News: Transitioning from Construction to Survey-Ready Compliance - Part 2

By David Stymiest, PE, FASHE, CHFM

Part 1 appeared in the September/October 2009 issue of Compliance News.

The management plans, policies and procedures for renovations or expansions on an existing campus should reflect the impacts of the project on the existing facility. These impacts can include changes to facilities and areas, changes to infrastructure equipment and systems, new operational and infrastructure-related processes, and department locations or relocations.

Risk assessments may be required for safety, security, fire, and where the facility intends to permit patient smoking. Additional risk assessments may be done for input to the Emergency Operations Plan (EOP) and hazard vulnerability analysis (HVA), as well as hazardous chemicals, hazardous energy sources (including radiation, lasers, batteries), hazardous medications, hazardous gases and vapors, and radioactive materials. Other types of risk assessments apply to Life Safety Code™ deficiencies and Interim Life Safety Measure (ILSM) documentation, preconstruction risk assessments (PRA), and infection control risk assessments (ICRA).

Some of these risk assessments might be used to establish written inventories in the following areas as subsets based upon risk:

• Hazardous materials and waste
• Medical equipment (evaluation prior to initial use)
• Operating components of utility systems (evaluation of new component types prior to initial use)

Many of the systems and equipment, including life safety building features or components, must be commissioned and/or tested prior to initial use. It is not practical to list all of these item types here. Presumably project record documentation that includes all of the information required by the AHJ would be acceptable as long as it is available during survey.

The Project Record Documentation can be helpful in providing the complete list of components for ongoing testing provided that it is available early enough to be useful. The following systems and components require ongoing testing, and there would have to be policies, procedures, schedules, requirements, and forms that detail this testing:

• Fire safety equipment, fire safety building features, fire alarm, fire protection and sprinklers, fire extinguishers and extinguishing systems
• Smoke and fire dampers, air handling unit shutdown, elevator recall, etc.
• Door operation, exit door and corridor door resistance
• Medical equipment on the inventory
• Operating components of utility systems on the inventory
• Emergency power, medical gas, and vacuum systems and equipment
• Pathogenic biological agents in cooling towers, hot water and cold water systems
• Temporary systems required for ILSM

Project testing and certification reports would have to be on file and easily accessible during unannounced surveys. Types of project-related testing and certification reports could include, but are not limited to, the following:

• Contractor documentation and commissioning (Cx) agent documentation
• Documentation of typical AHJ inspections and approvals: Local, State, NRC, DOT, FAA, etc.
• Helipads and separator tank, elevators, fuel tanks, pressure vessels, fire protection water systems, lightning protection systems
• Building automation or building management system
• Low voltage systems, both medical and otherwise

Thursday, October 1, 2009

Shock Resistant: Preventing Arc-Flash Hazards in the Hospital Setting

By David L. Stymiest, P.E., CHFM, FASHE (in Health Facilities Management)

With the 2009 edition release of the National Fire Protection Association's NFPA 70E, Standard for Electrical Safety in the Workplace, increased attention is being focused on electrical power system safety and the dangers associated with electrical arc flashes. Why is there ever- increasing emphasis on electrical system safety?

According to the Centers for Disease Control and Prevention's (CDC's) National Institute of Occupational Safety & Health (NIOSH), electrical hazards cause more than 300 deaths and 4,000 injuries in the workplace each year. Some electrical injuries are instantly fatal, while up to 40 percent of electrical injuries are ultimately fatal, according to a paper written by three critical care physicians and referenced in a recent electrical industry magazine article. A research and consulting firm specializing in workplace injuries has compiled often-quoted statistics indicating that five to 10 reported electrical equipment arc-flash explosions occur per day in the United States.

Read entire article here: Shock Resistant


Tuesday, September 29, 2009

Compliance News: Flammable Liquid Storage Rooms

By Robert Trotter, CBO, CFM

Flammable liquid storage rooms located in healthcare occupancies must comply with stringent requirements for hazardous areas as prescribed in the 2009 Hospital Accreditation Standards for Life Safety as published by The Joint Commission. LS.02.01.30 Element of Performance Number 2 mandates that existing and new flammable liquid storage rooms must have two-hour fire-rated walls with 1 ½-hour fire-rated doors.

For additional information see the 1996 edition of NFPA 30, Flammable and Combustible Liquids Code which requires doors to be normally in the closed position. However, doors are permitted to be arranged to stay open during material handling operations if the doors are designed to close automatically in a fire emergency by provision of listed closure devices.

Compliance News: Where is that “Proof of Compliance”?

By Barbie Pankoski, CHFM, CHSP

Hospitals typically have most of the documents they need for presenting to The Joint Commission; however, all too often they just can’t seem to put their hands on some of the “proof of compliance” at the time of survey. This may be due to lack of organization, employee turn over, or the “one person” who has all the answers may be on vacation. Then what happens?

Some surveyors allow only a limited amount of time to find your needed documents before they score you for non-compliance. Hospitals should plan ahead, determine where their needed documents are located, and keep at least one copy in a central location(s), ensuring that more than one employee can locate and present them to TJC at the time of survey. Go through every standard and all of the elements of performance and ask yourself, “How do I show compliance with these requirements? Is there a written policy or task sheet to show compliance? Did I cover this in my management plans? Am I sure my employees or outside contractors are doing this task correctly and are documenting appropriately? What else can I do to ensure putting my hands on this documentation if I am asked to show proof of compliance?”

The following recommendations may help:
1. Organize
2. Centralize
3. Educate

Organize:
The hospital should organize their important documentation by going through The Joint Commission Standards, Elements of Performance (EP), and other regulatory requirements one by one and putting the back-up documentation or the “the proof of compliance” in a manageable format such as in binders or electronically stored and sorted by the Environment of Care (EOC), Emergency Management (EM), and Life Safety (LS) standards, EPs and other regulatory numbers.

Centralize:
Now that documentation and “proof” have been gathered and organized, the hospital should consider where the information will be kept, for example, in the Facilities Engineering Department, Safety Office, or Accreditation/Compliance Department. It is critical that appropriate staff be informed as to the location(s) of the documentation.

Educate:
The hospital should have a backup plan just in case the “one person” who knows everything and here it’s located is not there on the survey days. Educate several staff members on the EOC, EM, and LS standards and programs, and the location of the documentation. As required, they can retrieve the documentation and present it to the surveyor(s).

If documentation is organized, centralized and the appropriate backup staff is educated, the hospital can be confident that staff can quickly retrieve the requested documentation showing “proof of compliance” with the standards and EPs resulting in a successful TJC survey!

Compliance News: Egress Obstructions

By Robert Trotter, CBO, CFM

The 2000 edition of NFPA 101®, Life Safety Code® states in Appendix A.1.2.1, “Experience indicates that panic seldom develops, even in the presence of potential danger, as long as occupants of buildings are moving toward exits that they can see within a reasonable distance without obstructions or undue congestion in the path of travel.” Specifically, the Life Safety Code® section 7.1.10.1 mandates the following, “Means of egress shall be continuously maintained free of all obstructions or impediments to full instant use in the case of fire or other emergency.”

The Joint Commission addressed egress obstructions in the The 2009 Hospital Accreditation Standards under LS.02.01.20 Element of Performance 13 “Exits, exit accesses, and exit discharges are clear of obstructions or impediments to the public way, such as clutter (for example, equipment, carts, furniture), construction material, and snow and ice.”

Compliance News: Piped Oxygen Tank Supply Rooms

By Robert Trotter, CBO, CFM

The 2009 Hospital Accreditation Standards of The Joint Commission require piped oxygen tank supply rooms to be treated as hazardous areas protected by walls and doors in accordance with NFPA 101-2000: 18/19.3.2.1. Specifically, LS.02.01.30 Element of Performance 2 states that both existing and new piped oxygen tank supply rooms have 1-hour fire-rated walls with ¾-hour fire-rated doors. The 1999 edition of NFPA 99, Standard for Health Care Facilities, also offers the following precautions:

• Other nonflammable (inert) medical gases may be stored in the enclosure.
• Flammable gases shall not be stored with oxidizing agents.
• Storage of full or empty cylinders is permitted.
• Such enclosures shall serve no other purpose.
• Provisions shall be made for racks or fastenings to protect cylinders from accidental damage or dislocation.
• Combustible materials, such as paper, cardboard, plastics, and fabrics, shall not be stored or kept near supply system cylinders or manifolds containing oxygen or nitrous oxide.

Compliance News: Transitioning from Construction to Survey-Ready Compliance - Part 1

By David Stymiest, PE, FASHE, CHFM

Transitioning from a construction project to survey-ready compliance at occupancy is challenging at best. Facility activation and move-in are usually foremost and it is often difficult to get all of the compliance work done on time. This can put the hospital at risk during an early survey. This series of articles will discuss the major environment of care (EC) compliance issues and needs for Day 2 – the day after a facility opens.

Proactive compliance recognizes that “continuous compliance” could include an unannounced accreditation survey shortly after occupancy – and some hospitals will tell you that this has occurred. Rather than finding what is wrong and fixing it, proactive compliance involves determining what is needed and when it is needed for compliance, identifying what is missing in time to obtain it, and then thoroughly managing this process.

Unfortunately, many construction projects reflect one or more of the following conditions about some of the compliance-related project record documentation:

• The work never gets done.
• The work gets done but is not accurately documented.
• The work gets done and gets accurately documented, but that documentation does not meet
the AHJ’s rules.
• The work gets done, gets accurately documented, the documentation would be acceptable to
the AHJ, but it does not arrive on time for an early AHJ survey.

It is necessary to identify all of the required documentation, and who on the project team is responsible for each item. If documentation is not contractually required in a format that will be survey-ready, chances are that it will not be survey-ready without more work by the Owner. And that extra work is not always completed before occupancy because of the conflicting priorities associated with opening and occupying the project area. The best situation occurs when the AHJ’s compliance requirements related to the initial inspections, testing, documentation and training are factored into project construction documents – with the intent to ensure that project record documents are survey-ready when received on time to support an early survey. This approach leverages already scarce resources by assuring that facility personnel do not need to spend time or funds redoing, to make survey-ready, what the Contractor has already prepared.

The following types of EC compliance documentation should be ready and easily retrievable during a survey on Day 2:

• Project record documentation: test and inspection reports, permits, licenses, certifications, documentation of all required “testing prior to initial use,” AHJ approvals, etc.
• Documentation for the new facility/expansion: inventories, management plans, policies and procedures (P&Ps), risk assessments, training records, maintenance decision processes, inputs into P&Ps and maintenance management systems from O&M manuals, evaluations, lists, spreadsheets, databases, schedules and forms for ongoing required drills, exercises, tests, inspections and maintenance, and all required Emergency Operations Plan (EOP) documentation.
• Life Safety Assessment™ and accurate updated life safety plans, eSOC™, any Plan for Improvement items, and performance-based options for new construction or equivalencies for existing construction.
• Personnel protective equipment (PPE), spill kits, monitoring equipment and other supplies.
• Mapping of utility systems and labeling for critical utility disconnects.

Wednesday, July 29, 2009

Compliance News: Master Fire Alarm Control Panel

By Robert Trotter, CBO, CFM

It is imperative that the master fire alarm control panel be adequately protected to ensure the integrity of the fire alarm system. The 2009 Hospital Accreditation Standards of The Joint Commission mandate in LS.02.01.34 Element of Performance 2, “The master fire alarm panel is located in a protected environment (an area enclosed with 1-hour fire-rated walls and ¾-hour fire-rated doors) that is continuously occupied or in an area with a smoke detector.” Health care occupancies unlike other occupancies practice a defend-in-place concept whereas other occupants of other occupancy classifications evacuate upon activation of the fire alarm system. Since health care occupants remain in the building, persons assigned to monitor the master fire alarm panel (where applicable) must remain at the panel to acknowledge all alarms received. Therefore, the area must be enclosed with one-hour fire-rated walls and ¾-hour fire-rated doors. Where off-site monitoring is provided for the organization and no staff is assigned alarm monitoring duties, the master fire alarm control panel must be protected by a smoke detector and the additional fire-rated walls and doors are not required.

Compliance News: Fire Watch for Scheduled and Unscheduled “Out of Service” Fire Alarm or Sprinkler System

By Dean H. Samet, CHSP

In a June 2009 The Joint Commission Perspectives® article titled “Conducting the Fire Watch of Standard LS.01.02.01,” TJC clarified when a “fire watch” is required during both scheduled and unscheduled outages.

Background: Standard LS.01.02.01, EP1 states, “The hospital notifies the fire department (or other emergency response group) and initiates a fire watch when a fire alarm or sprinkler system is ‘out of service’ more than 4 hours in a 24-hour period in an occupied building. Notification and fire watch times are documented. (For full text and any exceptions, refer to NFPA 101®-2000: 9.6.1.8 and 9.7.6.1).” See also Life Safety Code® Annex A.9.6.1.8 and A.9.7.6. At a minimum, TJC expects the organization to:

• Notify the fire department, fire marshal, or other appropriate emergency response group, and document when that notification occurs; and
• Conduct rounds of the area(s) affected by the outage, and document those rounds.

It is mandated that the fire watch be enforced until the fire alarm or sprinkler system has been returned to service, is stable, and is fully functioning.

Fire Watch Defined: Per the NFPA 101®-2000: Annex A.9.6.1.8, “A fire watch should at least involve some special action beyond normal staffing, such as assigning an additional security guard(s) to walk the areas affected. These individuals should be specially trained in fire prevention and in occupant and fire department notification techniques, and they should understand the particular fire safety situation for public education purposes.” The Health Care Interpretations Task Force (see NFPA website for HITF info) agreed in 1998 that the clinical staff in an area affected by a fire alarm or sprinkler system impairment could be used to satisfy the requirements for a fire watch, provided there would be adequate staffing to continuously patrol the affected area(s), and staff would have the means to make proper notification to building occupants in the event of a fire.

Per the aforementioned Perspectives article, a “scheduled activity” (planned) would be an event known to and under the control of the organization’s staff, e.g., a new installation or servicing or upgrading an existing fire alarm or sprinkler system. All other outages would typically be considered “unscheduled activities” (unplanned).

A table is provided in the June 2009 The Joint Commission Perspectives article defining “Out of Service” responsibilities, showing different service situations, whether a fire watch is required, and whether an interim life safety measure (ILSM) evaluation is required. It is intended only to provide guidance regarding the phrase “out of service.” Organizations still need to assess each outage or activity to determine the need for a fire watch and if ILSM procedures should be implemented per their written ILSM policies.

Out of Service Situations:

• Putting a shield over one smoke detector to prevent dust/false alarms for more than four hours - No fire watch required; ILSM evaluation recommended.

• Covering all smoke detectors during a “controlled” event, such as only during the time the contractors are working in an affected area, although after hours, the entire area is fully operational - No fire watch required; ILSM evaluation required.

• Shutting off a zone valve to the sprinkler system or disabling a fire alarm zone for more than four hours as part of a:
1. “Scheduled” event, e.g., working on, servicing, or upgrading the fire alarm or sprinkler system - Fire watch not required in all cases; ILSM evaluation required with emphasis on occupant notification.
2. “Unscheduled” event, e.g., shutting off a zone valve to the sprinkler system or disabling a smoke zone for more than four hours in response to a system failure - Fire watch required; ILSM evaluation required.

Further clarification was provided recently by TJC’s senior engineer, George Mills, at a June 2009 NFPA conference in Chicago where George talked about “planned” vs. “unplanned” outages of the fire alarm or sprinkler system. He said that if the outage was planned and only covered one alarm zone at a time, a fire watch would probably not be needed. However, if the outage was not planned and resulted from an indeterminate cause, then it would be a good idea to set up a fire watch and appropriate ILSMs. George also suggested that your ILSM policy not be overly restrictive and be matched to the hazard(s) being addressed.

In order to ensure as safe an environment as possible during any potential outages of the fire alarm system or automatic sprinkler system, whether scheduled or unscheduled, planned or unplanned, it is imperative that the above listed criteria be followed. Failure to do so could result in an adverse accreditation decision of either Conditional Accreditation or Preliminary Denial of Accreditation per the 2009 “criticality model” of scoring and Accreditation Decision Rules.

For questions about conducting a fire watch, you may contact The Joint Commission’s Standards Interpretation Group (SIG) at 630-792-5900 or on-line at SIGInquiries@jointcommission.org.

Compliance News: Novel Influenza A (H1N1): Swine Flu and You

By Dean H. Samet, CHSP

On June 11, 2009, the World Health Organization signaled that a global pandemic of novel influenza A (H1N1) was underway by raising the worldwide pandemic alert to Phase 6 as a reflection of the spread of this virus, not the severity of illness caused by the virus. Most of us have been informed and warned about this new so-called “swine flu” virus first detected in people in the United States in April of 2009. The Centers for Disease Control and Prevention (CDC) has determined that this now named novel influenza A (H1N1) flu virus is contagious and spreading from person to person the same way regular seasonal influenza viruses spread - primarily by the coughing and sneezing of those infected with the virus. What can you do to stay healthy?

If you have what feels like seasonal flu symptoms, e.g., fever, cough, sore throat, runny or stuffy nose, body aches, headache, chills, fatigue, possibly diarrhea, and vomiting, you might be infected with the H1N1 virus. The CDC suggests:

• Stay informed via the CDC website (www.cdc.gov/h1n1flu).
• Cover your nose and mouth with a tissue when you cough or sneeze. Then throw the tissue in the trash after you use it.
• Wash your hands often with soap and water for 15 to 20 seconds, especially after you cough or
sneeze.
• Use alcohol-based hand cleansers or disposable hand wipes.
• Avoid touching your eyes, nose or mouth. You may have touched something with flu viruses on it. Germs spread that way.
• Try to avoid close contact with sick people.
• Stay home if you get sick except to seek medical care. The CDC recommends that you stay home from work or school and limit contact with others to keep from infecting them.
• If you have severe illness or you are at high risk for flu complications, contact your health care
provider or seek medical care.
• Stay home if you are sick for seven days after your symptoms begin or until you have been
symptom-free for 24 hours, whichever is longer.
• Follow public health advice regarding school closures, avoiding crowds and other social distancing measures.
• Call 1-800-CDC-INFO for more information.

Furthermore, the CDC recommends urgent medical attention for children experiencing the following emergency warning signs:

• Fast breathing
• Bluish or gray skin color
• Not drinking enough fluids
• Severe or persistent vomiting
• Not waking up or not interacting

• Being so irritable that the child does not want to be held
• Flu-like symptoms improve but then return with fever and worse cough

In adults, emergency warning signs that need urgent medical attention include:

• Difficulty breathing or shortness of breath
• Pain or pressure in the chest or abdomen
• Sudden dizziness
• Confusion
• Severe or persistent vomiting
• Flu-like symptoms improve but then return with fever and worse cough

The United States continues to report the largest number of novel H1N1 cases of any country worldwide. According to the CDC, as of July 17, 2009 there have been 40,617 reported cases of H1N1 flu infection in all 50 states, including the District of Columbia, and American Samoa, Guam, Puerto Rico, and the US Virgin Islands, and 263 deaths as a result of illness associated with this virus. A July 6th World Health Organization (WHO) update showed 94,512 confirmed cases in 122 countries with 429 deaths. The good news is that most people who have become ill have recovered without requiring medical treatment.

CDC anticipates that there will be more cases in the United States over the summer and into the fall and winter this year. By following the above-listed CDC suggestions and everyday actions, you can help prevent the spread of germs that cause respiratory illness like the H1N1 flu virus and that will permit you, your family, fellow workers, and those around you to stay healthy!

Friday, May 29, 2009

Compliance News: Temporary Lighting

By Robert Trotter, CBO, CFM

Wiring for power and lighting during a period of construction, remodeling, maintenance, repair, or demolition, and similar purposes must comply with the provisions of NFPA 70 National Electrical Code, 1999 edition. Under the requirements of section 305-3 temporary electrical power and lighting installations are permitted during the period of construction, remodeling, maintenance, repair, or demolition of buildings, structures, equipment, or similar activities.

Temporary electrical power and lighting installations are permitted for a period not to exceed 90 days for Christmas decorative lighting and similar purposes. Temporary wiring must be removed immediately upon completion of construction or purpose for which the wiring was installed.

Compliance News: Fusible Links for Fire Doors

By Robert Trotter, CBO, CFM

Fusible links often play an important role for fire door operation. NFPA 80, Standard for Fire Doors and Fire Windows, 1999 edition, describes the provisions for the use of fusible links. First it is important to understand that a fusible link is two pieces of metal held together by low-melting-point solder. Horizontally sliding doors, vertically sliding doors, rolling steel doors and service counter doors of the rolling type must close automatically upon activation or release of a fusible link or detector. In reference to the example pictured, section 1-10.2 states, “All detectors including fusible links shall not be placed in the dead air space developed at the intersection of the wall and ceiling directly above the fire door.” The dead air space is measured four inches down from the ceiling to the closest edge of the fusible link or four inches along the ceiling extending outward from the corner. NFPA 80 also requires detectors or fusible links to be installed on both sides of the wall, interconnected so that the operation of any single detector or fusible link causes the door to close. Where fusible links are used, one fusible link must be located near the top of the opening, and additional links shall be located at or near the ceiling on each side of the wall. Fusible links located above the ceiling are not acceptable. Refer to NFPA 80 for full text and exceptions.

Compliance News: BMP: An ISO 9001 Process Approach?

By Arthur J. Mahanna, Architect

In 1999 The Joint Commission (TJC) issued a revised Statement of Conditions (SOC) document that included a Building Maintenance Program option for Healthcare occupancies under the Part 3, Life Safety Assessment, questions 6I (new) and 6J (existing). This option provided hospitals scoring benefits for ten specific items prone to failure if they could demonstrate they had implemented an effective Building Maintenance Program (BMP). These included specific issues related to fire doors, smoke doors, corridor doors, smoke barriers, corridor walls, exit signs, egress lights, trash and linen chutes, ice and snow removal in the means of egress, and grease producing devices.

By their definition, if a hospital could show a 95% effectiveness rating for these issues, a BMP would be considered effective. What this really meant for example, was that if on the day of the Environment of Care (EOC) inspection, the hospital had a few exit signs burned out, a Requirement for Improvement (RFI) would not be received for each exit sign if you could produce the appropriate inspection and analysis information for a BMP on your exit signs.

For the next 12 years people analyzed, discussed, and microscopically dissected what TJC meant by 95% and the many different ways this data could be reported and managed. In many cases the emphasis was on how to get the scoring benefit rather than the actual reason for the BMP. As a result, the Centers for Medicare & Medicaid Services (CMS), and even some TJC Life Safety Code Specialist Surveyors, would not accept BMP as a legitimate substitute for 100% compliance at all times.

In January of 2009, TJC released its new Hospital Accreditation Standards (HAS) as part of their standards improvement initiative. While this new document mentioned BMP as an effective method for ensuring compliance, the scoring benefits were eliminated. On the surface this may have seemed like TJC was backing off the need for such programs, but in reality for those who truly had taken the BMP concept to heart, the value beyond scoring was clear. Not only does BMP serve as a valuable tool in reducing the risk of RFIs, it also can be used to support a hospital when RFIs and possible Conditional Accreditation become a reality.

In eliminating the scoring, TJC has actually opened up the use of this concept for many more items previously excluded from the BMP methodology. For example, in the 2009 Hospital Accreditation Standards, per Standard EC.02.03.05, “The hospital maintains fire safety equipment and fire safety building features.” Numerous tests and inspections are required, such as: quarterly testing of supervisory signals; semi-annual testing of valve tamper switches and water flow devices; and monthly inspections of fire extinguishers. In particular, items like these, with large volumes of devices to inspect and test, lend themselves well to the BMP concept. This also holds true for some items per Standard EC.02.05.07, “The hospital inspects, tests, and maintains emergency power systems,” e.g., battery operated egress lights, or Standard EC.02.05.09, “The hospital inspects, tests, and maintains medical gas and vacuum systems.”

In addition, if someone is inspecting traditional BMP items such as fire or smoke doors, why not add a check for unauthorized coverings and decorations or even unapproved protective plates at the same time the closers, latches, gaps and undercuts are reviewed?

Interestingly, fire walls were never part of the original ten BMP items. The reason given during the original BMP development process was that fire walls needed to be 100% compliant all the time. While this does emphasize the importance of maintaining fire walls, the words do little to actually ensure 100% compliance. Only a “process approach” to managing these items can truly reduce the possibility of failures and the likelihood of an RFI.

While a “process approach” can assist in the accreditation process with The Joint Commission, this methodology also fits quite nicely with the ISO 9001 standards adopted by Det Norske Veritas Healthcare (DNVHC), the new accrediting body approved last year by the Centers for Medicare & Medicaid Services.

Per ISO 9001, 0.2 Process Approach:

“This International Standard promotes the adoption of a process approach when developing, implementing and improving the effectiveness of a quality management system, to enhance customer satisfaction by meeting customer requirements.

For an organization to function effectively, it has to identify and manage numerous linked activities. An activity using resources, and managed in order to enable the transformation of inputs into outputs, can be considered as a process. Often the output from one process directly forms the input to the next.

The application of a system of processes within an organization, together with the identification and interactions of these processes, and their management, can be referred to as the ‘process approach’.”

An advantage of the process approach is the ongoing control that it provides over the linkage between the individual processes within the system of processes, as well as over their combination and interaction.

When used within a quality management system, such an approach emphasizes the importance of:
a) Understanding and meeting requirements,
b) The need to consider processes in terms of added value,
c) Obtaining results of process performance and effectiveness, and
d) Continual improvement of processes based on objective measurement.

NOTE: In addition, the methodology known as “Plan-Do-Check-Act” (PDCA) can be applied to all processes. PDCA can be briefly described as follows.

Plan: Establish the objectives and processes necessary to deliver results in accordance with customer requirements and the organization’s policies.

Do: Implement the processes.

Check: Monitor and measure processes and product against policies, objectives and requirements for the product and report the results.

Act: Take actions to continually improve process performance.

Note the similarities between a Building Maintenance Program and the “Process Approach” described in the ISO standards:

• “Planning” a BMP requires identifying the locations and quantities of fire doors, smoke doors, etc., within your facility and identifying what requirements should be evaluated for each item.

• “Doing” a BMP involves inspecting the requirements for each item and recording when a specific requirement is non-compliant.

• “Checking” a BMP involves reviewing findings and analyzing the survey results for problem areas.

• “Acting” on BMP results means that the 95% rule can still be used as a means of evaluating success as well as determining where improvements are needed. If the closers and latches on a particular set of fire doors continue to fail, you should determine the reasons for the failure and correct. Perhaps training staff that use carts is warranted. Or, if inspecting fire doors quarterly simply isn’t resulting in a 95% rating, then it may be necessary to conduct monthly inspections of fire doors, or perhaps monthly inspection of fire doors in certain areas.

Another critical aspect of a BMP’s success is your work order repair process. As described earlier, “An advantage of the process approach is the ongoing control that it provides over the linkage between the individual processes within the system of processes, as well as over their combination and interaction.” Another possible cause for continued failure of the same items over and over again is a failure to repair items. Since the BMP and work order repair processes are ultimately linked together, the BMP can help to determine the success of the work order repair process.

Regardless of the AHJ you choose now or in the future, a process approach that follows the ISO “Plan-Do-Check-Act” methodology and/or BMP will improve your quality management system and ultimately reduce problems in future accreditation surveys and inspections. BMP is alive and well for those wise enough to see its benefits.

Sunday, March 29, 2009

Compliance News: Noncombustible Sills for Fire Doors

By Robert Trotter, CBO, CFM

Fire rated doors must be installed properly so that fire cannot spread below, around, or above the door. To minimize the risk for fire spread at the undercut of a fire door, NFPA 80, Standard for Fire Doors and Fire Windows, 1999 edition describes the requirements for sills. Section 1- 1.2.1 states, “In buildings with noncombustible floors, special sill construction shall not be required, provided the floor structure is extended through the door opening.” Largely, healthcare occupancies have noncombustible floor construction and no special sill construction would be required. This means the example pictured would be compliant even though the carpet extends through the door opening. However, Section 1-11.2.3 states, “Combustible floor coverings shall not extend through openings protected by 3-hour rated fire protection door assemblies.”

In buildings with combustible floors or combustible floor coverings, special sill construction is required if the floor structure is extended through the door opening, as combustible floor construction is not permitted to extend through the door opening except door openings required to be protected by 20- or 30-minute doors. All sills must be constructed of noncombustible materials. Consult NFPA 80 for additional details regarding the arrangement of sills.

Compliance News: Unusual Observations

By Robert Trotter, CBO, CFM

Whether you complete your own life safety assessment for compliance with the Life Safety Code® or the work is performed by a third party, frequently an issue is discovered that is not described in the Statement of Conditions™. For the past several years we have been noting these issues as Unusual Observations. Starting in January 2009, as a result of The Joint Commission Standards Improvement Initiative, the new Life Safety Chapter incorporates an Element of Performance at the end of each individual standard to note other deficiencies. For example, under the Hospital Accreditation Program Standard LS.02.01.20 EP (32) states, “The hospital meets all other Life Safety Code means of egress requirements related to NFPA 101- 000: 18/19.2.” This Element of Performance gives you the latitude to create a Work Order or a Plan for Improvement (PFI) for any deficiency discovered that can not be associated with one of the Standard’s preceding Elements of Performance.

Regarding the example photograph, the Hospital Standard does offer Element of Performance (13) relative to the exit discharge and obstructions or impediments to the public way that may be acceptable for the landscape in the means egress. However, the full text and exceptions sends you NFPA 101-2000: 7.1.10.1 for means of egress reliability. Another key observation that may not be discernible in the photograph is the change in elevation in excess of 21 inches without a ramp or stair as required by NFPA 101-2000: 7.1.7.2. This would be an excellent example of when to cite noncompliance at LS.02.01.20 EP (32).

Compliance News: Magnetic Locks Create Headroom Obstruction

By Robert Trotter, CBO, CFM

As pictured in the example, magnetic locks installed to control access or egress often are located in a position that creates a headroom obstruction. According to section 7.2.1.2.2 of the NFPA 101®, Life Safety Code®, 2000 edition, “Projections into the required clear door opening width that are not less than 34 inches but that do not exceed 80 inches above the floor or ground shall be limited to the hinge side of each door opening and shall not exceed 4 inches.” This space allows for projections such as self-closing or automatic-closing devices, panic hardware and fire exit hardware. Projections exceeding 80 inches above the floor or ground are not limited.

Compliance News: Stair Identification Signs

By Michael L. Hawkins, CFSI, CHMT

All too often when conducting SOC surveys in Health Care Occupancies, we come across improper stair identification. NFPA 101 Life Safety Code®, 2000 ed., Chapter 19 “Existing Healthcare” requirements refers back to Chapter 7 “Means of Egress” for proper stair identification.

NFPA 101®, Life Safety Code® 2000 edition
7.2.2.5.4* Stair Identification Signs
Stairs serving five or more stories shall be provided with signage within the enclosure at each floor landing. The signage shall indicate the story, the terminus of the top and bottom of the stair enclosure, and the identification of the stair enclosure. The signage also shall state the story of, and the direction to, exit discharge. The signage shall be inside the enclosure located approximately 5 feet (1.5 m) above the floor landing in a position that is readily visible when the door is in the open or closed position.

7.2.2.5.5 Egress Direction Signs
Wherever an enclosed stair requires travel in an upward direction to reach the level of exit discharge, signs with directional indicators indicating the direction to the level of exit discharge shall be provided at each floor level landing from which upward direction of travel is required. Such signage shall be readily visible when the door is in the open or closed position.

Exception No. 1: This requirement shall not apply where signs required by 7.2.2.5.4 are provided.
Exception No. 2: Stairs extending not more than one story below the level of exit discharge where the exit discharge is clearly obvious shall not be subject to this requirement.

Stairwell signage is extremely important not only for the evacuation of occupants but for the responding fire and rescue personnel. Please check those in your hospital to ensure that the needed and appropriate signs are in place.

Compliance News: Power Strips in Patient Care Areas

By David Stymiest, PE, CHFM, FASHE, CEM, GBE

A subject that bears watching is the current concern about stand-alone power strips being used in General Patient Care Areas and Critical Patient Care Areas. ASHE/AHA Listserv users saw considerable traffic recently on this topic. The issue stems from a Centers of Medicare and Medicaid (CMS) document (Publication 100-07, Transmittal 27 dated August 17, 2007, entitled Revisions to Appendix PP – Guidance to Surveyors for Long Term Care Facilities) that includes the following excerpt: “Power strips may not be used as a substitute for adequate electrical outlets in a facility. Power strips may be used for a computer, monitor, and printer. Power strips are not designed to be used with medical devices in patient care areas.” Some hospitals are reporting that CMS hospital surveyors have used this LTC Facility guidance to cite them for using power strips (called “Relocatable Power Taps” in UL terminology) in General Patient Care Areas and Critical Patient Care Areas.

It appears that this issue arose because of Underwriters Laboratories’ (UL’s) concern that there are no listed power taps for patient care areas of health care facilities per UL product category “Relocatable Power Taps (XBYS).” UL stated in a March 1, 2008 posting on the International Association of Electrical Inspectors (IAEI) website www.iaei.org, “The use is restricted from these patient care areas because UL cannot control what is connected to the power taps which could result in leakage current that would be in excess of what is permitted for patient care areas of hospitals.” UL further stated that “UL does Classify complete system medical cart assemblies for use in hospitals under the product category “Medical Equipment (PIDF).” Those medical cart assemblies may contain a power tap as part of the tested assembly per UL 60601-1 Medical Electrical Equipment (previously UL 2601-1.) Interpreting UL’s statements, it appears that external equipment (that not already tested as part of the listing process) may not be plugged into the cart-mounted power strips.

Some hospitals are taking the risk assessment approach to this issue – that is recognizing that power strips, or relocatable power taps, are subject to failure just like any other device and therefore inventorying them and subjecting them to the same risk-based testing and maintenance regimens as outlets and medical devices.

Stay tuned to ASHE’s ongoing advocacy efforts – this subject is likely to continue to be part of those efforts due to its potential cost impact on America’s hospitals.

As always, regardless of the area in which such devices are used, facilities need to be aware of the total loading of devices plugged into them and ensure that the portable devices themselves, and the branch circuits that feed them, do not become overloaded. If power strips are presently being used, regardless of the area, high current-draw equipment should not be plugged into them.

Thursday, January 29, 2009

Compliance News: TJC Standards and Scoring Changes for 2009

There have been some significant changes to The Joint Commission’s (TJC) standards and scoring for 2009. The Emergency Management (EM) requirements have been removed from the Environment of Care chapter and incorporated into their own EM chapter. The Life Safety Code® requirements, Statement of onditions™ (SOC™), and Interim Life Safety Measures (ILSM) have all been relocated to a new Life Safety (LS) chapter. While there are purportedly no new requirements as a result of all these changes, there are some subtle nuances that may be viewed as new requirements along with items that might have been implied in the past which are now specified. However, the most significant changes can be found in the scoring.

Compliance News: TJC Thresholds to Serve as Screens for PDA & CA Decisions

By Dean Samet, CHSP

In their December 2008 The Joint Commission Perspectives, Volume 28, Number 12, The Joint Commission (TJC) reported that at its October 2008 meeting, TJC’s Accreditation Committee (AC) approved the remaining component for the 2009 accreditation decision methodology which included elimination of the use of thresholds” as determinants of Conditional Accreditation (CA) and Preliminary Denial of Accreditation (PDA). Thresholds have been used by TJC for years to determine whether to invoke or recommend CA or PDA if and when an organization had exceeded a preset number of Requirements for Improvement (RFIs).

Compliance News: Sprinkler Obstructions

By Robert Trotter, CBO, CFM

The Joint Commission’s Life Safety Standard LS.02.01.10 states, “…buildings contain approved automatic sprinkler systems as required…” In order to determine where sprinklers are required facility managers should consult NFPA 13, Standard for the Installation of Sprinkler Systems.  Recently, TJC surveyors have recognized deficiencies related to sprinkler obstructions and noted such observations.  NFPA 13 states, “Sprinklers shall be installed under fixed obstructions over 4 foot wide such as ducts, decks, open grate flooring, cutting tables, and overhead doors.  Sprinklers are not required under obstructions that are not fixed in place such as conference tables.” The example shows sprinkler protection under an HVAC duct which was an obstruction that prevents sprinkler discharge from reaching the hazard.  Consult your licensed fire sprinkler contractor for assistance.

Compliance News: Beyond Level of Exit Discharge

By Robert Trotter, CBO, CFM

NFPA 101®, Life Safety Code® states in section 7.7.3 “Stairs shall be arranged so as to make clear the direction of egress to a public way.  Stairs that continue more than one-half story beyond the level of exit discharge shall be interrupted at the level of exit discharge by partitions, doors, or other effective means.”  The example shown is a barrier that restricts downward travel.  Upward travel to the rooftop may also require a barrier.  The LSC also prescribes provisions for signs.  Section 7.10.8.3.1 states,  “Any door, passage, or stairway that is neither an exit nor a way of exit access and that is located or arranged so that it is likely to be mistaken for an exit shall be identified by a sign that reads as follows: NO EXIT.”  The NO EXIT sign shall have the word NO in letters two inches high, with a stroke width of ⅜ inch, and the word EXIT in letters one inch high, with the word EXIT below the word NO, unless such sign is an approved existing sign.  The sign in the example may be an approved existing sign as it appears to be meeting the intent of the code.

Compliance News: Storage in Exit Enclosures

By Robert Trotter, CBO, CFM

Maintaining the means of egress is a critical role for any facility manager.  It is important to note that NFPA 101®, Life Safety Code® section 7.2.2.5.3.1 addresses storage in exit enclosures,“Open space within the exit enclosure shall not be used for any purpose that has the potential to interfere with egress.”  Clearly by
the examples shown, this storage arrangement has the potential to interfere with egress by leaving this stairway completely inaccessible should these stored materials catch on fire. Moreover, it also presents an opportunity for an incendiary fire.

Compliance News: Combustible Decorations

By Robert Trotter, CBO, CFM


Evaluation of combustible decorations is always difficult because interpretation of the requirement is subjective.  One person may believe the decorations are acceptable and do not constitute a hazard, while another may feel that the decorations are too much.  Regardless, combustible decorations must meet the requirements of the Life Safety Code®. For those organizations accredited by The Joint Commission, requirements for combustible decorations are found in the Life Safety Chapter. For example, the hospital accreditation program Standard LS.02.01.70 Element of Performance (1) states, “The hospital prohibits all combustible decorations that are not flame retardant. (For full text and any exceptions, refer to NFPA 101-2000: 18/19.7.5.4.)”  Both the new and existing health care occupancy chapters state, “Combustible decorations shall be prohibited in any health care occupancy unless they are flame-retardant. Exception:  Combustible decorations, such as photographs and paintings, in such limited quantities that a hazard of fire development or spread is not present.”