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.