tag:blogger.com,1999:blog-61961545518223268802024-03-18T04:47:26.665-05:00SSR Compliance and Facilities Management ArticlesSSR Compliance and Facilities Managementhttp://www.blogger.com/profile/08001053767242037976noreply@blogger.comBlogger351125tag:blogger.com,1999:blog-6196154551822326880.post-73027169664551152532014-02-20T12:23:00.000-06:002014-02-20T12:23:00.756-06:00TJC Clarifies Emergency Power Expectations <div class="separator" style="clear: both; text-align: center;">
<a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhbcq68pxZXiloExtgGcO0JxSPbmNV-r204ext3blXIAIPA3sFrySxxnxh8fRo64ZgqiLw4UkdC4P7jiAKlc9ihYafLDmwa0zVXAsg-YAmVVxLyKeuQ_cD8nDLKqufgOfY8jivwUaqTuEg/s1600/Compliance+News+header.jpg" imageanchor="1" style="clear: left; float: left; margin-bottom: 1em; margin-right: 1em;"><img border="0" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhbcq68pxZXiloExtgGcO0JxSPbmNV-r204ext3blXIAIPA3sFrySxxnxh8fRo64ZgqiLw4UkdC4P7jiAKlc9ihYafLDmwa0zVXAsg-YAmVVxLyKeuQ_cD8nDLKqufgOfY8jivwUaqTuEg/s1600/Compliance+News+header.jpg" height="70" width="200" /></a></div>
By David Stymiest, PE, CHFM, CHSP, FASHE<br />
<br />
<span style="font-family: Arial,Helvetica,sans-serif;">In the January 2014 editions of both TJC Perspectives and TJC EC News, TJC Director of Engineering George Mills listed numerous clarifications and expectations for emergency power systems. Below are the design-related issues that he covered.</span><br />
<a name='more'></a><br />Mr. Mills discussed the NFPA 110-2010 requirements for Emergency Power Supply System (EPSS) equipment and stated that the 2010 edition wording below provides guidance as to placement and protection of the EPSS. He also asked if healthcare organizations will have completed a risk assessment prior to designing and installing a new EPSS.<br /><br />“The rooms, shelters, or separate buildings housing Level 1 or Level 2 EPSS equipment <b>shall be designed and located</b> [emphasis added] to minimize the damage from flooding, including that caused by the following: (1) Flooding resulting from fire fighting (2) Sewer water backup (3) Similar disasters or occurrences.” (NFPA 110-2010, Section 7.2.3)<br /><br />“Minimizing the possibility of damage resulting from interruptions of the emergency source <b>shall be a design consideration</b> [emphasis added] for EPSS equipment.” (NFPA 110-2010, Section 7.2.4)<br /><br />Mr. Mills also discussed using battery-powered lights in both generator locations and transfer switch locations. He referenced only NFPA 110 in this portion of his discussion, but I am including the NFPA 99 reference below because an understanding of both standards is necessary. NFPA 99 (not NFPA 110) requires battery-powered emergency lighting at transfer switch locations.<br /><br />From NFPA 110-2010 and NFPA 110-2013 (note that the EPS is the Emergency Power Supply (generator) and does not include transfer switches): <br />7.3 Lighting.<br />7.3.1 The Level 1 or Level 2 EPS equipment location(s) shall be provided with battery-powered emergency lighting. This requirement shall not apply to units located outdoors in enclosures that do not include walk-in access.<br /><br /><i>From NFPA 99-2002 (note the underlined phrase below regarding transfer switch locations was added in the 2002 edition of NFPA 99. The wording remains the same in NFPA 99-2012):</i><br />4.4.2.2.2.2 Life Safety Branch.<br />(5) Generator set location: Task illumination, battery charger for emergency battery-powered lighting unit(s), and selected receptacles at the generator set location and essential electrical system transfer switch locations.<br /><br /><span style="font-size: x-small;">NFPA Disclaimer: Although the author is Chairman of the NFPA Technical Committee on Emergency Power Supplies, which is responsible for NFPA 110 and 111, the views and opinions expressed in this message are purely those of the author and shall not be considered the official position of NFPA or any of its Technical Committees and shall not be considered to be, nor be relied upon as, a Formal Interpretation. Readers are encouraged to refer to the entire text of all referenced documents. NFPA members can obtain NFPA staff interpretations at www.nfpa.org.</span><br /><br />Smith Seckman Reid, Inchttp://www.blogger.com/profile/13913803032935481245noreply@blogger.com0tag:blogger.com,1999:blog-6196154551822326880.post-36141825166606757732014-02-19T12:20:00.000-06:002014-02-19T12:20:05.758-06:00TJC Modifies Emergency Power Test Intervals for 2014<div class="separator" style="clear: both; text-align: center;">
<a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhbcq68pxZXiloExtgGcO0JxSPbmNV-r204ext3blXIAIPA3sFrySxxnxh8fRo64ZgqiLw4UkdC4P7jiAKlc9ihYafLDmwa0zVXAsg-YAmVVxLyKeuQ_cD8nDLKqufgOfY8jivwUaqTuEg/s1600/Compliance+News+header.jpg" imageanchor="1" style="clear: left; float: left; margin-bottom: 1em; margin-right: 1em;"><img border="0" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhbcq68pxZXiloExtgGcO0JxSPbmNV-r204ext3blXIAIPA3sFrySxxnxh8fRo64ZgqiLw4UkdC4P7jiAKlc9ihYafLDmwa0zVXAsg-YAmVVxLyKeuQ_cD8nDLKqufgOfY8jivwUaqTuEg/s1600/Compliance+News+header.jpg" height="70" width="200" /></a></div>
<span style="font-family: Arial,Helvetica,sans-serif;"><span style="font-size: small;"> By David Stymiest, PE, CHFM, CHSP, FASHE</span></span><br />
<span style="font-family: Arial,Helvetica,sans-serif;"><span style="font-size: small;"><br /></span></span>
<span style="font-family: Arial,Helvetica,sans-serif;"><span style="font-size: small;">The 2014 TJC Hospital Accreditation Standards include wording changes in Standard EC.02.05.07, EP-4 (generator test intervals) and EP-6 (transfer switch test intervals) that tweak the required test intervals a little.<br /><br />The new 2014 test interval language in both EPs states “At least monthly, the hospital tests ….” This is a change from the 2013 TJC wording in both EPs that stated “Twelve times a year, at intervals of not less than 20 days and not more than 40 days ….”</span></span><br />
<a name='more'></a><span style="font-size: small;"><br />The use of the term “monthly” has also been in NFPA 110 since at least 1999. That 1999 edition is referenced by the 2000 edition of NFPA 101, which is still enforced by CMS. The NFPA 110-1999 language states: <br /><br />6-4 Operational Inspection and Testing.<br />6-4.1* Level 1 and Level 2 EPSSs, including all appurtenant components, shall be inspected weekly and shall be exercised under load at least monthly.<br /><br />However we suggest that TJC-accredited organizations be careful before relaxing their existing test interval schedules. We understand that CMS is still enforcing the NFPA 99-1999 language, which states:<br /><br />5.4.4.1.1 Maintenance and Testing of Alternate Power Source and Transfer Switches<br />(b) Inspection and Testing.<br />1.* Test Criteria. Generator sets shall be tested twelve (12) times a year with testing intervals between not less than 20 days or exceeding 40 days….<br /><br /><b>We suggest that organizations consider maintaining a testing schedule that meets both the “monthly” criteria and the “20-40 day” criteria until both CMS and TJC agree with each other.</b><br /><br />What about the 2012 editions of NFPA 101 and NFPA 99 that the healthcare facilities industry is eagerly anticipating for CMS adoption?<br /><br />NFPA 110-2010 (which is referenced by both NFPA 101-2012 and NFPA 99-2012) states: <br /><br />“8.4.2* Diesel generator sets in service shall be exercised at least once monthly….” <br /><br />NFPA 99-2012, on the other hand, states:<br /><br />“6.4.4.1.1.4 Inspection and Testing. Criteria, conditions, and personnel requirements shall be in accordance with 6.4.4.1.1.4(A) through 6.4.4.1.1.4(C).<br />(A)* Test Criteria. Generator sets shall be tested 12 times a year, with testing intervals of not less than 20 days nor more than 40 days. Generator sets serving essential electrical systems shall be tested in accordance with NFPA 110, Standard for Emergency and Standby Power Systems, Chapter 8.”<br /><br />Our recommendation above – continue to meet both sets of criteria – stands.<br /><br /><span style="font-size: x-small;">NFPA Disclaimer: Although the author is Chairman of the NFPA Technical Committee on Emergency Power Supplies, which is responsible for NFPA 110 and 111, the views and opinions expressed in this message are purely those of the author and shall not be considered the official position of NFPA or any of its Technical Committees and shall not be considered to be, nor be relied upon as, a Formal Interpretation. Readers are encouraged to refer to the entire text of all referenced documents. NFPA members can obtain NFPA staff interpretations at www.nfpa.org.</span></span><br /><br />Smith Seckman Reid, Inchttp://www.blogger.com/profile/13913803032935481245noreply@blogger.com0tag:blogger.com,1999:blog-6196154551822326880.post-82828121529377090342014-02-18T12:18:00.001-06:002014-02-18T12:18:58.291-06:00TJC Redefines “Quarterly” and “Every 3 Years” for 2014<div class="separator" style="clear: both; text-align: center;">
<a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhbcq68pxZXiloExtgGcO0JxSPbmNV-r204ext3blXIAIPA3sFrySxxnxh8fRo64ZgqiLw4UkdC4P7jiAKlc9ihYafLDmwa0zVXAsg-YAmVVxLyKeuQ_cD8nDLKqufgOfY8jivwUaqTuEg/s1600/Compliance+News+header.jpg" imageanchor="1" style="clear: left; float: left; margin-bottom: 1em; margin-right: 1em;"><img border="0" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhbcq68pxZXiloExtgGcO0JxSPbmNV-r204ext3blXIAIPA3sFrySxxnxh8fRo64ZgqiLw4UkdC4P7jiAKlc9ihYafLDmwa0zVXAsg-YAmVVxLyKeuQ_cD8nDLKqufgOfY8jivwUaqTuEg/s1600/Compliance+News+header.jpg" height="70" width="200" /></a></div>
<span style="font-size: small;"><span style="font-family: Arial,Helvetica,sans-serif;">By David Stymiest, PE, CHFM, CHSP, FASHE</span></span><br />
<span style="font-size: small;"><span style="font-family: Arial,Helvetica,sans-serif;"><br /></span></span>
<span style="font-size: small;"><span style="font-family: Arial,Helvetica,sans-serif;">Take a close look at your 2014 schedules for quarterly requirements such as fire safety system testing found in several elements of performance (EPs) under Standard EC.02.03.05. The brand new 2014 TJC definition of QUARTERLY can be found on page EC-3 at the beginning of the EC Chapter in the 2014 Hospital Accreditation Standards. The previous definition allowed quarterly activities to be accomplished anytime during a calendar quarter. The 2014 definition, however, is “every three months, plus or minus 10 days.” We recommend that you interpret this new requirement conservatively as three months from the date of the previous activity, plus or minus 10 days.</span></span><br />
<span style="font-family: Arial,Helvetica,sans-serif;"></span><br />
<a name='more'></a><br />Also look at quarterly fire drill schedules in accordance with Standard EC.02.03.03, EP-1. Although it is not clear if an EC-chapter definition would extend to a related LS-chapter requirement, we recommend that a safe approach would be to look also at the additional quarterly fire drills scheduled to comply with the Standard LS.01.02.01, EP-11 Interim Life Safety Measure. We recommend that you take a close look at the new definition and check the schedule dates for the first day shift drills in each quarter, the second day shift drills in each quarter, the first evening shift drills in each quarter, etc.<br />
<span style="font-size: small;"><span style="font-family: Arial,Helvetica,sans-serif;"><br />And for those organizations that have a stored emergency power supply system (SEPSS), the Standard EC.02.05.07 EP-3 requirement for SEPSS quarterly testing is another area to review.</span></span><br />
<span style="font-size: small;"><span style="font-family: Arial,Helvetica,sans-serif;"><br />We recommend that organizations look at the actual dates for quarterly testing in 2013-Q4 and make sure that the 2014-Q1 dates will be in compliance with the new definition. And then take a close look at the entire 2014 testing calendar as well.</span></span><br />
<span style="font-size: small;"><span style="font-family: Arial,Helvetica,sans-serif;"><br />The other 2014 change in how TJC defines time between testing and inspection activities is the 3-Year test. The new EC chapter definition is 36 months from the date of the last event, plus or minus 45 days.” This is a change from the previous “plus or minus 30 days” requirement and is a minor relaxation of the rule that applies to the generator 4-hour tests required by Standard EC.02.05.07, EP-7. </span></span><br />
<br />Smith Seckman Reid, Inchttp://www.blogger.com/profile/13913803032935481245noreply@blogger.com0tag:blogger.com,1999:blog-6196154551822326880.post-51496839440866500492014-02-05T13:12:00.001-06:002014-02-05T13:12:28.135-06:00 Smart Money: Making the case for hospital infrastructure funding <div class="Subhead">
</div>
<div class="Subhead">
<span style="font-family: Arial,Helvetica,sans-serif;"><span style="font-size: small;">By David Stymiest, PE, CHFM, CHSP, FASHE</span></span> </div>
<div class="Subhead">
<span style="font-family: Arial,Helvetica,sans-serif;"><span style="font-size: small;"><br /></span></span></div>
<div class="Subhead">
<i><span style="font-family: Arial,Helvetica,sans-serif;"><span style="font-size: small;">This article recently appeared in Health Facilities Management.</span></span></i><br />
<span style="font-family: Arial,Helvetica,sans-serif;"><span style="font-size: small;"> </span></span><br />
<span style="font-family: Arial,Helvetica,sans-serif;"><span style="font-size: small;">Many health facilities managers would like to be more successful in
obtaining depreciation dollars to fund maintenance and infrastructure
capital renewal adequately. Gaining access to depreciation funding often
involves being more successful at selling the maintenance mission and
requires a multifaceted approach.</span></span><br />
<br />
<span style="font-family: Arial,Helvetica,sans-serif;"><span style="font-size: small;">The rules of engagement include such disparate approaches as
communicating with budget committees and chief financial officers (CFOs)
while employing the terminology they use for other hospital
initiatives, wise use of empirical information to communicate salient
facts regarding the hospital infrastructure, making sure to shift the
risk of non-funding to those who make funding decisions, and fitting
budget requests into the strategic big picture.</span></span><br />
<br />
<span style="color: blue;"><span style="font-family: Arial,Helvetica,sans-serif;"><span style="font-size: small;"><a href="http://www.hfmmagazine.com/hfmmagazine/jsp/articledisplay.jsp?dcrpath=HFMMAGAZINE/Article/data/01JAN2014/0114HFM_FEA_infrastructure&domain=HFMMAGAZINE">Read More. </a></span></span></span></div>
Smith Seckman Reid, Inchttp://www.blogger.com/profile/13913803032935481245noreply@blogger.com0tag:blogger.com,1999:blog-6196154551822326880.post-39241269842552245302013-11-13T15:34:00.000-06:002013-11-13T15:34:00.261-06:00TJC Expands Required Documents List<div class="separator" style="clear: both; text-align: center;">
<a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhbcq68pxZXiloExtgGcO0JxSPbmNV-r204ext3blXIAIPA3sFrySxxnxh8fRo64ZgqiLw4UkdC4P7jiAKlc9ihYafLDmwa0zVXAsg-YAmVVxLyKeuQ_cD8nDLKqufgOfY8jivwUaqTuEg/s1600/Compliance+News+header.jpg" imageanchor="1" style="clear: left; float: left; margin-bottom: 1em; margin-right: 1em;"><img border="0" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhbcq68pxZXiloExtgGcO0JxSPbmNV-r204ext3blXIAIPA3sFrySxxnxh8fRo64ZgqiLw4UkdC4P7jiAKlc9ihYafLDmwa0zVXAsg-YAmVVxLyKeuQ_cD8nDLKqufgOfY8jivwUaqTuEg/s1600/Compliance+News+header.jpg" height="70" width="200" /></a></div>
<span style="font-family: Arial,Helvetica,sans-serif;">In the September 2013 update to the 2013 Survey Activity Guide, The Joint Commission (TJC) added the following environment of care documents to its list of documents required at the beginning of a hospital survey. </span><br />
<span style="font-family: Arial,Helvetica,sans-serif;"><br />28. Written fire response plan<br />29. Interim Life Safety Measure policy<br />30. Fire drill evaluations</span>Smith Seckman Reid, Inchttp://www.blogger.com/profile/13913803032935481245noreply@blogger.com0tag:blogger.com,1999:blog-6196154551822326880.post-81313590854870793252013-11-12T15:33:00.000-06:002013-11-12T15:33:00.349-06:00TJC Notification Requirements for CMS Categorical Waivers<div class="separator" style="clear: both; text-align: center;">
<a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhbcq68pxZXiloExtgGcO0JxSPbmNV-r204ext3blXIAIPA3sFrySxxnxh8fRo64ZgqiLw4UkdC4P7jiAKlc9ihYafLDmwa0zVXAsg-YAmVVxLyKeuQ_cD8nDLKqufgOfY8jivwUaqTuEg/s1600/Compliance+News+header.jpg" imageanchor="1" style="clear: left; float: left; margin-bottom: 1em; margin-right: 1em;"><img border="0" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhbcq68pxZXiloExtgGcO0JxSPbmNV-r204ext3blXIAIPA3sFrySxxnxh8fRo64ZgqiLw4UkdC4P7jiAKlc9ihYafLDmwa0zVXAsg-YAmVVxLyKeuQ_cD8nDLKqufgOfY8jivwUaqTuEg/s1600/Compliance+News+header.jpg" height="70" width="200" /></a></div>
<span style="font-family: Arial,Helvetica,sans-serif;">The Joint Commission (TJC) recently clarified its notification requirements if an organization decides to take advantage of any CMS categorical waivers. If a categorical waiver relates to a Life Safety Code requirement, TJC has requested that the organization identify that decision in the Additional Comments field of the eBBI section of the eSOC at TJC’s eConnect website for that organization. On the other hand, if a categorical waiver relates to another chapter requirement, such as the motor-driven fire pump testing requirement within EC chapter Standard EC.02.03.05, TJC asks that the organization document its decision in the Safety Committee or EOC Committee meeting minutes. This is a change from information previously disseminated by ASHE shortly after the waivers were released by CMS.<br /><br />The organization should also notify the TJC surveyors at the beginning of the survey of any waivers that the organization has elected to use. </span>Smith Seckman Reid, Inchttp://www.blogger.com/profile/13913803032935481245noreply@blogger.com0tag:blogger.com,1999:blog-6196154551822326880.post-26395436261814644852013-11-11T15:30:00.000-06:002013-11-11T15:30:02.068-06:00TJC Emphasizes Pressure Relationships for Infection Prevention<div class="separator" style="clear: both; text-align: center;">
<a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhbcq68pxZXiloExtgGcO0JxSPbmNV-r204ext3blXIAIPA3sFrySxxnxh8fRo64ZgqiLw4UkdC4P7jiAKlc9ihYafLDmwa0zVXAsg-YAmVVxLyKeuQ_cD8nDLKqufgOfY8jivwUaqTuEg/s1600/Compliance+News+header.jpg" imageanchor="1" style="clear: left; float: left; margin-bottom: 1em; margin-right: 1em;"><img border="0" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhbcq68pxZXiloExtgGcO0JxSPbmNV-r204ext3blXIAIPA3sFrySxxnxh8fRo64ZgqiLw4UkdC4P7jiAKlc9ihYafLDmwa0zVXAsg-YAmVVxLyKeuQ_cD8nDLKqufgOfY8jivwUaqTuEg/s1600/Compliance+News+header.jpg" height="70" width="200" /></a></div>
<span style="font-family: Arial,Helvetica,sans-serif;">By David Stymiest, PE, CHFM, CHSP, FASHE</span><br />
<span style="font-family: Arial,Helvetica,sans-serif;"><br /></span>
<span style="font-family: Arial,Helvetica,sans-serif;">In his October 25th ASHE-sponsored webinar, TJC Director of Engineering George Mills emphasized the importance of maintaining proper pressure relationships for infection prevention where rooms are required to be positive or negative with respect to adjacent rooms or spaces. Mr. Mills reiterated previous statements regarding how TJC surveyors will test for required pressure relationships – surveyors will use the tissue test very early to assess the adequacy of pressure relationships at the doorways of rooms subject to those requirements. The tissue test is often performed by holding a thin tissue at the bottom door gap of a closed door. The tissue will typically bend or flutter in the direction of air flow, which will be from a more positive to a less positive (or from a less negative to a more negative) space. As a rule of thumb, the “more clean” areas need to be positive pressure with respect to the “less clean” areas. If the tissue flutters from the “more clean” areas to the “less clean” areas – no problem. If the tissue flutters in the opposite direction however – big problem. This is likely to result in a Requirement for Improvement (RFI) against Standard EC.02.05.01, Element of Performance (EP) #6, which states the requirements for areas designed to control airborne contaminants along with the concomitant need for appropriate pressure relationships, air-exchange rates, and filtration efficiencies. </span><br />
<a name='more'></a><br />
<span style="font-family: Arial,Helvetica,sans-serif;">Mr. Mills stated that this RFI will result in a Condition Level Deficiency reported to CMS, which of course requires a re-survey within 45 days. Mr. Mills also stated that if the hospital is able to correct the process that led to the improper air flow (and it sounded as if simply adjusting some dampers would not be sufficient) the Life Safety surveyor may review the finding, and can contact TJC to discuss the possibility of reducing the Condition Level Deficiency to a Standard Level Deficiency. Mr. Mills cautioned that this lesser outcome was not guaranteed. Regardless of the Condition Level Deficiency outcome, the RFI will remain. He stated his hope that very rapid correction of such findings will result in a safer environment for the hospital’s patients.</span><br />
<span style="font-family: Arial,Helvetica,sans-serif;"><br /></span>
<span style="font-family: Arial,Helvetica,sans-serif;">Besides being a direct impact requirement, EC.02.05.01 EP6 is also an identified risk (R icon) EP and is scoring category A. Scoring category A means that a single instance of noncompliance will result in an RFI. As an identified risk EP, EP6 would also be addressed annually by TJC-accredited organizations during the annual Focused Standards Assessment.</span><br />
<span style="font-family: Arial,Helvetica,sans-serif;"><br /></span>
<span style="font-family: Arial,Helvetica,sans-serif;">It has been previously indicated that a TJC surveyor may initiate an environment of care tracer upon discovery of an improper pressure relationship in order to arrive at the cause of the problem. TJC surveyors may request details on previous inspection, testing and monitoring (ITM) activities relative to both those areas and the equipment that create the pressure relationships. Follow-up questions could also address the adequacy of maintenance processes, training, and competencies. Reports from the field during 2013 indicate that multiple RFIs may result from these types of EC tracers since they often probe utility infection control operating components, ITM activities, ITM frequencies, follow-up and corrective actions on problems found, and the like. </span><br />
<span style="font-family: Arial,Helvetica,sans-serif;"><br /></span>
<span style="font-family: Arial,Helvetica,sans-serif;">We recommend that organizations have a current inventory of all areas designed to control air flow (both positive and negative); the required air exchange rates, air handling unit filter efficiencies, along with a maintenance activities matrix for this equipment. ASHE recently developed a spreadsheet template for such testing and inspection activities and made it available to ASHE members. Mr. Mills included a graphic of that template, entitled VENTILATION SYSTEM PARAMETERS,” in his presentation.</span><br />
<span style="font-family: Arial,Helvetica,sans-serif;"><br /></span>
<span style="font-family: Arial,Helvetica,sans-serif;">This issue is not just an engineering issue – it is an environment of care issue. Because some rooms will have the required pressure relationships only with doors closed, it is important that users (clinical, environmental services, central sterilization personnel and others) understand both the operational behavioral requirements and the importance of compliance.</span><br />
<span style="font-family: Arial,Helvetica,sans-serif;"><br /></span>
<span style="font-family: Arial,Helvetica,sans-serif;">This is one of those cases where meeting a compliance requirement can coincide with doing the right things for the right reasons. We recommend that facility managers educate all affected users about this issue, the spaces with their requirements, and the behavioral issues that can drive a hospital out of compliance. Although some facilities have permanently installed monitoring equipment for those rooms, not all facilities have such equipment. We also recommend that facility managers in hospitals that do not have permanent monitoring use their inventories and conduct their own regular testing using either the tissue testing method or the smoke tube testing method. This more frequent monitoring would be in addition to the scheduled verification of the overall system air balance.</span><br />
<span style="font-family: Arial,Helvetica,sans-serif;"><br /></span>
<br />Smith Seckman Reid, Inchttp://www.blogger.com/profile/13913803032935481245noreply@blogger.com0tag:blogger.com,1999:blog-6196154551822326880.post-39176623653485300792013-09-30T11:00:00.000-05:002013-09-30T11:00:04.579-05:00Joint Commission discusses Fire Safety Equipment Inventories at ASHE Conference <span style="font-size: small;"><span style="font-family: Arial,Helvetica,sans-serif;"></span></span><br />
<a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhbcq68pxZXiloExtgGcO0JxSPbmNV-r204ext3blXIAIPA3sFrySxxnxh8fRo64ZgqiLw4UkdC4P7jiAKlc9ihYafLDmwa0zVXAsg-YAmVVxLyKeuQ_cD8nDLKqufgOfY8jivwUaqTuEg/s1600/Compliance+News+header.jpg" style="clear: left; float: left; margin-bottom: 1em; margin-right: 1em;"><img border="0" height="70" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhbcq68pxZXiloExtgGcO0JxSPbmNV-r204ext3blXIAIPA3sFrySxxnxh8fRo64ZgqiLw4UkdC4P7jiAKlc9ihYafLDmwa0zVXAsg-YAmVVxLyKeuQ_cD8nDLKqufgOfY8jivwUaqTuEg/s1600/Compliance+News+header.jpg" width="200" /></a><span style="font-size: small;"><span style="font-family: Arial,Helvetica,sans-serif;"> </span></span><span style="font-family: Arial,Helvetica,sans-serif;">By David Stymiest, PE CHFM CHSP FASHE </span><br />
<span style="font-family: Arial,Helvetica,sans-serif;"><br />The Joint Commission (TJC) Engineering Director George Mills addressed the issue of fire safety equipment inventories at his 2013 ASHE Annual Conference plenary in July. <br /><br /> Mr. Mills stated that with respect to Standard EC.02.03.05, Elements of Performance (EPs) # 1 through # 20 inclusive, every device required to be tested must be documented in an inventory. He further stated that TJC surveyors will expect the facility to be able to identify specific variances in devices tested from year to year, and that simply having the total quantity of devices without more specific definition will not be adequate. Finally, Mr. Mills stated that lack of a written, electronic, or other form of inventory addressing the devices covered by any of the 20 EPs could result in a finding against that EP. Needless to say, Organizations who have yet not finalized their EC.02.03.05 inventories can be subject to numerous RFIs during survey.</span><br />
<br />
<br />
<br />
<br />
<!-- Blogger automated replacement: "https://images-blogger-opensocial.googleusercontent.com/gadgets/proxy?url=http%3A%2F%2F1.bp.blogspot.com%2F-HmZAO28ouK4%2FUajIM3O9wvI%2FAAAAAAAAACc%2FNyI7Em-GSlE%2Fs1600%2FCompliance%2BNews%2Bheader.jpg&container=blogger&gadget=a&rewriteMime=image%2F*" with "https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhbcq68pxZXiloExtgGcO0JxSPbmNV-r204ext3blXIAIPA3sFrySxxnxh8fRo64ZgqiLw4UkdC4P7jiAKlc9ihYafLDmwa0zVXAsg-YAmVVxLyKeuQ_cD8nDLKqufgOfY8jivwUaqTuEg/s1600/Compliance+News+header.jpg" -->Smith Seckman Reid, Inchttp://www.blogger.com/profile/13913803032935481245noreply@blogger.com0tag:blogger.com,1999:blog-6196154551822326880.post-84264119299379224802013-09-27T11:00:00.000-05:002013-09-27T11:00:05.101-05:00TJC Addresses CMS Categorical Waivers <br />
<div class="separator" style="clear: both; text-align: center;">
<a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhbcq68pxZXiloExtgGcO0JxSPbmNV-r204ext3blXIAIPA3sFrySxxnxh8fRo64ZgqiLw4UkdC4P7jiAKlc9ihYafLDmwa0zVXAsg-YAmVVxLyKeuQ_cD8nDLKqufgOfY8jivwUaqTuEg/s1600/Compliance+News+header.jpg" imageanchor="1" style="clear: left; float: left; margin-bottom: 1em; margin-right: 1em;"><img border="0" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhbcq68pxZXiloExtgGcO0JxSPbmNV-r204ext3blXIAIPA3sFrySxxnxh8fRo64ZgqiLw4UkdC4P7jiAKlc9ihYafLDmwa0zVXAsg-YAmVVxLyKeuQ_cD8nDLKqufgOfY8jivwUaqTuEg/s1600/Compliance+News+header.jpg" height="70" width="200" /></a></div>
<span style="font-family: Arial,Helvetica,sans-serif;"><span style="font-size: large;"><span style="color: #6fa8dc;"> </span></span><br />By David Stymiest, PE CHFM CHSP FASHE <br /><br /> ASHE recently discussed in its Listserv TJC’s response to the CMS categorical waivers. <br /><br />According to ASHE, TJC requested that organizations indicate in the eBBI’s Additional Comments field the acceptance of any categorical waivers as well as so noting those decisions in the EOC Committee minutes. TJC Life Safety Code surveyors will field-verify that the CMS conditions are being met for any accepted waiver, similarly to the CMS onsite field-verification approach.</span>Smith Seckman Reid, Inchttp://www.blogger.com/profile/13913803032935481245noreply@blogger.com0tag:blogger.com,1999:blog-6196154551822326880.post-2220555804423227172013-09-26T11:00:00.000-05:002013-09-26T11:00:02.878-05:00CMS ISSUES MORE CATEGORICAL WAIVERS<br />
<div class="separator" style="clear: both; text-align: center;">
<a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhbcq68pxZXiloExtgGcO0JxSPbmNV-r204ext3blXIAIPA3sFrySxxnxh8fRo64ZgqiLw4UkdC4P7jiAKlc9ihYafLDmwa0zVXAsg-YAmVVxLyKeuQ_cD8nDLKqufgOfY8jivwUaqTuEg/s1600/Compliance+News+header.jpg" imageanchor="1" style="clear: left; float: left; margin-bottom: 1em; margin-right: 1em;"><img border="0" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhbcq68pxZXiloExtgGcO0JxSPbmNV-r204ext3blXIAIPA3sFrySxxnxh8fRo64ZgqiLw4UkdC4P7jiAKlc9ihYafLDmwa0zVXAsg-YAmVVxLyKeuQ_cD8nDLKqufgOfY8jivwUaqTuEg/s1600/Compliance+News+header.jpg" height="70" width="200" /></a></div>
<br />
<span style="font-family: Arial,Helvetica,sans-serif;">By David Stymiest, PE, CHFM, CHSP, FASHE</span><br />
<span style="font-family: Arial,Helvetica,sans-serif;"><br /></span>
<b><span style="font-family: Arial,Helvetica,sans-serif; font-size: small;"> </span></b><br />
<br />
<b><span style="font-family: Arial,Helvetica,sans-serif; font-size: small;">Waivers address selected life safety, medical gas master alarm, emergency power testing, and firesafety equipment testing requirements.</span></b><br />
<span style="font-family: Arial,Helvetica,sans-serif;"><br /></span>
<!--[if gte mso 9]><xml>
<o:OfficeDocumentSettings>
<o:RelyOnVML/>
<o:AllowPNG/>
</o:OfficeDocumentSettings>
</xml><![endif]--><br />
<!--[if gte mso 9]><xml>
<w:WordDocument>
<w:View>Normal</w:View>
<w:Zoom>0</w:Zoom>
<w:TrackMoves/>
<w:TrackFormatting/>
<w:DoNotShowComments/>
<w:PunctuationKerning/>
<w:ValidateAgainstSchemas/>
<w:SaveIfXMLInvalid>false</w:SaveIfXMLInvalid>
<w:IgnoreMixedContent>false</w:IgnoreMixedContent>
<w:AlwaysShowPlaceholderText>false</w:AlwaysShowPlaceholderText>
<w:DoNotPromoteQF/>
<w:LidThemeOther>EN-US</w:LidThemeOther>
<w:LidThemeAsian>X-NONE</w:LidThemeAsian>
<w:LidThemeComplexScript>X-NONE</w:LidThemeComplexScript>
<w:Compatibility>
<w:BreakWrappedTables/>
<w:SnapToGridInCell/>
<w:WrapTextWithPunct/>
<w:UseAsianBreakRules/>
<w:DontGrowAutofit/>
<w:SplitPgBreakAndParaMark/>
<w:DontVertAlignCellWithSp/>
<w:DontBreakConstrainedForcedTables/>
<w:DontVertAlignInTxbx/>
<w:Word11KerningPairs/>
<w:CachedColBalance/>
</w:Compatibility>
<m:mathPr>
<m:mathFont m:val="Cambria Math"/>
<m:brkBin m:val="before"/>
<m:brkBinSub m:val="--"/>
<m:smallFrac m:val="off"/>
<m:dispDef/>
<m:lMargin m:val="0"/>
<m:rMargin m:val="0"/>
<m:defJc m:val="centerGroup"/>
<m:wrapIndent m:val="1440"/>
<m:intLim m:val="subSup"/>
<m:naryLim m:val="undOvr"/>
</m:mathPr></w:WordDocument>
</xml><![endif]--><!--[if gte mso 9]><xml>
<w:LatentStyles DefLockedState="false" DefUnhideWhenUsed="true"
DefSemiHidden="true" DefQFormat="false" DefPriority="99"
LatentStyleCount="267">
<w:LsdException Locked="false" Priority="0" SemiHidden="false"
UnhideWhenUsed="false" QFormat="true" Name="Normal"/>
<w:LsdException Locked="false" Priority="9" SemiHidden="false"
UnhideWhenUsed="false" QFormat="true" Name="heading 1"/>
<w:LsdException Locked="false" Priority="9" QFormat="true" Name="heading 2"/>
<w:LsdException Locked="false" Priority="9" QFormat="true" Name="heading 3"/>
<w:LsdException Locked="false" Priority="9" QFormat="true" Name="heading 4"/>
<w:LsdException Locked="false" Priority="9" QFormat="true" Name="heading 5"/>
<w:LsdException Locked="false" Priority="9" QFormat="true" Name="heading 6"/>
<w:LsdException Locked="false" Priority="9" QFormat="true" Name="heading 7"/>
<w:LsdException Locked="false" Priority="9" QFormat="true" Name="heading 8"/>
<w:LsdException Locked="false" Priority="9" QFormat="true" Name="heading 9"/>
<w:LsdException Locked="false" Priority="39" Name="toc 1"/>
<w:LsdException Locked="false" Priority="39" Name="toc 2"/>
<w:LsdException Locked="false" Priority="39" Name="toc 3"/>
<w:LsdException Locked="false" Priority="39" Name="toc 4"/>
<w:LsdException Locked="false" Priority="39" Name="toc 5"/>
<w:LsdException Locked="false" Priority="39" Name="toc 6"/>
<w:LsdException Locked="false" Priority="39" Name="toc 7"/>
<w:LsdException Locked="false" Priority="39" Name="toc 8"/>
<w:LsdException Locked="false" Priority="39" Name="toc 9"/>
<w:LsdException Locked="false" Priority="35" QFormat="true" Name="caption"/>
<w:LsdException Locked="false" Priority="10" SemiHidden="false"
UnhideWhenUsed="false" QFormat="true" Name="Title"/>
<w:LsdException Locked="false" Priority="1" Name="Default Paragraph Font"/>
<w:LsdException Locked="false" Priority="11" SemiHidden="false"
UnhideWhenUsed="false" QFormat="true" Name="Subtitle"/>
<w:LsdException Locked="false" Priority="22" SemiHidden="false"
UnhideWhenUsed="false" QFormat="true" Name="Strong"/>
<w:LsdException Locked="false" Priority="20" SemiHidden="false"
UnhideWhenUsed="false" QFormat="true" Name="Emphasis"/>
<w:LsdException Locked="false" Priority="59" SemiHidden="false"
UnhideWhenUsed="false" Name="Table Grid"/>
<w:LsdException Locked="false" UnhideWhenUsed="false" Name="Placeholder Text"/>
<w:LsdException Locked="false" Priority="1" SemiHidden="false"
UnhideWhenUsed="false" QFormat="true" Name="No Spacing"/>
<w:LsdException Locked="false" Priority="60" SemiHidden="false"
UnhideWhenUsed="false" Name="Light Shading"/>
<w:LsdException Locked="false" Priority="61" SemiHidden="false"
UnhideWhenUsed="false" Name="Light List"/>
<w:LsdException Locked="false" Priority="62" SemiHidden="false"
UnhideWhenUsed="false" Name="Light Grid"/>
<w:LsdException Locked="false" Priority="63" SemiHidden="false"
UnhideWhenUsed="false" Name="Medium Shading 1"/>
<w:LsdException Locked="false" Priority="64" SemiHidden="false"
UnhideWhenUsed="false" Name="Medium Shading 2"/>
<w:LsdException Locked="false" Priority="65" SemiHidden="false"
UnhideWhenUsed="false" Name="Medium List 1"/>
<w:LsdException Locked="false" Priority="66" SemiHidden="false"
UnhideWhenUsed="false" Name="Medium List 2"/>
<w:LsdException Locked="false" Priority="67" SemiHidden="false"
UnhideWhenUsed="false" Name="Medium Grid 1"/>
<w:LsdException Locked="false" Priority="68" SemiHidden="false"
UnhideWhenUsed="false" Name="Medium Grid 2"/>
<w:LsdException Locked="false" Priority="69" SemiHidden="false"
UnhideWhenUsed="false" Name="Medium Grid 3"/>
<w:LsdException Locked="false" Priority="70" SemiHidden="false"
UnhideWhenUsed="false" Name="Dark List"/>
<w:LsdException Locked="false" Priority="71" SemiHidden="false"
UnhideWhenUsed="false" Name="Colorful Shading"/>
<w:LsdException Locked="false" Priority="72" SemiHidden="false"
UnhideWhenUsed="false" Name="Colorful List"/>
<w:LsdException Locked="false" Priority="73" SemiHidden="false"
UnhideWhenUsed="false" Name="Colorful Grid"/>
<w:LsdException Locked="false" Priority="60" SemiHidden="false"
UnhideWhenUsed="false" Name="Light Shading Accent 1"/>
<w:LsdException Locked="false" Priority="61" SemiHidden="false"
UnhideWhenUsed="false" Name="Light List Accent 1"/>
<w:LsdException Locked="false" Priority="62" SemiHidden="false"
UnhideWhenUsed="false" Name="Light Grid Accent 1"/>
<w:LsdException Locked="false" Priority="63" SemiHidden="false"
UnhideWhenUsed="false" Name="Medium Shading 1 Accent 1"/>
<w:LsdException Locked="false" Priority="64" SemiHidden="false"
UnhideWhenUsed="false" Name="Medium Shading 2 Accent 1"/>
<w:LsdException Locked="false" Priority="65" SemiHidden="false"
UnhideWhenUsed="false" Name="Medium List 1 Accent 1"/>
<w:LsdException Locked="false" UnhideWhenUsed="false" Name="Revision"/>
<w:LsdException Locked="false" Priority="34" SemiHidden="false"
UnhideWhenUsed="false" QFormat="true" Name="List Paragraph"/>
<w:LsdException Locked="false" Priority="29" SemiHidden="false"
UnhideWhenUsed="false" QFormat="true" Name="Quote"/>
<w:LsdException Locked="false" Priority="30" SemiHidden="false"
UnhideWhenUsed="false" QFormat="true" Name="Intense Quote"/>
<w:LsdException Locked="false" Priority="66" SemiHidden="false"
UnhideWhenUsed="false" Name="Medium List 2 Accent 1"/>
<w:LsdException Locked="false" Priority="67" SemiHidden="false"
UnhideWhenUsed="false" Name="Medium Grid 1 Accent 1"/>
<w:LsdException Locked="false" Priority="68" SemiHidden="false"
UnhideWhenUsed="false" Name="Medium Grid 2 Accent 1"/>
<w:LsdException Locked="false" Priority="69" SemiHidden="false"
UnhideWhenUsed="false" Name="Medium Grid 3 Accent 1"/>
<w:LsdException Locked="false" Priority="70" SemiHidden="false"
UnhideWhenUsed="false" Name="Dark List Accent 1"/>
<w:LsdException Locked="false" Priority="71" SemiHidden="false"
UnhideWhenUsed="false" Name="Colorful Shading Accent 1"/>
<w:LsdException Locked="false" Priority="72" SemiHidden="false"
UnhideWhenUsed="false" Name="Colorful List Accent 1"/>
<w:LsdException Locked="false" Priority="73" SemiHidden="false"
UnhideWhenUsed="false" Name="Colorful Grid Accent 1"/>
<w:LsdException Locked="false" Priority="60" SemiHidden="false"
UnhideWhenUsed="false" Name="Light Shading Accent 2"/>
<w:LsdException Locked="false" Priority="61" SemiHidden="false"
UnhideWhenUsed="false" Name="Light List Accent 2"/>
<w:LsdException Locked="false" Priority="62" SemiHidden="false"
UnhideWhenUsed="false" Name="Light Grid Accent 2"/>
<w:LsdException Locked="false" Priority="63" SemiHidden="false"
UnhideWhenUsed="false" Name="Medium Shading 1 Accent 2"/>
<w:LsdException Locked="false" Priority="64" SemiHidden="false"
UnhideWhenUsed="false" Name="Medium Shading 2 Accent 2"/>
<w:LsdException Locked="false" Priority="65" SemiHidden="false"
UnhideWhenUsed="false" Name="Medium List 1 Accent 2"/>
<w:LsdException Locked="false" Priority="66" SemiHidden="false"
UnhideWhenUsed="false" Name="Medium List 2 Accent 2"/>
<w:LsdException Locked="false" Priority="67" SemiHidden="false"
UnhideWhenUsed="false" Name="Medium Grid 1 Accent 2"/>
<w:LsdException Locked="false" Priority="68" SemiHidden="false"
UnhideWhenUsed="false" Name="Medium Grid 2 Accent 2"/>
<w:LsdException Locked="false" Priority="69" SemiHidden="false"
UnhideWhenUsed="false" Name="Medium Grid 3 Accent 2"/>
<w:LsdException Locked="false" Priority="70" SemiHidden="false"
UnhideWhenUsed="false" Name="Dark List Accent 2"/>
<w:LsdException Locked="false" Priority="71" SemiHidden="false"
UnhideWhenUsed="false" Name="Colorful Shading Accent 2"/>
<w:LsdException Locked="false" Priority="72" SemiHidden="false"
UnhideWhenUsed="false" Name="Colorful List Accent 2"/>
<w:LsdException Locked="false" Priority="73" SemiHidden="false"
UnhideWhenUsed="false" Name="Colorful Grid Accent 2"/>
<w:LsdException Locked="false" Priority="60" SemiHidden="false"
UnhideWhenUsed="false" Name="Light Shading Accent 3"/>
<w:LsdException Locked="false" Priority="61" SemiHidden="false"
UnhideWhenUsed="false" Name="Light List Accent 3"/>
<w:LsdException Locked="false" Priority="62" SemiHidden="false"
UnhideWhenUsed="false" Name="Light Grid Accent 3"/>
<w:LsdException Locked="false" Priority="63" SemiHidden="false"
UnhideWhenUsed="false" Name="Medium Shading 1 Accent 3"/>
<w:LsdException Locked="false" Priority="64" SemiHidden="false"
UnhideWhenUsed="false" Name="Medium Shading 2 Accent 3"/>
<w:LsdException Locked="false" Priority="65" SemiHidden="false"
UnhideWhenUsed="false" Name="Medium List 1 Accent 3"/>
<w:LsdException Locked="false" Priority="66" SemiHidden="false"
UnhideWhenUsed="false" Name="Medium List 2 Accent 3"/>
<w:LsdException Locked="false" Priority="67" SemiHidden="false"
UnhideWhenUsed="false" Name="Medium Grid 1 Accent 3"/>
<w:LsdException Locked="false" Priority="68" SemiHidden="false"
UnhideWhenUsed="false" Name="Medium Grid 2 Accent 3"/>
<w:LsdException Locked="false" Priority="69" SemiHidden="false"
UnhideWhenUsed="false" Name="Medium Grid 3 Accent 3"/>
<w:LsdException Locked="false" Priority="70" SemiHidden="false"
UnhideWhenUsed="false" Name="Dark List Accent 3"/>
<w:LsdException Locked="false" Priority="71" SemiHidden="false"
UnhideWhenUsed="false" Name="Colorful Shading Accent 3"/>
<w:LsdException Locked="false" Priority="72" SemiHidden="false"
UnhideWhenUsed="false" Name="Colorful List Accent 3"/>
<w:LsdException Locked="false" Priority="73" SemiHidden="false"
UnhideWhenUsed="false" Name="Colorful Grid Accent 3"/>
<w:LsdException Locked="false" Priority="60" SemiHidden="false"
UnhideWhenUsed="false" Name="Light Shading Accent 4"/>
<w:LsdException Locked="false" Priority="61" SemiHidden="false"
UnhideWhenUsed="false" Name="Light List Accent 4"/>
<w:LsdException Locked="false" Priority="62" SemiHidden="false"
UnhideWhenUsed="false" Name="Light Grid Accent 4"/>
<w:LsdException Locked="false" Priority="63" SemiHidden="false"
UnhideWhenUsed="false" Name="Medium Shading 1 Accent 4"/>
<w:LsdException Locked="false" Priority="64" SemiHidden="false"
UnhideWhenUsed="false" Name="Medium Shading 2 Accent 4"/>
<w:LsdException Locked="false" Priority="65" SemiHidden="false"
UnhideWhenUsed="false" Name="Medium List 1 Accent 4"/>
<w:LsdException Locked="false" Priority="66" SemiHidden="false"
UnhideWhenUsed="false" Name="Medium List 2 Accent 4"/>
<w:LsdException Locked="false" Priority="67" SemiHidden="false"
UnhideWhenUsed="false" Name="Medium Grid 1 Accent 4"/>
<w:LsdException Locked="false" Priority="68" SemiHidden="false"
UnhideWhenUsed="false" Name="Medium Grid 2 Accent 4"/>
<w:LsdException Locked="false" Priority="69" SemiHidden="false"
UnhideWhenUsed="false" Name="Medium Grid 3 Accent 4"/>
<w:LsdException Locked="false" Priority="70" SemiHidden="false"
UnhideWhenUsed="false" Name="Dark List Accent 4"/>
<w:LsdException Locked="false" Priority="71" SemiHidden="false"
UnhideWhenUsed="false" Name="Colorful Shading Accent 4"/>
<w:LsdException Locked="false" Priority="72" SemiHidden="false"
UnhideWhenUsed="false" Name="Colorful List Accent 4"/>
<w:LsdException Locked="false" Priority="73" SemiHidden="false"
UnhideWhenUsed="false" Name="Colorful Grid Accent 4"/>
<w:LsdException Locked="false" Priority="60" SemiHidden="false"
UnhideWhenUsed="false" Name="Light Shading Accent 5"/>
<w:LsdException Locked="false" Priority="61" SemiHidden="false"
UnhideWhenUsed="false" Name="Light List Accent 5"/>
<w:LsdException Locked="false" Priority="62" SemiHidden="false"
UnhideWhenUsed="false" Name="Light Grid Accent 5"/>
<w:LsdException Locked="false" Priority="63" SemiHidden="false"
UnhideWhenUsed="false" Name="Medium Shading 1 Accent 5"/>
<w:LsdException Locked="false" Priority="64" SemiHidden="false"
UnhideWhenUsed="false" Name="Medium Shading 2 Accent 5"/>
<w:LsdException Locked="false" Priority="65" SemiHidden="false"
UnhideWhenUsed="false" Name="Medium List 1 Accent 5"/>
<w:LsdException Locked="false" Priority="66" SemiHidden="false"
UnhideWhenUsed="false" Name="Medium List 2 Accent 5"/>
<w:LsdException Locked="false" Priority="67" SemiHidden="false"
UnhideWhenUsed="false" Name="Medium Grid 1 Accent 5"/>
<w:LsdException Locked="false" Priority="68" SemiHidden="false"
UnhideWhenUsed="false" Name="Medium Grid 2 Accent 5"/>
<w:LsdException Locked="false" Priority="69" SemiHidden="false"
UnhideWhenUsed="false" Name="Medium Grid 3 Accent 5"/>
<w:LsdException Locked="false" Priority="70" SemiHidden="false"
UnhideWhenUsed="false" Name="Dark List Accent 5"/>
<w:LsdException Locked="false" Priority="71" SemiHidden="false"
UnhideWhenUsed="false" Name="Colorful Shading Accent 5"/>
<w:LsdException Locked="false" Priority="72" SemiHidden="false"
UnhideWhenUsed="false" Name="Colorful List Accent 5"/>
<w:LsdException Locked="false" Priority="73" SemiHidden="false"
UnhideWhenUsed="false" Name="Colorful Grid Accent 5"/>
<w:LsdException Locked="false" Priority="60" SemiHidden="false"
UnhideWhenUsed="false" Name="Light Shading Accent 6"/>
<w:LsdException Locked="false" Priority="61" SemiHidden="false"
UnhideWhenUsed="false" Name="Light List Accent 6"/>
<w:LsdException Locked="false" Priority="62" SemiHidden="false"
UnhideWhenUsed="false" Name="Light Grid Accent 6"/>
<w:LsdException Locked="false" Priority="63" SemiHidden="false"
UnhideWhenUsed="false" Name="Medium Shading 1 Accent 6"/>
<w:LsdException Locked="false" Priority="64" SemiHidden="false"
UnhideWhenUsed="false" Name="Medium Shading 2 Accent 6"/>
<w:LsdException Locked="false" Priority="65" SemiHidden="false"
UnhideWhenUsed="false" Name="Medium List 1 Accent 6"/>
<w:LsdException Locked="false" Priority="66" SemiHidden="false"
UnhideWhenUsed="false" Name="Medium List 2 Accent 6"/>
<w:LsdException Locked="false" Priority="67" SemiHidden="false"
UnhideWhenUsed="false" Name="Medium Grid 1 Accent 6"/>
<w:LsdException Locked="false" Priority="68" SemiHidden="false"
UnhideWhenUsed="false" Name="Medium Grid 2 Accent 6"/>
<w:LsdException Locked="false" Priority="69" SemiHidden="false"
UnhideWhenUsed="false" Name="Medium Grid 3 Accent 6"/>
<w:LsdException Locked="false" Priority="70" SemiHidden="false"
UnhideWhenUsed="false" Name="Dark List Accent 6"/>
<w:LsdException Locked="false" Priority="71" SemiHidden="false"
UnhideWhenUsed="false" Name="Colorful Shading Accent 6"/>
<w:LsdException Locked="false" Priority="72" SemiHidden="false"
UnhideWhenUsed="false" Name="Colorful List Accent 6"/>
<w:LsdException Locked="false" Priority="73" SemiHidden="false"
UnhideWhenUsed="false" Name="Colorful Grid Accent 6"/>
<w:LsdException Locked="false" Priority="19" SemiHidden="false"
UnhideWhenUsed="false" QFormat="true" Name="Subtle Emphasis"/>
<w:LsdException Locked="false" Priority="21" SemiHidden="false"
UnhideWhenUsed="false" QFormat="true" Name="Intense Emphasis"/>
<w:LsdException Locked="false" Priority="31" SemiHidden="false"
UnhideWhenUsed="false" QFormat="true" Name="Subtle Reference"/>
<w:LsdException Locked="false" Priority="32" SemiHidden="false"
UnhideWhenUsed="false" QFormat="true" Name="Intense Reference"/>
<w:LsdException Locked="false" Priority="33" SemiHidden="false"
UnhideWhenUsed="false" QFormat="true" Name="Book Title"/>
<w:LsdException Locked="false" Priority="37" Name="Bibliography"/>
<w:LsdException Locked="false" Priority="39" QFormat="true" Name="TOC Heading"/>
</w:LatentStyles>
</xml><![endif]--><!--[if gte mso 10]>
<style>
/* Style Definitions */
table.MsoNormalTable
{mso-style-name:"Table Normal";
mso-tstyle-rowband-size:0;
mso-tstyle-colband-size:0;
mso-style-noshow:yes;
mso-style-priority:99;
mso-style-qformat:yes;
mso-style-parent:"";
mso-padding-alt:0in 5.4pt 0in 5.4pt;
mso-para-margin-top:0in;
mso-para-margin-right:0in;
mso-para-margin-bottom:0in;
mso-para-margin-left:.75in;
mso-para-margin-bottom:.0001pt;
text-align:justify;
text-indent:-.25in;
mso-pagination:widow-orphan;
font-size:11.0pt;
font-family:"Calibri","sans-serif";
mso-ascii-font-family:Calibri;
mso-ascii-theme-font:minor-latin;
mso-hansi-font-family:Calibri;
mso-hansi-theme-font:minor-latin;}
</style>
<![endif]--><span style="font-family: Arial,Helvetica,sans-serif;">
</span><br />
<div class="MsoNormal">
<span style="font-family: Arial,Helvetica,sans-serif;"><span style="font-size: 10pt;">The
Centers for Medicare & Medicaid Services (CMS) issued a new Survey &
Certification memorandum # S&C: 13-58-LSC to its State Survey Agency
Directors on August 30, 2013.<span style="mso-spacerun: yes;"> </span>This new
S&C memo identifies several areas where several separate requirements more
than a decade old are being relaxed for (and only for) those facilities that
take the necessary steps to elect to use the waivers.</span></span></div>
<span style="font-family: Arial,Helvetica,sans-serif;">
</span><br />
<div class="MsoNormal">
<br />
<a name='more'></a></div>
<span style="font-family: Arial,Helvetica,sans-serif;">
</span><br />
<div class="MsoNormal">
<span style="font-family: Arial,Helvetica,sans-serif;"><span style="font-size: 10pt;">In
its S&C memo, CMS referenced more recent code changes in NFPA 101, NFPA 99,
NFPA 110 and NFPA 25 that resulted in the relaxed requirements.<span style="mso-spacerun: yes;"> </span>Many healthcare facilities are expected to take
advantage of at least some of these changes.<span style="mso-spacerun: yes;">
</span>Note that these categorical waivers only deal with the specific
requirements detailed therein, and do not fully adopt the more recent
standards.</span></span></div>
<span style="font-family: Arial,Helvetica,sans-serif;">
</span><br />
<div class="MsoNormal">
<br /></div>
<span style="font-family: Arial,Helvetica,sans-serif;">
</span><br />
<div class="MsoNormal">
<span style="font-family: Arial,Helvetica,sans-serif;"><i><span style="font-size: 10pt;">Additionally,
many of the relaxed requirements require compliance with stipulated paragraphs
or sections within the newer NFPA standards.<span style="mso-spacerun: yes;">
</span>Facilities electing to use any waiver must comply with all conditions of
that waiver.<span style="mso-spacerun: yes;"> </span>CMS stated it intends to confirm
that the facility is complying with all applicable categorical waiver
provisions associated with each elected waiver.</span></i><i><span style="font-style: normal;"></span></i></span></div>
<span style="font-family: Arial,Helvetica,sans-serif;">
</span><br />
<div class="MsoNormal">
<br /></div>
<span style="font-family: Arial,Helvetica,sans-serif;">
</span><br />
<span style="font-family: Arial,Helvetica,sans-serif;"><u><span style="font-size: 10pt;">One
MedGas master alarm may be a centralized computer system:</span></u><span style="font-size: 10pt;"></span></span><span style="font-family: Arial,Helvetica,sans-serif;">
</span><br />
<div class="MsoListParagraph" style="mso-list: l2 level1 lfo2; text-indent: -.25in;">
<span style="font-family: Arial,Helvetica,sans-serif;"><span style="font-size: 10pt;"><span style="mso-list: Ignore;">·<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-size: 7pt; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span></span></span><span style="font-size: 10pt;">This
categorical waiver allows a centralized computer system (first permitted in the
2005 edition of NFPA 99) to substitute for one of the required Category 1
medical gas master alarms, providing that the facility complies with all other
applicable NFPA 99-1999 medical gas master alarm provisions, as well as with
section 5.1.9.4 of NFPA 99-2012.</span></span></div>
<span style="font-family: Arial,Helvetica,sans-serif;">
</span><br />
<div class="MsoNormal">
<span style="font-family: Arial,Helvetica,sans-serif;"><u><span style="font-size: 10pt;"><span style="text-decoration: none;"><br /></span></span></u></span></div>
<span style="font-family: Arial,Helvetica,sans-serif;">
</span><br />
<span style="font-family: Arial,Helvetica,sans-serif;"><u><span style="font-size: 10pt;">Annual
generator load test duration reduced</span></u><span style="font-size: 10pt;">:</span></span><span style="font-family: Arial,Helvetica,sans-serif;">
</span><br />
<div class="MsoListParagraph" style="mso-list: l1 level1 lfo3; text-indent: -.25in;">
<span style="font-family: Arial,Helvetica,sans-serif;"><span style="font-size: 10pt;"><span style="mso-list: Ignore;">·<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-size: 7pt; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span></span></span><span style="font-size: 10pt;">This
categorical waiver allows the annual load test requirement to be shortened from
the previous 2 hours to not less than 90 minutes (this 30 minute reduction was first
permitted in the 2010 edition of NFPA 110, when the first 30 minutes at 25% of
rated load was eliminated.)<span style="mso-spacerun: yes;"> </span>Note that
this annual load test is only required at all as a measure to mitigate
potential wet stacking when the monthly diesel generator testing does not
comply with the stipulated minimum loading requirements.<span style="mso-spacerun: yes;"> </span>CMS will permit this waiver only if the facility
is in compliance with all other applicable NFPA 110-1999 operational inspection
and testing provisions, as well as with paragraph 8.4.2.3 of NFPA 110-2010.<span style="mso-spacerun: yes;"> </span></span></span></div>
<div class="MsoListParagraph" style="mso-list: l1 level1 lfo3; text-indent: -.25in;">
<br /></div>
<span style="font-family: Arial,Helvetica,sans-serif;">
</span><br />
<div class="MsoNormal">
<span style="font-family: Arial,Helvetica,sans-serif;"><u><span style="font-size: 9pt;">NFPA Disclaimer</span></u><span style="font-size: 9pt;">:
Although the author is Chairman of the NFPA Technical Committee on Emergency
Power Supplies, which is responsible for NFPA 110 and 111, the views and
opinions expressed in this newsletter are purely those of the author and shall
not be considered the official position of NFPA or any of its Technical
Committees and shall not be considered to be, nor be relied upon as, a Formal
Interpretation. Readers are encouraged to refer to the entire text of all
referenced documents.</span><span style="font-size: 10pt;"></span></span></div>
<span style="font-family: Arial,Helvetica,sans-serif;">
</span><br />
<div class="MsoNormal">
<span style="font-family: Arial,Helvetica,sans-serif;"><u><span style="font-size: 10pt;"><span style="text-decoration: none;"><br /></span></span></u></span></div>
<span style="font-family: Arial,Helvetica,sans-serif;">
</span><br />
<span style="font-family: Arial,Helvetica,sans-serif;"><u><span style="font-size: 10pt;">Fire
protection system testing frequencies reduced:</span></u></span><span style="font-family: Arial,Helvetica,sans-serif;">
</span><br />
<div class="MsoListParagraph" style="mso-list: l1 level1 lfo3; text-indent: -.25in;">
<span style="font-family: Arial,Helvetica,sans-serif;"><span style="font-size: 10pt;"><span style="mso-list: Ignore;">·<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-size: 7pt; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span></span></span><span style="font-size: 10pt;">This
categorical waiver will permit reducing the testing frequencies for sprinkler
system vane-type and pressure switch type waterflow alarm devices from
quarterly to semi-annually, and testing of electric motor-driven pump
assemblies (commonly known as the fire pump churn test) from weekly to monthly.
These changes were first permitted by the 2011 edition of NFPA 25.<span style="mso-spacerun: yes;"> </span>CMS states it will only permit this waiver if
the facility is in compliance with all other applicable NFPA 25-1998 testing
provisions (as referenced in section 9.7.5 of the 2000 LSC) as well as with
sections 5.3 and 8.3 of NFPA 25-2011.</span></span></div>
<span style="font-family: Arial,Helvetica,sans-serif;">
</span><br />
<div class="MsoNormal">
<span style="font-family: Arial,Helvetica,sans-serif;"><u><span style="font-size: 10pt;"><span style="text-decoration: none;"><br /></span></span></u></span></div>
<span style="font-family: Arial,Helvetica,sans-serif;">
</span><br />
<span style="font-family: Arial,Helvetica,sans-serif;"><u><span style="font-size: 10pt;">Waivers
to specific NFPA 101-2000 requirements</span></u><span style="font-size: 10pt;">:</span></span><span style="font-family: Arial,Helvetica,sans-serif;">
</span><br />
<ul>
<li><span style="font-family: Arial,Helvetica,sans-serif;"><span style="font-size: 10pt;"><span style="mso-list: Ignore;"><span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-size: 7pt; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"></span></span></span><u><span style="font-size: 10pt;">Openings in exit enclosures</span></u><span style="font-size: 10pt;">: This categorical
waiver will allow existing openings in exit enclosures to mechanical equipment
spaces that are protected by fire-rated door assemblies (first permitted in the
2003 edition of NFPA 101.) However, those 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. Note that
the absolute combustible material storage restriction may be problematic for
many storage-challenged facilities.<span style="mso-spacerun: yes;"> </span>CMS
will permit this waiver only if the facility is in compliance with all other
applicable NFPA 101-2000 exit provisions, as well as with section
7.1.3.2.1(9)(c) of NFPA 101-2012.</span></span></li>
<li><span style="font-family: Arial,Helvetica,sans-serif;"><span style="font-size: 10pt;"><span style="mso-list: Ignore;"><span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-size: 7pt; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"></span></span></span><u><span style="font-size: 10pt;">Door locking arrangements</span></u><span style="font-size: 10pt;">: This categorical
waiver allows door locking arrangements (first permitted in the 2009 edition of
NFPA 101) where there are clinical needs justifying them, where patients pose a
security risk, or where patients require specialized protective measures for
their safety, but only if the facility is in compliance with all other
applicable NFPA 101-2000 door provisions, as well as with sections
18/19.2.2.2.2 through 18/19.2.2.2.6 of NFPA 101-2012.</span></span></li>
<li><span style="font-family: Arial,Helvetica,sans-serif;"><span style="font-size: 10pt;"><span style="mso-list: Ignore;"><span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-size: 7pt; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"></span></span></span><u><span style="font-size: 10pt;">Multiple delayed-egress locks</span></u><span style="font-size: 10pt;">:<span style="mso-spacerun: yes;"> </span>This categorical waiver allows more than one
delayed-egress lock in the egress path (first permitted in the 2009 edition of
NFPA 101) but only if the facility is in compliance with all other applicable
NFPA 101-2000 door provisions, as well as with sections 18/19.2.2.2.4 of NFPA
101-2012.<span style="mso-spacerun: yes;"> </span>Those sections require
compensating safety measures to facilitate rapid removal of occupants.</span></span></li>
<li><span style="font-family: Arial,Helvetica,sans-serif;"><span style="font-size: 10pt;"><span style="mso-list: Ignore;"><span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-size: 7pt; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"></span></span></span><u><span style="font-size: 10pt;">Suites</span></u><span style="font-size: 10pt;">: The categorical waiver further accommodates
the use of suites as initially permitted in the 2006 edition of NFPA 101.<span style="mso-spacerun: yes;"> </span>CMS will permit this waiver only if the facility
is in compliance with all other applicable NFPA 101-2000 suite provisions, as
well as with sections 18/19.2.5.7 of NFPA 101-2012.<span style="mso-spacerun: yes;"> </span>The waiver allows: </span></span></li>
</ul>
<span style="font-family: Arial,Helvetica,sans-serif;">
</span><br />
<div class="MsoListParagraphCxSpMiddle" style="margin-left: 1.0in; mso-add-space: auto; mso-list: l0 level2 lfo1; text-indent: -.25in;">
<span style="font-family: Arial,Helvetica,sans-serif;"><span style="font-size: 10pt;"><span style="mso-list: Ignore;">o<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-size: 7pt; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span></span><span style="font-size: 10pt;">One
of the required means of egress from sleeping and non-sleeping suites to be
through another suite, provided adequate separation exists between suites</span></span></div>
<span style="font-family: Arial,Helvetica,sans-serif;">
</span><br />
<div class="MsoListParagraphCxSpMiddle" style="margin-left: 1.0in; mso-add-space: auto; mso-list: l0 level2 lfo1; text-indent: -.25in;">
<span style="font-family: Arial,Helvetica,sans-serif;"><span style="font-size: 10pt;"><span style="mso-list: Ignore;">o<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-size: 7pt; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span></span><span style="font-size: 10pt;">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</span></span></div>
<span style="font-family: Arial,Helvetica,sans-serif;">
</span><br />
<div class="MsoListParagraphCxSpMiddle" style="margin-left: 1.0in; mso-add-space: auto; mso-list: l0 level2 lfo1; text-indent: -.25in;">
<span style="font-family: Arial,Helvetica,sans-serif;"><span style="font-size: 10pt;"><span style="mso-list: Ignore;">o<span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-size: 7pt; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span></span><span style="font-size: 10pt;">An
increase in sleeping room suite size up to 10,000 sq. ft.</span></span></div>
<span style="font-family: Arial,Helvetica,sans-serif;">
</span><br />
<ul>
<li><span style="font-family: Arial,Helvetica,sans-serif;"><span style="font-size: 10pt;"><span style="mso-list: Ignore;"><span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-size: 7pt; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"></span></span></span><span style="font-size: 10pt;">In
a waiver that only applies to containers used solely for recycling clean waste
or for patient records awaiting destruction outside a hazardous storage area,
CMS is going along with a change that first appeared in the 2012 edition of
NFPA 101.<span style="mso-spacerun: yes;"> </span>CMS will allow these containers
to be increased to 96 gallons maximum, only if the facility is in compliance
with sections 18/19.7.5.7.2 of the NFPA 101-2012.</span></span></li>
</ul>
<span style="font-family: Arial,Helvetica,sans-serif;">
</span><br />
<div class="MsoNormal">
<br /></div>
<span style="font-family: Arial,Helvetica,sans-serif;">
</span><br />
<div class="MsoNormal">
<span style="font-family: Arial,Helvetica,sans-serif;"><span style="font-size: 10pt;">Facilities
will not need to apply for these waivers or wait until they are cited by CMS or
by state validation surveyors representing CMS.<span style="mso-spacerun: yes;">
</span>However if facilities choose to take advantage of any of categorical
waivers offered by S&C memo # S&C: 13-58-LSC, they are required to
document their prior decision to do so (such as within Safety Committee meeting
minutes) before they start using it.<span style="mso-spacerun: yes;"> </span>The
facility is also required to advise every <i>Life
Safety Code survey team at the </i>entrance conference for any survey
assessing Life Safety Code compliance<i>
of its prior decision to use the CMS waiver, and that it meets the applicable
waiver provisions. ASHE recommends that organizations provide
documentation at the entrance conference and also advise the survey team verbally
of those elections.</i><i><span style="font-style: normal;"></span></i></span></span></div>
<span style="font-family: Arial,Helvetica,sans-serif;">
</span><br />
<div class="MsoNormal">
<br /></div>
<span style="font-family: Arial,Helvetica,sans-serif;">
</span><br />
<div class="MsoNormal">
<span style="font-family: Arial,Helvetica,sans-serif;"><i><span style="font-size: 10pt;">Although
not explicitly stated in this S&C memo as it was stated in a similar
S&C memo issued a few months ago, it is expected that these CMS waivers do not
overrule more stringent state or local laws or regulations.</span></i><i><span style="font-size: 10pt; font-style: normal;"></span></i></span></div>
<span style="font-family: Arial,Helvetica,sans-serif;">
</span><br />
<div class="MsoNormal">
<br /></div>
<span style="font-family: Arial,Helvetica,sans-serif;">
</span><br />
<div class="MsoNormal">
<span style="font-family: Arial,Helvetica,sans-serif;"><span style="font-size: 10pt;">The
categorical waiver S&C memo contains 5 pages of details that should be
reviewed closely by any organizations considering electing to use any of the
categorical waivers.<span style="mso-spacerun: yes;"> </span>The URL for the
full CMS S&C Memo is:</span></span></div>
<span style="font-family: Arial,Helvetica,sans-serif;">
</span><br />
<div class="MsoNormal">
<span style="font-family: Arial,Helvetica,sans-serif;"><a href="http://www.cms.gov/Medicare/Provider-Enrollment-and-Certification/SurveyCertificationGenInfo/Downloads/Survey-and-Cert-Letter-13-58.pdf"><span style="font-size: 7pt;">http://www.cms.gov/Medicare/Provider-Enrollment-and-Certification/SurveyCertificationGenInfo/Downloads/Survey-and-Cert-Letter-13-58.pdf</span></a></span><span style="font-family: "Arial","sans-serif"; font-size: 6.0pt; mso-bidi-font-size: 10.0pt;"></span></div>
Smith Seckman Reid, Inchttp://www.blogger.com/profile/13913803032935481245noreply@blogger.com0tag:blogger.com,1999:blog-6196154551822326880.post-42990447909443240792013-07-19T09:30:00.000-05:002013-09-24T15:31:09.836-05:00<span style="color: #6fa8dc;"><span style="font-size: large;"><span style="font-family: Arial,Helvetica,sans-serif;">TJC Provides Tips for Meeting Problematic Life Safety Compliance Requirements </span></span></span><br />
<br />
<div class="separator" style="clear: both; text-align: center;">
<a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhbcq68pxZXiloExtgGcO0JxSPbmNV-r204ext3blXIAIPA3sFrySxxnxh8fRo64ZgqiLw4UkdC4P7jiAKlc9ihYafLDmwa0zVXAsg-YAmVVxLyKeuQ_cD8nDLKqufgOfY8jivwUaqTuEg/s1600/Compliance+News+header.jpg" imageanchor="1" style="clear: left; float: left; margin-bottom: 1em; margin-right: 1em;"><img border="0" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhbcq68pxZXiloExtgGcO0JxSPbmNV-r204ext3blXIAIPA3sFrySxxnxh8fRo64ZgqiLw4UkdC4P7jiAKlc9ihYafLDmwa0zVXAsg-YAmVVxLyKeuQ_cD8nDLKqufgOfY8jivwUaqTuEg/s1600/Compliance+News+header.jpg" height="70" width="200" /></a></div>
<span style="font-size: small;"><span style="font-family: Arial,Helvetica,sans-serif;"><br />By David Stymiest, PE, CHFM, CHSP, FASHE</span></span><br />
<br />
<span style="font-size: small;"><span style="font-family: Arial,Helvetica,sans-serif;">TJC Director of Engineering George Mills provides tips for meeting problematic life safety compliance issues in the July 2013 of The Joint Commission’s EC News. This valuable multi-page article addresses the following elements of performance (EPs) and related types of survey requirements for improvement:</span></span><br />
<a name='more'></a><span style="font-size: small;"></span><br />
<ul>
<li><span style="font-size: small;"><span style="font-family: Arial,Helvetica,sans-serif;">The “all other” means of egress code requirements such as door width requirements that are commonly scored under Standard LS.02.01.20, EP-32.</span></span></li>
<li><span style="font-size: small;"><span style="font-family: Arial,Helvetica,sans-serif;">The smoke barrier door requirements such as fire ratings, swing directions, smoke door width and door edge treatments that are typically scored under Standard LS.02.01.30, EP-25.</span></span></li>
<li><span style="font-size: small;"><span style="font-family: Arial,Helvetica,sans-serif;">The fire alarm requirements such as pull station locations that are typically scored under Standard LS.02.01.34, EP-4.</span></span></li>
<li><span style="font-size: small;"><span style="font-family: Arial,Helvetica,sans-serif;">The automatic sprinkler system requirements such as water pressure inadequacies that are typically scored under Standard LS.02.01.35, EP-14.</span></span></li>
<li><span style="font-size: small;"><span style="font-family: Arial,Helvetica,sans-serif;">The “No Smoking” signage and ashtray requirements typically scored under LS.02.01.70, EP-4.</span></span></li>
<li><span style="font-size: small;"><span style="font-family: Arial,Helvetica,sans-serif;">The bedding, curtains, and other furnishings issues typically scored under Standard LS.02.01.70, EP-4 and Standard LS.02.01.35, EP-6.</span></span></li>
</ul>
Smith Seckman Reid, Inchttp://www.blogger.com/profile/13913803032935481245noreply@blogger.com0tag:blogger.com,1999:blog-6196154551822326880.post-57918120965607728152013-07-18T09:30:00.000-05:002013-09-24T15:31:09.842-05:00<span style="color: #6fa8dc;"><span style="font-size: large;"><span style="font-family: Arial,Helvetica,sans-serif;">ASHRAE Publishes Improved HVAC Design Manual for Hospitals & Clinics </span></span></span><br />
<br />
<a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhbcq68pxZXiloExtgGcO0JxSPbmNV-r204ext3blXIAIPA3sFrySxxnxh8fRo64ZgqiLw4UkdC4P7jiAKlc9ihYafLDmwa0zVXAsg-YAmVVxLyKeuQ_cD8nDLKqufgOfY8jivwUaqTuEg/s1600/Compliance+News+header.jpg" imageanchor="1" style="clear: left; float: left; margin-bottom: 1em; margin-right: 1em;"><img border="0" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhbcq68pxZXiloExtgGcO0JxSPbmNV-r204ext3blXIAIPA3sFrySxxnxh8fRo64ZgqiLw4UkdC4P7jiAKlc9ihYafLDmwa0zVXAsg-YAmVVxLyKeuQ_cD8nDLKqufgOfY8jivwUaqTuEg/s1600/Compliance+News+header.jpg" height="70" width="200" /></a><span style="font-size: small;"><span style="font-family: Arial,Helvetica,sans-serif;">By Ron Holdaway, PE, CEM, LEED AP</span></span><br />
<br />
<span style="font-size: small;"><span style="font-family: Arial,Helvetica,sans-serif;">ASHRAE recently published the 2nd edition of the HVAC Design Manual for Hospitals and Clinics. ASHRAE states that this book, a complete rewrite of the 1st edition, focuses specifically on HVAC system design for health care facilities, omitting general system descriptions that are readily available in other ASHRAE publications.</span></span><br />
<a name='more'></a><span style="font-family: Arial,Helvetica,sans-serif;"><span style="font-size: small;">This new ASHRAE publication is an excellent resource on current HVAC design topics for today’s health care facilities. Topics range from HVAC Systems, Infection Control, Utilities, O&M, and Infection Control Risk Assessments (ICRA) to sustainability in healthcare facilities and seismic design for HVAC systems in healthcare. All of these are very relevant topics for design engineers and building owners of health care facilities.<br /><br />The new ASHRAE book has an entire chapter on Infection Control. Generally the ASHRAE design manual acknowledges a lack of definitive industry knowledge on mechanisms of transmission of airborne contaminants. The manual states on page 19 ”Transmission of airborne hazards is influenced by factors beyond the control of the engineer that include movement of patients, undiagnosed patients, visitors, concentration of patients, and patient susceptibility. The nature of infectious pathogens, the modes of transmission, the causation of infections, and the relationships to HVAC system design are complicated and not fully understood.”<br /><br />However, the design manual does contain some specific suggestions such as the following excerpt from page 19: “HVAC systems can affect the distribution patterns of airborne particles by diluting or concentrating them, moving them into or out of the breathing zones of susceptible persons, or by accelerating or decelerating the rate of growth of airborne microbes.” The design manual also cautions healthcare facility operations personnel that “Improperly operated and maintained HVAC systems can even become a reservoir for microorganisms.”<br /><br />The ASHRAE HVAC Design Manual for Hospitals and Clinics is available at the ASHRAE bookstore: www.ashrae.org/bookstore.</span></span><br />
<br />Smith Seckman Reid, Inchttp://www.blogger.com/profile/13913803032935481245noreply@blogger.com0tag:blogger.com,1999:blog-6196154551822326880.post-46623455140752526042013-07-17T09:30:00.000-05:002013-09-24T15:31:09.839-05:00<div class="MsoNormal">
<span style="color: #6fa8dc;"><span style="font-size: x-large;"><span style="font-family: Arial,Helvetica,sans-serif;">TJC Strengthens Leadership Accountability for Emergency Management</span></span></span></div>
<span style="font-family: Arial,Helvetica,sans-serif;"><span style="font-size: small;">
</span></span><br />
<div class="MsoNormal">
<br /></div>
<span style="font-family: Arial,Helvetica,sans-serif;"><span style="font-size: small;">
</span></span><br />
<a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhbcq68pxZXiloExtgGcO0JxSPbmNV-r204ext3blXIAIPA3sFrySxxnxh8fRo64ZgqiLw4UkdC4P7jiAKlc9ihYafLDmwa0zVXAsg-YAmVVxLyKeuQ_cD8nDLKqufgOfY8jivwUaqTuEg/s1600/Compliance+News+header.jpg" style="clear: left; float: left; margin-bottom: 1em; margin-right: 1em;"><img border="0" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhbcq68pxZXiloExtgGcO0JxSPbmNV-r204ext3blXIAIPA3sFrySxxnxh8fRo64ZgqiLw4UkdC4P7jiAKlc9ihYafLDmwa0zVXAsg-YAmVVxLyKeuQ_cD8nDLKqufgOfY8jivwUaqTuEg/s1600/Compliance+News+header.jpg" height="70" width="200" /></a><span style="font-family: Arial,Helvetica,sans-serif;">By David Stymiest, PE, CHFM, CHSP, FASHE</span><br />
<br />
<span style="font-family: Arial,Helvetica,sans-serif;">In the July 2014 issue of Joint Commission Perspectives, TJC officially issued new and revised leadership requirements intended to provide “a clearer description of leadership-level oversight of emergency management.” The new and revised elements of performance are all effective January 1, 2014. </span><br />
<a name='more'></a><br />
<ul>
<li><span style="font-family: Arial,Helvetica,sans-serif;">Within Leadership Standard LD.04.01.05 (the standard requiring effective management of programs, services and departments) TJC added a new EP-12 that requires the organization to identify a leader to be accountable for implementation of the 4 phases of emergency management, the 6 critical areas of emergency management, hospital-wide collaboration, and collaboration with community-response partners. This new EP is scoring category A.</span></li>
<li><span style="font-family: Arial,Helvetica,sans-serif;">Within Standard EM.03.01.01 (the standard requiring evaluation of the effectiveness of emergency management planning activities) TJC added a new EP-4 requiring that planning reviews be forwarded to senior (vice president and officer level) leadership for review. This new EP is scoring category A.</span></li>
<li><span style="font-family: Arial,Helvetica,sans-serif;">Within Standard EM.03.01.03 (the standard on evaluating the EOP effectiveness), TJC modified EP-13 (the EP requiring evaluation of all exercises and responses to actual emergencies) to require that relevant input from staff at all affected levels also be considered. Within the same standard, EP-15 regarding communication of emergency management deficiencies and opportunities for improvement was modified to require communication of this information to senior leadership.</span></li>
<li><span style="font-family: Arial,Helvetica,sans-serif;">And finally, within Leadership Standard LD.04.04.01 (the standard requiring that leaders establish performance improvement priorities) TJC added a new EP-25 that requires senior leaders to direct implementation of selected hospital-wide improvements in emergency management based on three listed considerations. This new EP is scoring category A.</span></li>
</ul>
<span style="font-family: Arial,Helvetica,sans-serif;">In explaining the reasoning behind the above changes, TJC stated “hospitals plan and respond more effectively when accountability for hospital-wide emergency management is assigned to leadership at a high level of the organization.” Since many hospitals consider the performance improvement activities for each year in January of that calendar year, SSR recommends that these changes be discussed in the near future to ensure that required activities have been completed on time. Besides appearing in Perspectives, the full text of these new requirements will also appear in 2013 Update 2 to the Comprehensive Accreditation Manual for the hospital and critical access hospital programs as well as in the fall 2013 Joint Commission online manual update.<br /> </span>Smith Seckman Reid, Inchttp://www.blogger.com/profile/13913803032935481245noreply@blogger.com0tag:blogger.com,1999:blog-6196154551822326880.post-783388461521995392013-07-16T09:30:00.000-05:002013-07-16T14:03:27.681-05:00<!--[if gte mso 9]><xml>
<w:WordDocument>
<w:View>Normal</w:View>
<w:Zoom>0</w:Zoom>
<w:TrackMoves/>
<w:TrackFormatting/>
<w:PunctuationKerning/>
<w:ValidateAgainstSchemas/>
<w:SaveIfXMLInvalid>false</w:SaveIfXMLInvalid>
<w:IgnoreMixedContent>false</w:IgnoreMixedContent>
<w:AlwaysShowPlaceholderText>false</w:AlwaysShowPlaceholderText>
<w:DoNotPromoteQF/>
<w:LidThemeOther>EN-US</w:LidThemeOther>
<w:LidThemeAsian>X-NONE</w:LidThemeAsian>
<w:LidThemeComplexScript>X-NONE</w:LidThemeComplexScript>
<w:Compatibility>
<w:BreakWrappedTables/>
<w:SnapToGridInCell/>
<w:WrapTextWithPunct/>
<w:UseAsianBreakRules/>
<w:DontGrowAutofit/>
<w:SplitPgBreakAndParaMark/>
<w:DontVertAlignCellWithSp/>
<w:DontBreakConstrainedForcedTables/>
<w:DontVertAlignInTxbx/>
<w:Word11KerningPairs/>
<w:CachedColBalance/>
</w:Compatibility>
<w:BrowserLevel>MicrosoftInternetExplorer4</w:BrowserLevel>
<m:mathPr>
<m:mathFont m:val="Cambria Math"/>
<m:brkBin m:val="before"/>
<m:brkBinSub m:val="--"/>
<m:smallFrac m:val="off"/>
<m:dispDef/>
<m:lMargin m:val="0"/>
<m:rMargin m:val="0"/>
<m:defJc m:val="centerGroup"/>
<m:wrapIndent m:val="1440"/>
<m:intLim m:val="subSup"/>
<m:naryLim m:val="undOvr"/>
</m:mathPr></w:WordDocument>
</xml><![endif]--><br />
<!--[if gte mso 9]><xml>
<w:LatentStyles DefLockedState="false" DefUnhideWhenUsed="true"
DefSemiHidden="true" DefQFormat="false" DefPriority="99"
LatentStyleCount="267">
<w:LsdException Locked="false" Priority="0" SemiHidden="false"
UnhideWhenUsed="false" QFormat="true" Name="Normal"/>
<w:LsdException Locked="false" Priority="9" SemiHidden="false"
UnhideWhenUsed="false" QFormat="true" Name="heading 1"/>
<w:LsdException Locked="false" Priority="9" QFormat="true" Name="heading 2"/>
<w:LsdException Locked="false" Priority="9" QFormat="true" Name="heading 3"/>
<w:LsdException Locked="false" Priority="9" QFormat="true" Name="heading 4"/>
<w:LsdException Locked="false" Priority="9" QFormat="true" Name="heading 5"/>
<w:LsdException Locked="false" Priority="9" QFormat="true" Name="heading 6"/>
<w:LsdException Locked="false" Priority="9" QFormat="true" Name="heading 7"/>
<w:LsdException Locked="false" Priority="9" QFormat="true" Name="heading 8"/>
<w:LsdException Locked="false" Priority="9" QFormat="true" Name="heading 9"/>
<w:LsdException Locked="false" Priority="39" Name="toc 1"/>
<w:LsdException Locked="false" Priority="39" Name="toc 2"/>
<w:LsdException Locked="false" Priority="39" Name="toc 3"/>
<w:LsdException Locked="false" Priority="39" Name="toc 4"/>
<w:LsdException Locked="false" Priority="39" Name="toc 5"/>
<w:LsdException Locked="false" Priority="39" Name="toc 6"/>
<w:LsdException Locked="false" Priority="39" Name="toc 7"/>
<w:LsdException Locked="false" Priority="39" Name="toc 8"/>
<w:LsdException Locked="false" Priority="39" Name="toc 9"/>
<w:LsdException Locked="false" Priority="35" QFormat="true" Name="caption"/>
<w:LsdException Locked="false" Priority="10" SemiHidden="false"
UnhideWhenUsed="false" QFormat="true" Name="Title"/>
<w:LsdException Locked="false" Priority="1" Name="Default Paragraph Font"/>
<w:LsdException Locked="false" Priority="11" SemiHidden="false"
UnhideWhenUsed="false" QFormat="true" Name="Subtitle"/>
<w:LsdException Locked="false" Priority="22" SemiHidden="false"
UnhideWhenUsed="false" QFormat="true" Name="Strong"/>
<w:LsdException Locked="false" Priority="20" SemiHidden="false"
UnhideWhenUsed="false" QFormat="true" Name="Emphasis"/>
<w:LsdException Locked="false" Priority="59" SemiHidden="false"
UnhideWhenUsed="false" Name="Table Grid"/>
<w:LsdException Locked="false" UnhideWhenUsed="false" Name="Placeholder Text"/>
<w:LsdException Locked="false" Priority="1" SemiHidden="false"
UnhideWhenUsed="false" QFormat="true" Name="No Spacing"/>
<w:LsdException Locked="false" Priority="60" SemiHidden="false"
UnhideWhenUsed="false" Name="Light Shading"/>
<w:LsdException Locked="false" Priority="61" SemiHidden="false"
UnhideWhenUsed="false" Name="Light List"/>
<w:LsdException Locked="false" Priority="62" SemiHidden="false"
UnhideWhenUsed="false" Name="Light Grid"/>
<w:LsdException Locked="false" Priority="63" SemiHidden="false"
UnhideWhenUsed="false" Name="Medium Shading 1"/>
<w:LsdException Locked="false" Priority="64" SemiHidden="false"
UnhideWhenUsed="false" Name="Medium Shading 2"/>
<w:LsdException Locked="false" Priority="65" SemiHidden="false"
UnhideWhenUsed="false" Name="Medium List 1"/>
<w:LsdException Locked="false" Priority="66" SemiHidden="false"
UnhideWhenUsed="false" Name="Medium List 2"/>
<w:LsdException Locked="false" Priority="67" SemiHidden="false"
UnhideWhenUsed="false" Name="Medium Grid 1"/>
<w:LsdException Locked="false" Priority="68" SemiHidden="false"
UnhideWhenUsed="false" Name="Medium Grid 2"/>
<w:LsdException Locked="false" Priority="69" SemiHidden="false"
UnhideWhenUsed="false" Name="Medium Grid 3"/>
<w:LsdException Locked="false" Priority="70" SemiHidden="false"
UnhideWhenUsed="false" Name="Dark List"/>
<w:LsdException Locked="false" Priority="71" SemiHidden="false"
UnhideWhenUsed="false" Name="Colorful Shading"/>
<w:LsdException Locked="false" Priority="72" SemiHidden="false"
UnhideWhenUsed="false" Name="Colorful List"/>
<w:LsdException Locked="false" Priority="73" SemiHidden="false"
UnhideWhenUsed="false" Name="Colorful Grid"/>
<w:LsdException Locked="false" Priority="60" SemiHidden="false"
UnhideWhenUsed="false" Name="Light Shading Accent 1"/>
<w:LsdException Locked="false" Priority="61" SemiHidden="false"
UnhideWhenUsed="false" Name="Light List Accent 1"/>
<w:LsdException Locked="false" Priority="62" SemiHidden="false"
UnhideWhenUsed="false" Name="Light Grid Accent 1"/>
<w:LsdException Locked="false" Priority="63" SemiHidden="false"
UnhideWhenUsed="false" Name="Medium Shading 1 Accent 1"/>
<w:LsdException Locked="false" Priority="64" SemiHidden="false"
UnhideWhenUsed="false" Name="Medium Shading 2 Accent 1"/>
<w:LsdException Locked="false" Priority="65" SemiHidden="false"
UnhideWhenUsed="false" Name="Medium List 1 Accent 1"/>
<w:LsdException Locked="false" UnhideWhenUsed="false" Name="Revision"/>
<w:LsdException Locked="false" Priority="34" SemiHidden="false"
UnhideWhenUsed="false" QFormat="true" Name="List Paragraph"/>
<w:LsdException Locked="false" Priority="29" SemiHidden="false"
UnhideWhenUsed="false" QFormat="true" Name="Quote"/>
<w:LsdException Locked="false" Priority="30" SemiHidden="false"
UnhideWhenUsed="false" QFormat="true" Name="Intense Quote"/>
<w:LsdException Locked="false" Priority="66" SemiHidden="false"
UnhideWhenUsed="false" Name="Medium List 2 Accent 1"/>
<w:LsdException Locked="false" Priority="67" SemiHidden="false"
UnhideWhenUsed="false" Name="Medium Grid 1 Accent 1"/>
<w:LsdException Locked="false" Priority="68" SemiHidden="false"
UnhideWhenUsed="false" Name="Medium Grid 2 Accent 1"/>
<w:LsdException Locked="false" Priority="69" SemiHidden="false"
UnhideWhenUsed="false" Name="Medium Grid 3 Accent 1"/>
<w:LsdException Locked="false" Priority="70" SemiHidden="false"
UnhideWhenUsed="false" Name="Dark List Accent 1"/>
<w:LsdException Locked="false" Priority="71" SemiHidden="false"
UnhideWhenUsed="false" Name="Colorful Shading Accent 1"/>
<w:LsdException Locked="false" Priority="72" SemiHidden="false"
UnhideWhenUsed="false" Name="Colorful List Accent 1"/>
<w:LsdException Locked="false" Priority="73" SemiHidden="false"
UnhideWhenUsed="false" Name="Colorful Grid Accent 1"/>
<w:LsdException Locked="false" Priority="60" SemiHidden="false"
UnhideWhenUsed="false" Name="Light Shading Accent 2"/>
<w:LsdException Locked="false" Priority="61" SemiHidden="false"
UnhideWhenUsed="false" Name="Light List Accent 2"/>
<w:LsdException Locked="false" Priority="62" SemiHidden="false"
UnhideWhenUsed="false" Name="Light Grid Accent 2"/>
<w:LsdException Locked="false" Priority="63" SemiHidden="false"
UnhideWhenUsed="false" Name="Medium Shading 1 Accent 2"/>
<w:LsdException Locked="false" Priority="64" SemiHidden="false"
UnhideWhenUsed="false" Name="Medium Shading 2 Accent 2"/>
<w:LsdException Locked="false" Priority="65" SemiHidden="false"
UnhideWhenUsed="false" Name="Medium List 1 Accent 2"/>
<w:LsdException Locked="false" Priority="66" SemiHidden="false"
UnhideWhenUsed="false" Name="Medium List 2 Accent 2"/>
<w:LsdException Locked="false" Priority="67" SemiHidden="false"
UnhideWhenUsed="false" Name="Medium Grid 1 Accent 2"/>
<w:LsdException Locked="false" Priority="68" SemiHidden="false"
UnhideWhenUsed="false" Name="Medium Grid 2 Accent 2"/>
<w:LsdException Locked="false" Priority="69" SemiHidden="false"
UnhideWhenUsed="false" Name="Medium Grid 3 Accent 2"/>
<w:LsdException Locked="false" Priority="70" SemiHidden="false"
UnhideWhenUsed="false" Name="Dark List Accent 2"/>
<w:LsdException Locked="false" Priority="71" SemiHidden="false"
UnhideWhenUsed="false" Name="Colorful Shading Accent 2"/>
<w:LsdException Locked="false" Priority="72" SemiHidden="false"
UnhideWhenUsed="false" Name="Colorful List Accent 2"/>
<w:LsdException Locked="false" Priority="73" SemiHidden="false"
UnhideWhenUsed="false" Name="Colorful Grid Accent 2"/>
<w:LsdException Locked="false" Priority="60" SemiHidden="false"
UnhideWhenUsed="false" Name="Light Shading Accent 3"/>
<w:LsdException Locked="false" Priority="61" SemiHidden="false"
UnhideWhenUsed="false" Name="Light List Accent 3"/>
<w:LsdException Locked="false" Priority="62" SemiHidden="false"
UnhideWhenUsed="false" Name="Light Grid Accent 3"/>
<w:LsdException Locked="false" Priority="63" SemiHidden="false"
UnhideWhenUsed="false" Name="Medium Shading 1 Accent 3"/>
<w:LsdException Locked="false" Priority="64" SemiHidden="false"
UnhideWhenUsed="false" Name="Medium Shading 2 Accent 3"/>
<w:LsdException Locked="false" Priority="65" SemiHidden="false"
UnhideWhenUsed="false" Name="Medium List 1 Accent 3"/>
<w:LsdException Locked="false" Priority="66" SemiHidden="false"
UnhideWhenUsed="false" Name="Medium List 2 Accent 3"/>
<w:LsdException Locked="false" Priority="67" SemiHidden="false"
UnhideWhenUsed="false" Name="Medium Grid 1 Accent 3"/>
<w:LsdException Locked="false" Priority="68" SemiHidden="false"
UnhideWhenUsed="false" Name="Medium Grid 2 Accent 3"/>
<w:LsdException Locked="false" Priority="69" SemiHidden="false"
UnhideWhenUsed="false" Name="Medium Grid 3 Accent 3"/>
<w:LsdException Locked="false" Priority="70" SemiHidden="false"
UnhideWhenUsed="false" Name="Dark List Accent 3"/>
<w:LsdException Locked="false" Priority="71" SemiHidden="false"
UnhideWhenUsed="false" Name="Colorful Shading Accent 3"/>
<w:LsdException Locked="false" Priority="72" SemiHidden="false"
UnhideWhenUsed="false" Name="Colorful List Accent 3"/>
<w:LsdException Locked="false" Priority="73" SemiHidden="false"
UnhideWhenUsed="false" Name="Colorful Grid Accent 3"/>
<w:LsdException Locked="false" Priority="60" SemiHidden="false"
UnhideWhenUsed="false" Name="Light Shading Accent 4"/>
<w:LsdException Locked="false" Priority="61" SemiHidden="false"
UnhideWhenUsed="false" Name="Light List Accent 4"/>
<w:LsdException Locked="false" Priority="62" SemiHidden="false"
UnhideWhenUsed="false" Name="Light Grid Accent 4"/>
<w:LsdException Locked="false" Priority="63" SemiHidden="false"
UnhideWhenUsed="false" Name="Medium Shading 1 Accent 4"/>
<w:LsdException Locked="false" Priority="64" SemiHidden="false"
UnhideWhenUsed="false" Name="Medium Shading 2 Accent 4"/>
<w:LsdException Locked="false" Priority="65" SemiHidden="false"
UnhideWhenUsed="false" Name="Medium List 1 Accent 4"/>
<w:LsdException Locked="false" Priority="66" SemiHidden="false"
UnhideWhenUsed="false" Name="Medium List 2 Accent 4"/>
<w:LsdException Locked="false" Priority="67" SemiHidden="false"
UnhideWhenUsed="false" Name="Medium Grid 1 Accent 4"/>
<w:LsdException Locked="false" Priority="68" SemiHidden="false"
UnhideWhenUsed="false" Name="Medium Grid 2 Accent 4"/>
<w:LsdException Locked="false" Priority="69" SemiHidden="false"
UnhideWhenUsed="false" Name="Medium Grid 3 Accent 4"/>
<w:LsdException Locked="false" Priority="70" SemiHidden="false"
UnhideWhenUsed="false" Name="Dark List Accent 4"/>
<w:LsdException Locked="false" Priority="71" SemiHidden="false"
UnhideWhenUsed="false" Name="Colorful Shading Accent 4"/>
<w:LsdException Locked="false" Priority="72" SemiHidden="false"
UnhideWhenUsed="false" Name="Colorful List Accent 4"/>
<w:LsdException Locked="false" Priority="73" SemiHidden="false"
UnhideWhenUsed="false" Name="Colorful Grid Accent 4"/>
<w:LsdException Locked="false" Priority="60" SemiHidden="false"
UnhideWhenUsed="false" Name="Light Shading Accent 5"/>
<w:LsdException Locked="false" Priority="61" SemiHidden="false"
UnhideWhenUsed="false" Name="Light List Accent 5"/>
<w:LsdException Locked="false" Priority="62" SemiHidden="false"
UnhideWhenUsed="false" Name="Light Grid Accent 5"/>
<w:LsdException Locked="false" Priority="63" SemiHidden="false"
UnhideWhenUsed="false" Name="Medium Shading 1 Accent 5"/>
<w:LsdException Locked="false" Priority="64" SemiHidden="false"
UnhideWhenUsed="false" Name="Medium Shading 2 Accent 5"/>
<w:LsdException Locked="false" Priority="65" SemiHidden="false"
UnhideWhenUsed="false" Name="Medium List 1 Accent 5"/>
<w:LsdException Locked="false" Priority="66" SemiHidden="false"
UnhideWhenUsed="false" Name="Medium List 2 Accent 5"/>
<w:LsdException Locked="false" Priority="67" SemiHidden="false"
UnhideWhenUsed="false" Name="Medium Grid 1 Accent 5"/>
<w:LsdException Locked="false" Priority="68" SemiHidden="false"
UnhideWhenUsed="false" Name="Medium Grid 2 Accent 5"/>
<w:LsdException Locked="false" Priority="69" SemiHidden="false"
UnhideWhenUsed="false" Name="Medium Grid 3 Accent 5"/>
<w:LsdException Locked="false" Priority="70" SemiHidden="false"
UnhideWhenUsed="false" Name="Dark List Accent 5"/>
<w:LsdException Locked="false" Priority="71" SemiHidden="false"
UnhideWhenUsed="false" Name="Colorful Shading Accent 5"/>
<w:LsdException Locked="false" Priority="72" SemiHidden="false"
UnhideWhenUsed="false" Name="Colorful List Accent 5"/>
<w:LsdException Locked="false" Priority="73" SemiHidden="false"
UnhideWhenUsed="false" Name="Colorful Grid Accent 5"/>
<w:LsdException Locked="false" Priority="60" SemiHidden="false"
UnhideWhenUsed="false" Name="Light Shading Accent 6"/>
<w:LsdException Locked="false" Priority="61" SemiHidden="false"
UnhideWhenUsed="false" Name="Light List Accent 6"/>
<w:LsdException Locked="false" Priority="62" SemiHidden="false"
UnhideWhenUsed="false" Name="Light Grid Accent 6"/>
<w:LsdException Locked="false" Priority="63" SemiHidden="false"
UnhideWhenUsed="false" Name="Medium Shading 1 Accent 6"/>
<w:LsdException Locked="false" Priority="64" SemiHidden="false"
UnhideWhenUsed="false" Name="Medium Shading 2 Accent 6"/>
<w:LsdException Locked="false" Priority="65" SemiHidden="false"
UnhideWhenUsed="false" Name="Medium List 1 Accent 6"/>
<w:LsdException Locked="false" Priority="66" SemiHidden="false"
UnhideWhenUsed="false" Name="Medium List 2 Accent 6"/>
<w:LsdException Locked="false" Priority="67" SemiHidden="false"
UnhideWhenUsed="false" Name="Medium Grid 1 Accent 6"/>
<w:LsdException Locked="false" Priority="68" SemiHidden="false"
UnhideWhenUsed="false" Name="Medium Grid 2 Accent 6"/>
<w:LsdException Locked="false" Priority="69" SemiHidden="false"
UnhideWhenUsed="false" Name="Medium Grid 3 Accent 6"/>
<w:LsdException Locked="false" Priority="70" SemiHidden="false"
UnhideWhenUsed="false" Name="Dark List Accent 6"/>
<w:LsdException Locked="false" Priority="71" SemiHidden="false"
UnhideWhenUsed="false" Name="Colorful Shading Accent 6"/>
<w:LsdException Locked="false" Priority="72" SemiHidden="false"
UnhideWhenUsed="false" Name="Colorful List Accent 6"/>
<w:LsdException Locked="false" Priority="73" SemiHidden="false"
UnhideWhenUsed="false" Name="Colorful Grid Accent 6"/>
<w:LsdException Locked="false" Priority="19" SemiHidden="false"
UnhideWhenUsed="false" QFormat="true" Name="Subtle Emphasis"/>
<w:LsdException Locked="false" Priority="21" SemiHidden="false"
UnhideWhenUsed="false" QFormat="true" Name="Intense Emphasis"/>
<w:LsdException Locked="false" Priority="31" SemiHidden="false"
UnhideWhenUsed="false" QFormat="true" Name="Subtle Reference"/>
<w:LsdException Locked="false" Priority="32" SemiHidden="false"
UnhideWhenUsed="false" QFormat="true" Name="Intense Reference"/>
<w:LsdException Locked="false" Priority="33" SemiHidden="false"
UnhideWhenUsed="false" QFormat="true" Name="Book Title"/>
<w:LsdException Locked="false" Priority="37" Name="Bibliography"/>
<w:LsdException Locked="false" Priority="39" QFormat="true" Name="TOC Heading"/>
</w:LatentStyles>
</xml><![endif]--><!--[if gte mso 10]>
<style>
/* Style Definitions */
table.MsoNormalTable
{mso-style-name:"Table Normal";
mso-tstyle-rowband-size:0;
mso-tstyle-colband-size:0;
mso-style-noshow:yes;
mso-style-priority:99;
mso-style-qformat:yes;
mso-style-parent:"";
mso-padding-alt:0in 5.4pt 0in 5.4pt;
mso-para-margin:0in;
mso-para-margin-bottom:.0001pt;
mso-pagination:widow-orphan;
font-size:10.0pt;
font-family:"Times New Roman","serif";}
</style>
<![endif]-->
<br />
<div class="MsoNormal">
<span style="color: #6fa8dc;"><span style="font-size: x-large;"><span style="font-family: Arial,Helvetica,sans-serif;">TJC Issues 2014 National Patient Safety Goal on Clinical Alarm System Safety</span></span></span></div>
<span style="font-family: Arial,Helvetica,sans-serif;"><span style="font-size: small;">
</span></span><br />
<div class="MsoNormal">
<br /></div>
<span style="font-family: Arial,Helvetica,sans-serif;"><span style="font-size: small;">
</span></span><br />
<div class="MsoNormal">
<a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhbcq68pxZXiloExtgGcO0JxSPbmNV-r204ext3blXIAIPA3sFrySxxnxh8fRo64ZgqiLw4UkdC4P7jiAKlc9ihYafLDmwa0zVXAsg-YAmVVxLyKeuQ_cD8nDLKqufgOfY8jivwUaqTuEg/s1600/Compliance+News+header.jpg" imageanchor="1" style="clear: left; float: left; margin-bottom: 1em; margin-right: 1em;"><img border="0" height="70" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhbcq68pxZXiloExtgGcO0JxSPbmNV-r204ext3blXIAIPA3sFrySxxnxh8fRo64ZgqiLw4UkdC4P7jiAKlc9ihYafLDmwa0zVXAsg-YAmVVxLyKeuQ_cD8nDLKqufgOfY8jivwUaqTuEg/s1600/Compliance+News+header.jpg" width="200" /></a><span style="font-family: Arial,Helvetica,sans-serif;">By David Stymiest, PE, CHFM, CHSP, FASHE</span><br />
<br />
<span style="font-family: Arial,Helvetica,sans-serif;"><span style="font-size: small;">In its Joint Commission Online article dated June 26, 2013
(available at <a href="http://www.jointcommission.org/assets/1/23/jconline_June_26_13.pdf">http://www.jointcommission.org/assets/1/23/jconline_June_26_13.pdf</a>)
The Joint Commission announced a new 2014 National Patient Safety Goal
NPSG.06.01.01 on clinical alarm safety for both hospitals and critical access
hospitals. The July 2013 issue of Joint Commission Perspectives discusses
the new NPSG in detail.</span></span></div>
<a name='more'></a><br />
<span style="font-family: Arial,Helvetica,sans-serif;"><span style="font-size: small;">
</span></span><br />
<div class="MsoNormal">
<span style="font-family: Arial,Helvetica,sans-serif;"><span style="font-size: small;">The NPSG requirements include 4 elements of performance
(EPs) all with the Risk [R] icons that were recently established by TJC to
identify patient risks due to a system's proximity to patient, probability of
harm, severity of harm, and number of patients at risk. The 4 EPs are
invoked in a phased process:</span></span></div>
<span style="font-family: Arial,Helvetica,sans-serif;"><span style="font-size: small;">
</span></span><br />
<ul>
<li><span style="font-family: Arial,Helvetica,sans-serif;"><span style="font-size: small;"><span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"></span>Starting on January 1, 2014 and completed by
July 1, 2014, hospital leaders are required to establish clinical alarm system
safety as a hospital priority. This EP-1 requirement is scoring category
A.</span></span></li>
<li><span style="font-family: Arial,Helvetica,sans-serif;"><span style="font-size: small;"><span style="-moz-font-feature-settings: normal; -moz-font-language-override: normal; font-size-adjust: none; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"></span>Starting on January 1, 2014 and to be completed
no later than the end of 2014, hospitals are required to identify the most important
clinical alarm signals to manage based on their own internal situations.
The EP-2 details include five separate issues (including published best
practices and guidelines) to be considered during this identification
process. This EP-2 requirement is scoring category A.</span></span></li>
<li><span style="font-family: Arial,Helvetica,sans-serif;"><span style="font-size: small;">As of January 1, 2016, hospitals will be
expected to establish policies and procedures for managing the alarms
previously identified. The EP-3 details include a minimum of eight
separate issues to be factored into the required policies and procedures.
This EP-3 requirement is also scoring category A.</span></span></li>
<li><span style="font-family: Arial,Helvetica,sans-serif;"><span style="font-size: small;">And finally, as of January 1, 2016, hospitals are
required to educate staff and licensed independent practitioners about the
purpose and proper operation of alarm systems for which they are responsible.
This EP-4 requirement is scoring category C.</span></span></li>
</ul>
<span style="font-family: Arial,Helvetica,sans-serif;"><span style="font-size: small;">
</span></span><br />
<div class="MsoNormal">
</div>
<span style="font-family: Arial,Helvetica,sans-serif;"><span style="font-size: small;">
</span></span><br />
<div class="MsoNormal">
<span style="font-family: Arial,Helvetica,sans-serif;"><span style="font-size: small;">It comes as no surprise that TJC has issued this NPSG.
We wrote about clinical alarm safety in our late 2012 <i>Compliance Newsletter</i>
article about the ECRI Institute’s 2013 top 10 health technology hazards.
Clinical alarm hazards were #1 on that list of top hazards. (The previous
article is available at <a href="http://ssr-cfm-articles.blogspot.com/2012/12/compliance-news-ecri-institute-lists.html">http://ssr-cfm-articles.blogspot.com/2012/12/compliance-news-ecri-institute-lists.html</a>.)
The NPSG’s current wording is not the end of the story - TJC also states within
the NPSG’s Rationale that the NPSG will be updated to reflect best practices as
further clinical alarm system management solutions are Identified.</span></span></div>
<span style="font-family: Arial,Helvetica,sans-serif;"><span style="font-size: small;">
</span></span><br />
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
<br /></div>
Smith Seckman Reid, Inchttp://www.blogger.com/profile/13913803032935481245noreply@blogger.com0tag:blogger.com,1999:blog-6196154551822326880.post-48221925482109300912013-06-04T11:15:00.000-05:002013-06-04T11:15:00.746-05:00<span style="font-family: Arial,Helvetica,sans-serif;"><span style="color: #6fa8dc;"><span style="font-size: x-large;">Compliance News: TJC Revisits EC Plans</span></span></span><br />
<div class="separator" style="clear: both; text-align: center;">
<a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhbcq68pxZXiloExtgGcO0JxSPbmNV-r204ext3blXIAIPA3sFrySxxnxh8fRo64ZgqiLw4UkdC4P7jiAKlc9ihYafLDmwa0zVXAsg-YAmVVxLyKeuQ_cD8nDLKqufgOfY8jivwUaqTuEg/s1600/Compliance+News+header.jpg" imageanchor="1" style="clear: left; float: left; margin-bottom: 1em; margin-right: 1em;"><img border="0" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhbcq68pxZXiloExtgGcO0JxSPbmNV-r204ext3blXIAIPA3sFrySxxnxh8fRo64ZgqiLw4UkdC4P7jiAKlc9ihYafLDmwa0zVXAsg-YAmVVxLyKeuQ_cD8nDLKqufgOfY8jivwUaqTuEg/s1600/Compliance+News+header.jpg" height="70" width="200" /></a></div>
<span style="font-family: Arial,Helvetica,sans-serif;"><span style="color: #6fa8dc;"><span style="font-size: x-large;"> </span></span><br />By David Stymiest, PE, CHFM, CHSP, FASHE</span><br />
<span style="font-family: Arial,Helvetica,sans-serif;"><br /></span>
<span style="font-family: Arial,Helvetica,sans-serif;">A recent article placed in both the EC News and TJC Perspectives clarified TJC requirements for management plans. Written for the June 2013 issues by TJC Department of Engineering Director George Mills for the Clarifications and Expectations segment of both publications, the article clarified some issues that have been resulting in TJC requirements for improvement (RFIs) during survey.</span><br />
<a name='more'></a><br />
<span style="font-family: Arial,Helvetica,sans-serif;">Mr. Mills reiterated previous guidance that management plans should not necessarily state how things are done, but could refer to policies or procedures for more specificity. The article provided background and explanatory material on the following major points:</span><br />
<ul>
<li><span style="font-family: Arial,Helvetica,sans-serif;">Don’t cite the standards (although it can be helpful to have a copy of each plan annotated with standards and element of performance numbers to facilitate responding to survey questions.)</span></li>
<li><span style="font-family: Arial,Helvetica,sans-serif;">Determine overall management plan format – 6 separate EC plans vs. 1 master plan covering multiple areas vs. other approaches</span></li>
<li><span style="font-family: Arial,Helvetica,sans-serif;">Keeping management plan structures consistent</span></li>
<li><span style="font-family: Arial,Helvetica,sans-serif;">Listing supporting material such as policies and procedures</span></li>
<li><span style="font-family: Arial,Helvetica,sans-serif;">Indicating where the organization is complying with not only TJC’s requirements but also with stricter requirements of another authority having jurisdiction (AHJ) and naming that AHJ</span></li>
<li><span style="font-family: Arial,Helvetica,sans-serif;">Identifying other related requirements (from other chapters of the TJC Hospital Accreditation Standards) that affect a management plan</span></li>
<li><span style="font-family: Arial,Helvetica,sans-serif;">Making sure to distribute management plans to every accredited site, and conversely making sure that accredited sites have management plans reflecting the activities occurring in those locations</span></li>
</ul>
<span style="font-family: Arial,Helvetica,sans-serif;">SSR recommends that TJC accredited organizations take the time to review this article and revisit their existing management plans.</span>Smith Seckman Reid, Inchttp://www.blogger.com/profile/13913803032935481245noreply@blogger.com0tag:blogger.com,1999:blog-6196154551822326880.post-66761635404438143812013-06-03T11:11:00.000-05:002013-06-03T11:11:00.395-05:00<span style="color: #6fa8dc;"><span style="font-size: x-large;"><span style="font-family: Arial,Helvetica,sans-serif;">Compliance News: Reducing Emergency Power Vulnerabilities</span></span></span><br />
<div class="separator" style="clear: both; text-align: center;">
<a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhbcq68pxZXiloExtgGcO0JxSPbmNV-r204ext3blXIAIPA3sFrySxxnxh8fRo64ZgqiLw4UkdC4P7jiAKlc9ihYafLDmwa0zVXAsg-YAmVVxLyKeuQ_cD8nDLKqufgOfY8jivwUaqTuEg/s1600/Compliance+News+header.jpg" imageanchor="1" style="clear: left; float: left; margin-bottom: 1em; margin-right: 1em;"><img border="0" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhbcq68pxZXiloExtgGcO0JxSPbmNV-r204ext3blXIAIPA3sFrySxxnxh8fRo64ZgqiLw4UkdC4P7jiAKlc9ihYafLDmwa0zVXAsg-YAmVVxLyKeuQ_cD8nDLKqufgOfY8jivwUaqTuEg/s1600/Compliance+News+header.jpg" height="70" width="200" /></a></div>
<span style="font-size: small;"><span style="font-family: Arial,Helvetica,sans-serif;"><br /> By David Stymiest, PE, CHFM, CHSP, FASHE</span></span><br />
<span style="font-size: small;"><span style="font-family: Arial,Helvetica,sans-serif;"><br /></span></span>
<span style="font-size: small;"><span style="font-family: Arial,Helvetica,sans-serif;">Healthcare facility emergency power systems are held to a very high standard. They are expected to deliver power to what they must, when they must, for as long as they must. A review of some medical journals will find references to clinical expectations for “uninterrupted power supply” and similar phrases. In fact uninterrupted power is not guaranteed despite the misconceptions of some clinical personnel. Hospital power systems are not as robust as large data center power systems, and even data center power systems sometimes fail. But healthcare facilities can take steps to reduce the probability of emergency power failures. </span></span><br />
<span style="font-size: small;"><span style="font-family: Arial,Helvetica,sans-serif;"><br />Firstly it is helpful to understand the differences between reliability, availability and dependability. Reliability can be considered the probability that a system operates and gives the same result on successive trials. Availability on the other hand can be considered the probability that a system will function at any instant required, including the next instant, and for as long as required from that point. And finally dependability can be considered as the metric that measures availability, reliability & maintenance support.</span></span><br />
<span style="font-size: small;"><span style="font-family: Arial,Helvetica,sans-serif;"></span></span><br />
<a name='more'></a><span style="font-size: small;"> <span style="font-family: Arial,Helvetica,sans-serif;">The Joint Commission’s (TJC’s) Sentinel Event Alert Issue 37 (SEA-37), entitled “Preventing adverse events caused by emergency electrical power system failures” was published in 2006. TJC addressed that topic again in EOC News in 2007. Power system failures during recent natural disasters indicate that we should consider addressing the SEA-37 power system vulnerability analysis again. This time we should also make sure to address potential common-mode failures, which are failures of two or more systems or components due to a single event or cause.</span></span><br />
<span style="font-size: small;"><span style="font-family: Arial,Helvetica,sans-serif;"><br />One way to reduce vulnerabilities is to find and then eliminate the potential for common-mode failures. A safety engineering concept considers that once a failure mode is identified, it usually can be mitigated by adding extra or redundant equipment to the system. However you cannot correct what you have not yet identified, and the existence of an uncorrected common mode failure potential removes the advantage of such redundancies.</span></span><br />
<span style="font-size: small;"><span style="font-family: Arial,Helvetica,sans-serif;"><br />It is helpful to take another look at existing conditions from a fresh perspective. There are many examples of potential common-mode failures, including single power sources to redundant equipment, common wiring, common feeder or equipment locations, susceptibility to the same internal or external hazards, and lack of maintenance. Many organizations consider external flooding, but what about the rupture of a chilled water line or domestic water line in a mechanical room adjacent to an emergency power equipment room? One major lesson learned from the past few years’ emergency power failures is that we really should sweat the small stuff. Things break, and details are critical. When failures do occur, power failure procedures that have been thoroughly considered before an incident are likely to be more effective than those developed afterwards.</span></span><br />
<br />
<span style="font-size: small;"><span style="font-family: Arial,Helvetica,sans-serif;">An effective approach to resolving potential vulnerabilities is to:</span></span><br />
<ul>
<li><span style="font-size: small;"><span style="font-family: Arial,Helvetica,sans-serif;">Consider each component that must operate successfully</span></span></li>
<li><span style="font-size: small;"><span style="font-family: Arial,Helvetica,sans-serif;">Use the “what if” analysis technique to determine all scenarios that can cause it to fail </span></span></li>
<li><span style="font-size: small;"><span style="font-family: Arial,Helvetica,sans-serif;">Determine whether any of these scenarios will also cause redundant components to fail</span></span></li>
<li><span style="font-size: small;"><span style="font-family: Arial,Helvetica,sans-serif;">Address the resulting potential common-mode failures</span></span></li>
</ul>
<span style="font-size: small;"><span style="font-family: Arial,Helvetica,sans-serif;"><br />Having dependable emergency power systems requires regular maintenance of all components. Maintenance will reduce operational vulnerabilities related to normal wear and tear. All emergency power supply system equipment and systems need to be maintained in full accordance with all applicable requirements as stated in NFPA 110:</span></span><br />
<i><span style="font-size: small;"><span style="font-family: Arial,Helvetica,sans-serif;">8.1.1 The routine maintenance and operational testing program shall be based on all of the following:</span></span></i><br />
<ul>
<li><i><span style="font-size: small;"><span style="font-family: Arial,Helvetica,sans-serif;">Manufacturer’s recommendations</span></span></i></li>
<li><i><span style="font-size: small;"><span style="font-family: Arial,Helvetica,sans-serif;">Instruction manuals</span></span></i></li>
<li><i><span style="font-size: small;"><span style="font-family: Arial,Helvetica,sans-serif;">Minimum requirements of this chapter [Ch. 8 - Routine Maintenance and Operational Testing]</span></span></i></li>
<li><i><span style="font-size: small;"><span style="font-family: Arial,Helvetica,sans-serif;">The authority having jurisdiction</span></span></i></li>
</ul>
<span style="font-size: small;"><span style="font-family: Arial,Helvetica,sans-serif;"><br />The requirement for maintenance includes automatic transfer switches, themselves a potential source of common-mode failure. Many hospitals are not presently performing required maintenance on automatic transfer switches because of equipment and operational restrictions, thereby increasing potential vulnerabilities. Although they are not required by codes and standards, isolation-bypass transfer switches represent a best practice that permits required maintenance without taking that branch out of service.</span></span><br />
<span style="font-size: small;"><span style="font-family: Arial,Helvetica,sans-serif;"><br />This article is based upon the author’s more comprehensive article entitled “After the Storm – Expanding the concept of emergency power reliability” that was originally published in the January 2013 issue of Health Facilities Management magazine, Vol. 26, No. 1. ©2013 by Health Forum Inc. Contact the author at<a href="mailto:dstymiest@ssr-inc.com"> dstymiest@ssr-inc.com</a> for a digital copy of that HFM article.</span></span><br />
<span style="font-size: small;"><span style="font-family: Arial,Helvetica,sans-serif;"><br />NFPA DISCLAIMER: Although the author is Chairman of the NFPA Technical Committee on Emergency Power Supplies, which is responsible for NFPA 110 and 111, the views and opinions expressed in this article are purely those of the author and shall not be considered the official position of NFPA or any of its Technical Committees and shall not be considered to be, nor be relied upon as, a Formal Interpretation. Readers are encouraged to refer to the entire text of all referenced documents. NFPA members can obtain NFPA staff interpretations at <a href="http://www.nfpa.org/">www.nfpa.org</a>.</span></span><br />
<br />Smith Seckman Reid, Inchttp://www.blogger.com/profile/13913803032935481245noreply@blogger.com0tag:blogger.com,1999:blog-6196154551822326880.post-33925589130003701282013-05-31T10:55:00.001-05:002013-05-31T11:18:20.481-05:00<span style="font-size: x-large;"><span style="color: #3d85c6;"><span style="font-family: Arial,Helvetica,sans-serif;">Compliance News: CMS Issues Categorical Waiver </span></span></span><br />
<br />
<div class="separator" style="clear: both; text-align: center;">
<a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhbcq68pxZXiloExtgGcO0JxSPbmNV-r204ext3blXIAIPA3sFrySxxnxh8fRo64ZgqiLw4UkdC4P7jiAKlc9ihYafLDmwa0zVXAsg-YAmVVxLyKeuQ_cD8nDLKqufgOfY8jivwUaqTuEg/s1600/Compliance+News+header.jpg" imageanchor="1" style="clear: left; float: left; margin-bottom: 1em; margin-right: 1em;"><img border="0" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhbcq68pxZXiloExtgGcO0JxSPbmNV-r204ext3blXIAIPA3sFrySxxnxh8fRo64ZgqiLw4UkdC4P7jiAKlc9ihYafLDmwa0zVXAsg-YAmVVxLyKeuQ_cD8nDLKqufgOfY8jivwUaqTuEg/s1600/Compliance+News+header.jpg" height="70" width="200" /></a></div>
<br />
<span style="font-family: Arial,Helvetica,sans-serif;"><span style="font-size: small;"> By David Stymiest, PE, CHFM, CHSP, FASHE</span></span><br />
<br />
<span style="font-family: Arial,Helvetica,sans-serif;"><span style="font-size: small;">The Centers for Medicare & Medicaid Services (CMS) issued a categorical Life Safety Code waiver permitting new and existing ventilation systems supplying hospital and critical access hospital (CAH) anesthetizing locations to operate with a relative humidity (RH) of ≥20%, instead of ≥35%. CMS is also recommending that RH not exceed 60% in these locations.</span></span><br />
<span style="font-family: Arial,Helvetica,sans-serif;"><span style="font-size: small;"><br />CMS issued the new Survey & Certification memorandum # S&C: 13-25-LSC & ASC on April 19, 2013. In its S&C memo, CMS referenced the recent code changes that adopted the lower requirements. Many hospitals are expected to welcome this change, and it was supported by ASHE.<br /><br />Organizations will not need to apply for this waiver or wait until they are cited by CMS or by state validation surveyors representing CMS. However if organizations choose to take advantage of this waiver, they are required to document their decision to do so (such as within Safety Committee meeting minutes) before they start using it. Organizations are also required to advise every Life Safety Code survey team at the beginning of any survey of their prior decision to use the CMS waiver. CMS stated that lack of documentation of the prior decision to use the waiver may result in citations that would otherwise have been unnecessary.<br /><br />The CMS waiver does not overrule more stringent state or local laws or regulations nor does it apply if the reduction of the relative humidity would negatively affect ventilation system performance.</span></span><br />
<span style="font-family: Arial,Helvetica,sans-serif;"><span style="font-size: small;"><br />According to CMS, organizations must still monitor relative humidity levels in anesthetizing locations and must take action when needed to ensure that RH levels remain at or above 20%. Specifically, the CMS S&C memo stated “Facilities must monitor RH levels in anesthetizing locations and be able to provide evidence that the RH levels are maintained at or above 20%. When outdoor humidity and internal moisture are not sufficient to achieve the minimum humidity level, then humidification must be provided by means of the hospital’s or CAH’s ventilation systems. In addition, facilities must provide evidence that timely corrective actions are performed successfully in instances when internal monitoring determines RH levels are below the permitted range.”<br /><br />The categorical waiver contains 17 pages of details including updated State Operations Manual Appendices A, I, L and W. All organizations should obtain a copy of the letter and review it closely. <br /><br />The URL for the CMS Survey and Certification Memo is: <br /><a href="http://www.cms.gov/Medicare/Provider-Enrollment-and-Certification/SurveyCertificationGenInfo/Downloads/Survey-and-Cert-Letter-13-25.pdf">http://www.cms.gov/Medicare/Provider-Enrollment-and-Certification/SurveyCertificationGenInfo/Downloads/Survey-and-Cert-Letter-13-25.pdf</a></span></span>Smith Seckman Reid, Inchttp://www.blogger.com/profile/13913803032935481245noreply@blogger.com0tag:blogger.com,1999:blog-6196154551822326880.post-32023761049386647542013-05-03T19:50:00.003-05:002013-05-03T19:53:15.702-05:00CMS Issues Categorical Waiver to Lower OR Humidity Requirement<div class="MsoNormal" style="margin: 0in 0in 0pt;">
<a href="http://www.blogger.com/null" name="_MailEndCompose"><span style="font-family: 'Arial','sans-serif'; font-size: 10pt;">Please see below and refer to the URL to obtain your own copy of the just-issued CMS categorical waiver regarding Operating Room minimum allowable relative humidity (RH).</span></a><span style="font-family: 'Arial','sans-serif'; font-size: 10pt;"><o:p></o:p></span></div>
<div class="MsoNormal" style="margin: 0in 0in 0pt;">
<br /></div>
<div class="MsoNormal" style="margin: 0in 0in 0pt;">
<span style="font-family: 'Arial','sans-serif'; font-size: 10pt;">CMS is lowering the humidity requirement for operating rooms from at least 35 percent to at least 20 percent. In its S&C letter, CMS referenced the recent code changes that adopted the lower requirements.<o:p></o:p></span></div>
<div class="MsoNormal" style="margin: 0in 0in 0pt;">
<br /></div>
<div class="MsoNormal" style="margin: 0in 0in 0pt;">
<span style="font-family: 'Arial','sans-serif'; font-size: 10pt;">You will not need to apply for this waiver or wait until you are cited, however if you choose to take advantage of this waiver (and I expect many hospitals will) you must document your decision to do so (such as within your Safety Committee meeting minutes) before you start using it. You must also advise every <em><span style="font-family: 'Arial','sans-serif';">Life Safety Code</span></em><em><span style="font-family: 'Arial','sans-serif'; font-style: normal;"> survey team at the beginning of any survey that you have made the prior decision to use the CMS waiver. CMS stated that lack of documentation of your prior decision to use the waiver may result in your being cited against the 35 percent requirement.</span></em></span></div>
<div class="MsoNormal" style="margin: 0in 0in 0pt;">
<br /></div>
<div class="MsoNormal" style="margin: 0in 0in 0pt;">
<em><span style="font-family: 'Arial','sans-serif'; font-size: 10pt; font-style: normal;">The CMS waiver does <u>not</u> overrule more stringent state or local laws or regulations.<o:p></o:p></span></em></div>
<div class="MsoNormal" style="margin: 0in 0in 0pt;">
<br /></div>
<div class="MsoNormal" style="margin: 0in 0in 0pt;">
<em><span style="font-family: 'Arial','sans-serif'; font-size: 10pt; font-style: normal;">The CMS waiver does <u>not</u> apply </span></em><span style="font-family: 'Arial','sans-serif'; font-size: 10pt;">if the reduction of the relative humidity would negatively affect ventilation system performance.<em><span style="font-family: 'Arial','sans-serif'; font-style: normal;"><o:p></o:p></span></em></span></div>
<div class="MsoNormal" style="margin: 0in 0in 0pt;">
<br /></div>
<div class="MsoNormal" style="margin: 0in 0in 0pt;">
<span style="font-family: 'Arial','sans-serif'; font-size: 10pt;">According to CMS, you must still monitor relative humidity levels in anesthetizing locations and must take action when needed to ensure that RH levels remain at or above 20 percent.</span></div>
<div class="MsoNormal" style="margin: 0in 0in 0pt;">
<br /></div>
<div class="MsoNormal" style="margin: 0in 0in 0pt;">
<span style="font-family: 'Arial','sans-serif'; font-size: 10pt;">The URL for the CMS Survey and Certification Memo is: <o:p></o:p></span></div>
<div class="MsoNormal" style="margin: 0in 0in 0pt;">
<a href="http://www.cms.gov/Medicare/Provider-Enrollment-and-Certification/SurveyCertificationGenInfo/Downloads/Survey-and-Cert-Letter-13-25.pdf"><span style="color: windowtext; font-family: 'Arial','sans-serif'; font-size: 10pt;">http://www.cms.gov/Medicare/Provider-Enrollment-and-Certification/SurveyCertificationGenInfo/Downloads/Survey-and-Cert-Letter-13-25.pdf</span></a><span style="color: #1f497d; font-family: 'Arial','sans-serif'; font-size: 10pt;"><o:p></o:p></span></div>
<div class="MsoNormal" style="margin: 0in 0in 0pt;">
<br /></div>
<div class="MsoNormal" style="margin: 0in 0in 0pt;">
<span style="color: #1f497d; font-family: 'Arial','sans-serif'; font-size: 10pt;">I suggest that you read the entire CMS S&C memo and share it with your staff.</span><span style="font-family: 'Arial','sans-serif'; font-size: 10pt;"><o:p></o:p></span></div>
David Stymiest, PE CHFM CHSP FASHEhttp://www.blogger.com/profile/06643428660378913498noreply@blogger.com0tag:blogger.com,1999:blog-6196154551822326880.post-12392206904731555802013-04-08T13:39:00.006-05:002013-05-03T19:53:57.245-05:00<h3 class="post-title entry-title" itemprop="name">
<span style="font-family: Arial, Helvetica, sans-serif;"><span style="color: #3d85c6;"><a href="http://www.ssr-inc.com/pdfs/Compliance%20News%20XIII%20I.pdf" target="_blank"><span style="color: #3d85c6;">Compliance News: The Power of Tracers</span></a> </span></span></h3>
<div class="post-body entry-content" itemprop="description articleBody">
<b><span style="font-family: Arial, Helvetica, sans-serif; font-size: small;">by David Stymiest, PE, CHFM, CHSP, FASHE </span></b></div>
<span style="font-family: Arial, Helvetica, sans-serif;"><span lang="EN"></span></span><br />
<div align="justify" class="post-body entry-content" itemprop="description articleBody">
<div align="justify">
<span style="font-family: Arial,Helvetica,sans-serif;"><span style="font-size: small;"><span lang="EN">The Joint Commission (TJC) discussed the use of a sample hazardous material and waste management environment of care (EOC) tracer in its March 2013 issue of EC News. The article provided specific examples for conducting the tracer to explore issues related to orientation and training, physical environment, and quality improvement priority focus areas. </span></span></span><br />
<br />
<span style="font-family: Arial,Helvetica,sans-serif;"><span style="font-size: small;"><span lang="EN">EC News articles also discussed the use of non-patient tracers in June 2011 (sterilizer maintenance) September 2012 (fire safety) and November 2012 (utilities systems). An earlier Joint Commission International publication also discussed the uses and benefits of a similar tracer methodology approach called System Tracers. In the writer’s opinion, tracers of this nature have been proven to be extremely powerful in assessing not only compliance with individual TJC Standards and Elements of Performance but also in determining where opportunities for improving the EOC management processes exist within an organization. As TJC also stated in its November 2012 issue, “Performing mock tracers can help your organization evaluate the effectiveness of its policies, engage staff in looking for opportunities to improve processes, and identify compliance issues that need attention.”</span></span></span></div>
<span style="font-family: Times, "Times New Roman", serif;"><span lang="EN"></span></span></div>
<br />
<div class="post-body entry-content" itemprop="description articleBody">
<a href="http://www.ssr-inc.com/pdfs/Compliance%20News%20XIII%20I.pdf" target="_blank" title="Compliance News: Holiday Decorations"><span style="color: #2288bb;">Read more »</span></a> </div>
SSR Compliance and Facilities Managementhttp://www.blogger.com/profile/08001053767242037976noreply@blogger.com0tag:blogger.com,1999:blog-6196154551822326880.post-26256787877308232412013-04-08T13:19:00.001-05:002013-05-03T19:54:50.928-05:00<h3 class="post-title entry-title" itemprop="name">
<span style="font-family: Arial, Helvetica, sans-serif;"><span style="color: #3d85c6;"><a href="http://www.ssr-inc.com/pdfs/Compliance%20News%20XIII%20I.pdf" target="_blank"><span style="color: #3d85c6;">Compliance News: Risk Icons Considered as TJC FSA Replaces PPR</span></a></span></span></h3>
<h3 class="post-body entry-content" itemprop="description articleBody">
<span style="font-family: Arial, Helvetica, sans-serif;"><span style="font-size: small;">by David Stymiest, PE, CHFM, CHSP, FASHE</span></span> </h3>
<span style="font-family: Arial, Helvetica, sans-serif;"><span lang="EN"></span></span><br />
<div align="justify" class="post-body entry-content" itemprop="description articleBody">
<span style="font-size: small;"><span style="font-family: Arial,Helvetica,sans-serif;"><span lang="EN">Users of The Joint Commission’s (TJC’s) 2012 "Update 2" and 2013 accreditation manuals found a new RISK ICON "R" in selected elements of performance. According to TJC in its September 26, 2012 Joint Commission Online edition, This new icon is related to TJC’s "Replacement of the Periodic Performance Review (PPR) with the Focused Standards Assessment (FSA)" and the "new risk icons denote elements of performance (EPs) assessed through the FSA process, applicable to all except the long term care program." A more comprehensive discussion occurred in TJC’s October 2012 Perspectives.</span></span></span><br />
<span style="font-family: Times, "Times New Roman", serif;"><span lang="EN"></span></span></div>
<br />
<div class="post-body entry-content" itemprop="description articleBody">
<a href="http://www.ssr-inc.com/pdfs/Compliance%20News%20XIII%20I.pdf" target="_blank" title="Compliance News: Holiday Decorations"><span style="color: #2288bb;">Read more »</span></a> </div>
SSR Compliance and Facilities Managementhttp://www.blogger.com/profile/08001053767242037976noreply@blogger.com0tag:blogger.com,1999:blog-6196154551822326880.post-6039345846714568142013-04-08T13:14:00.000-05:002013-04-08T15:56:22.908-05:00<h3 class="post-title entry-title" itemprop="name">
<span style="font-family: Arial, Helvetica, sans-serif;"><span style="color: #3d85c6;">Compliance News: EOC Risk Assessments</span> </span></h3>
<div class="post-body entry-content" itemprop="description articleBody" style="text-align: justify;">
<b><span style="font-family: Arial, Helvetica, sans-serif; font-size: small;">by David Stymiest, PE, CHFM, CHSP, FASHE</span><span style="font-size: small;"><span style="font-family: Arial,Helvetica,sans-serif;"><span lang="EN"> </span></span></span></b></div>
<div class="post-body entry-content" itemprop="description articleBody" style="text-align: justify;">
<span style="font-size: small;"><span style="font-family: Arial,Helvetica,sans-serif;"><span lang="EN"> </span></span><span style="font-family: Arial,Helvetica,sans-serif;"><span lang="EN"> </span></span></span></div>
<div class="post-body entry-content" itemprop="description articleBody" style="text-align: justify;">
<span style="font-size: small;"><span style="font-family: Arial,Helvetica,sans-serif;"><span lang="EN">In
its March 2013 issues of both Perspectives and EC News The Joint
Commission (TJC) continued to promote the use of risk assessments to
evaluate whether to accept, mitigate or avoid environmental risks when
there not definitive right or wrong answers. The articles by Joint
Commission engineering director George Mills reiterated previous TJC
guidance on 7-step risk assessments.</span></span></span><br />
<span style="font-size: small;"><span style="font-family: Arial,Helvetica,sans-serif;"><span lang="EN"> </span></span></span><span style="color: #2288bb;"> </span><br />
<a href="http://www.ssr-inc.com/pdfs/Compliance%20News%20XIII%20I.pdf" target="_blank" title="Compliance News: Holiday Decorations"><span style="color: #2288bb;">Read more »</span></a> </div>
<span style="font-family: Arial, Helvetica, sans-serif;"><span lang="EN">
</span></span>
<br />
<span style="font-family: Arial, Helvetica, sans-serif;">
</span>
<br />
<div class="post-body entry-content" itemprop="description articleBody">
</div>
SSR Compliance and Facilities Managementhttp://www.blogger.com/profile/08001053767242037976noreply@blogger.com0tag:blogger.com,1999:blog-6196154551822326880.post-33869184448250792362013-03-15T09:48:00.000-05:002013-04-08T15:57:01.799-05:00<div class="MsoPlainText" style="margin: 0in 0in 0pt;">
<h3 class="post-title entry-title" itemprop="name">
<span style="font-family: Arial, Helvetica, sans-serif;"><span style="color: #3d85c6;"><span style="color: #3d85c6;"> </span></span></span></h3>
<h3 class="post-title entry-title" itemprop="name">
<span style="font-family: Arial, Helvetica, sans-serif;"><span style="color: #3d85c6;">Generator Risk Assessments</span> </span></h3>
<span style="font-family: Arial,Helvetica,sans-serif;"><span style="font-size: small;">An ASHE member recently posted on the ASHE Listserv asking if anyone knew of a generator risk assessment.</span></span></div>
<div class="MsoPlainText" style="margin: 0in 0in 0pt; text-align: left;">
<span style="font-family: Arial,Helvetica,sans-serif;"><span style="font-size: small;">We responded to the Listerv: </span></span><br />
<span style="font-family: Arial,Helvetica,sans-serif;"><br /></span></div>
<div class="MsoPlainText" style="margin: 0in 0in 0pt; text-align: left;">
<span style="font-family: Arial,Helvetica,sans-serif;"><span style="font-size: small;">1. "Log into ASHE's website and go to <span style="color: purple;"> </span></span></span><br />
<span style="font-family: Arial,Helvetica,sans-serif;"><span style="font-size: small;"><span style="color: purple;"> </span><a href="http://www.ashe.org/resources/management_monographs/mg2009stymiest.html"><span style="color: purple;">http://www.ashe.org/resources/management_monographs/mg2009stymiest.html</span></a> </span></span><br />
<span style="font-family: Arial,Helvetica,sans-serif;"><br /></span></div>
<div class="MsoPlainText" style="margin: 0in 0in 0pt; text-align: left;">
<span style="font-family: Arial,Helvetica,sans-serif;"><span style="font-size: small;"><span style="font-size: small;">2. </span>"Managing Hospital Emergency Power Systems - Testing, Operation, Maintenance and Power Failure Planning". </span></span><br />
<span style="font-family: Arial,Helvetica,sans-serif;"><br /></span>
<span style="font-family: Arial,Helvetica,sans-serif;"><span style="font-size: small;">3. A PDF of this document is available for free to all ASHE members.<span style="mso-spacerun: yes;"> </span>It can be downloaded from that URL. </span></span></div>
<div class="MsoPlainText" style="margin: 0in 0in 0pt; text-align: left;">
<span style="font-family: Arial,Helvetica,sans-serif;"><br /></span>
<span style="font-family: Arial,Helvetica,sans-serif;"><span style="font-size: small;">Please feel free to contact me if you have any questions.</span></span></div>
<div class="MsoPlainText" style="margin: 0in 0in 0pt;">
</div>
David Stymiest, PE CHFM CHSP FASHEhttp://www.blogger.com/profile/06643428660378913498noreply@blogger.com0tag:blogger.com,1999:blog-6196154551822326880.post-23774629098467487002013-01-07T11:52:00.001-06:002013-04-08T15:57:20.707-05:00<div align="left">
<h3 class="post-title entry-title" itemprop="name">
<a href="http://www.hfmmagazine.com/hfmmagazine/jsp/articledisplay.jsp?dcrpath=HFMMAGAZINE/Article/data/01JAN2013/0113HFM_FEA_Infrastructure&domain=HFMMAGAZINE" target="_blank"><span style="font-family: Arial, Helvetica, sans-serif;"><span style="color: #3d85c6;"><span style="color: #3d85c6;">After The Storm - Expanding the Concept of Emergency Power Reliability</span></span></span></a></h3>
<div class="post-body entry-content" itemprop="description articleBody">
<b><span style="font-size: small;"><span style="font-family: Arial,Helvetica,sans-serif;">by David Stymiest, PE, CHFM, CHSP,
FASHE</span></span></b> </div>
<br />
<div style="text-align: justify;">
<span style="font-family: Arial,Helvetica,sans-serif;"><span lang="EN">As
mission-critical equipment, hospital emergency power systems are
expected to provide power consistently to what they must, when they must
and for as long as they must. This is a tall order, and the impact of
an emergency power system failure when normal utility power also has
failed is potentially severe for patient care.</span> </span></div>
<span style="font-family: Arial,Helvetica,sans-serif;"><br /></span>
<div style="text-align: justify;">
<span style="font-family: Arial,Helvetica,sans-serif;">The
failure of some facility emergency power systems during and after last
fall’s superstorm Sandy already has spawned investigations, which
ultimately will result in lessons learned and more knowledge upon which
health facilities professionals can base best practices to reduce
vulnerabilities.</span></div>
<div align="justify" class="post-body entry-content" itemprop="description articleBody">
<span style="font-family: Arial,Helvetica,sans-serif;"><span lang="EN">
</span></span></div>
<span style="font-family: Arial,Helvetica,sans-serif;"><br /></span>
<div class="post-body entry-content" itemprop="description articleBody">
<span style="font-family: Arial,Helvetica,sans-serif;"><a href="http://www.hfmmagazine.com/hfmmagazine/jsp/articledisplay.jsp?dcrpath=HFMMAGAZINE/Article/data/01JAN2013/0113HFM_FEA_Infrastructure&domain=HFMMAGAZINE" target="_blank" title="Compliance News: Holiday Decorations"><span style="color: #2288bb;">Read more »</span></a></span> </div>
</div>
David Stymiest, PE CHFM CHSP FASHEhttp://www.blogger.com/profile/06643428660378913498noreply@blogger.com0tag:blogger.com,1999:blog-6196154551822326880.post-12057608915731825992012-12-06T10:54:00.000-06:002013-04-08T15:58:00.284-05:00<h3 class="post-title entry-title" itemprop="name">
<span style="font-family: Arial, Helvetica, sans-serif;"><span style="color: #3d85c6;">Compliance News: Holiday Decorations </span> </span></h3>
<div class="post-body entry-content" itemprop="description articleBody">
<span style="font-family: Arial,Helvetica,sans-serif;"><b><span style="font-size: small;">by Robert Trotter, BS, MCP and David Stymiest, PE, CHFM, CHSP, FASHE</span></b></span><br />
<div style="text-align: justify;">
<span style="font-family: Arial,Helvetica,sans-serif;"><br /></span></div>
<div style="text-align: justify;">
<span style="font-family: Arial,Helvetica,sans-serif;"><span style="font-size: small;">Many of this newsletter’s readers are regularly confronted with questions concerning holiday decorations. The Joint Commission’s 2012 Hospital Accreditation Standards, Standard LS.02.01.70 EP-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.)”</span></span></div>
</div>
<div style="text-align: justify;">
<span style="font-family: Arial,Helvetica,sans-serif;"><span style="font-size: small;"><br /></span></span></div>
<div style="text-align: justify;">
<span style="font-family: Arial,Helvetica,sans-serif;"><span style="font-size: small;">In NFPA 101-2000®, paragraph 18/19.7.5.4 states “Combustible decorations shall be prohibited in any health care occupancy unless they are flame-retardant. <i>Exception: Combustible decorations, such as photographs and paintings, in such limited quantities that a hazard of fire development or spread is not present.</i>”</span></span></div>
<span style="font-family: Arial, Helvetica, sans-serif;"></span><br />
<a name='more'></a><div class="separator" style="clear: both; text-align: center;">
<a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjTuCsy_sFRQ6fdGSs53EhkAhsV6GFmHIgwGahthE9spow7w0LiH8krlPi4KAO7pFOQx5A-6iZQ2R61Wynb98EJlON8r7P-EAf7B0z_GlFpshueflhPDNW3KTDk0YEVQy96v0oZ3djxA_A/s1600/holiday+decor.bmp" imageanchor="1" style="clear: right; float: right; margin-bottom: 1em; margin-left: 1em;"><img border="0" height="214" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjTuCsy_sFRQ6fdGSs53EhkAhsV6GFmHIgwGahthE9spow7w0LiH8krlPi4KAO7pFOQx5A-6iZQ2R61Wynb98EJlON8r7P-EAf7B0z_GlFpshueflhPDNW3KTDk0YEVQy96v0oZ3djxA_A/s320/holiday+decor.bmp" width="320" /></a></div>
<div style="text-align: justify;">
<span style="font-family: Arial, Helvetica, sans-serif;">If the local or state authority having jurisdiction has adopted NFPA 101-2012, there are new provisions that apply to decorations. CMS has also indicated its willingness to allow compliance in accordance with the below NFPA 101-2012 wording; however, the organization would have to request a waiver after being cited by CMS. TJC has indicated that organizations may request a traditional equivalency based upon the NFPA 101-2012 decorations wording. Under NFPA 101-2012, 18/19.7.5 Furnishings, Mattresses, and Decorations, paragraph 18/19.7.5.1(b) states “Total area of drapery and curtain panels per room or area does not exceed 20 percent of the aggregate area of the wall on which they are located.” In the same section of the 2012 edition, paragraph 18/19.7.5.6 states “Combustible decorations shall be prohibited in any health care occupancy, unless one of the following criteria is met:</span></div>
<ul style="text-align: justify;">
<li><span style="font-family: Arial,Helvetica,sans-serif;">They are flame-retardant or are treated with approved fire-retardant coating that is listed and labeled for application to material to which it is applied.</span></li>
<li><span style="font-family: Arial,Helvetica,sans-serif;">The decorations meet the requirements of NFPA 701, Standard Methods of Fire Tests for Flame Propagation of Textiles and Films.</span></li>
<li><span style="font-family: Arial,Helvetica,sans-serif;">The decorations exhibit a heat release rate not exceeding 100 kW when tested in accordance with NFPA 289, Standard Method of Fire Tests for Individual Fuel Packages, using the 20 kW ignition source.</span></li>
<li><span style="font-family: Arial,Helvetica,sans-serif;">The decorations, such as photographs, paintings, and other art, are attached directly to the walls, ceiling, and non-fire-rated doors in accordance with the following:</span></li>
<ul>
<li><span style="font-family: Arial,Helvetica,sans-serif;">Decorations on non-fire-rated doors do not interfere with the operation or any required latching of the door and do not exceed the area limitations of 18/19.7.5.6(b), (c), or (d).</span></li>
<li><span style="font-family: Arial,Helvetica,sans-serif;">Decorations do not exceed 20 percent of the wall, ceiling, and door areas inside any room or space of a smoke compartment that is not protected throughout by an approved automatic sprinkler system in accordance with Section 9.7.</span></li>
<li><span style="font-family: Arial,Helvetica,sans-serif;">Decorations do not exceed 30 percent of the wall, ceiling, and door areas inside any room or space of a smoke compartment that is protected throughout by an approved automatic sprinkler system in accordance with Section 9.7.</span></li>
<li><span style="font-family: Arial,Helvetica,sans-serif;">Decorations do not exceed 50 percent of the wall, ceiling, and door areas inside patient sleeping rooms, having a capacity not exceeding four persons, in a smoke compartment that is protected throughout by an approved automatic sprinkler system in accordance with Section 9.7.</span></li>
</ul>
</ul>
<ul style="text-align: justify;">
<li><span style="font-family: Arial,Helvetica,sans-serif;">They are decorations, such as photographs and paintings, in such limited quantities that a hazard of fire development or spread is not present.”</span></li>
</ul>
<div style="text-align: justify;">
<span style="font-family: Arial,Helvetica,sans-serif;"><b>Appendix A.18/19.7.5.6(4) </b>The percentage of decorations should be measured against the area of the wall or ceiling, not the aggregate total of walls, ceilings, and doors. The door is considered part of the wall.</span></div>
SSR Compliance and Facilities Managementhttp://www.blogger.com/profile/08001053767242037976noreply@blogger.com0tag:blogger.com,1999:blog-6196154551822326880.post-18606842215074382322012-12-06T10:39:00.000-06:002013-04-08T15:24:00.194-05:00<h3 class="post-title entry-title" itemprop="name">
<span style="font-family: Arial, Helvetica, sans-serif;"><span style="color: #3d85c6;">Compliance News: ECRI Institute Lists 2013's Top 10 Health Technology Hazards </span> </span></h3>
<span style="font-family: Arial, Helvetica, sans-serif;"></span><span style="font-size: small;"><b><span style="font-family: Arial,Helvetica,sans-serif;"><span>by David Stymiest, PE, CHFM, CHSP, FASHE</span></span></b></span><br />
<div style="text-align: justify;">
<br /></div>
<div style="text-align: justify;">
<span style="font-family: Arial, Helvetica, sans-serif;">The ECRI Institute recently published a 25-page special report entitled “ECRI Institute 2013 Top 10 Health Technology Hazards” – available at <a href="http://www.ecri.org/2013hazards">www.ecri.org/2013hazards</a>. In its introduction, ECRI encourages facilities to use the list of generic hazards as a “starting point for patient safety discussions and for setting their health technology safety priorities.” This report is comprehensive with a multitude of useful recommendations along with exhaustive lists of further reference publications. We recommend that our readers use the link above to acquire their own copies of the ECRI publication for review and possible action.</span></div>
<div style="text-align: justify;">
<br /></div>
<div style="text-align: justify;">
<span style="font-family: Arial, Helvetica, sans-serif;">ECRI stated that it considered a number of factors in determining which hazards actually made it to the top 10 list, including potential for harm, frequency/likelihood of the hazard, how widespread is the hazard, whether the problem is difficult to recognize or challenging to rectify, and whether the hazard has a high profile in the media.</span></div>
<span style="font-family: Arial, Helvetica, sans-serif;"></span><br />
<a name='more'></a><div style="text-align: justify;">
<span style="font-family: Arial, Helvetica, sans-serif;"> The hazards discussed by ECRI are listed below, and a few of them are further discussed in this article. Several of the hazards on the 2013 list have been listed by ECRI in previous years. Most of these hazards are also receiving attention from The Joint Commission and other authorities having jurisdiction. Many of these hazards can fall under multiple Environment of Care (EOC) areas and require oversight by hospital EOC and Safety Committees.</span></div>
<br />
<br />
<div class="separator" style="clear: both; text-align: center;">
<a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgUEN3PnfXDbBSYYlTurXyNCyDPaMyjeTBo6qr7_jfZUnSbE-HcJ2rF42urh30Uaa6RBueEAx3iBy0a8vnGthYemqIKocjkoBMQlNxqOWXqore7-t54kqwvwEW4FzhTRJv77mdKJi3GlEI/s1600/ECRI+nurse.bmp" imageanchor="1" style="clear: right; float: right; margin-bottom: 1em; margin-left: 1em;"><span style="font-family: Arial, Helvetica, sans-serif;"><img border="0" height="192" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgUEN3PnfXDbBSYYlTurXyNCyDPaMyjeTBo6qr7_jfZUnSbE-HcJ2rF42urh30Uaa6RBueEAx3iBy0a8vnGthYemqIKocjkoBMQlNxqOWXqore7-t54kqwvwEW4FzhTRJv77mdKJi3GlEI/s200/ECRI+nurse.bmp" width="200" /></span></a></div>
<ol><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEiMrN97PupcwfDYxGxgVnLu-65aem3oNmMkb_dckVuQAMBRrQQZSn3pUtcTk2LUF1kH8_knkzRUmALWC0THpD2liVQgXWYBKaaB7z-CnNw9pjhaELp61B5tXrlTQSKtLaSPeWNkhgz0lKI/s1600/ECRI+Fire.bmp" imageanchor="1" style="clear: right; float: right; margin-bottom: 1em; margin-left: 1em;"><span style="font-family: Arial, Helvetica, sans-serif;"><img border="0" height="152" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEiMrN97PupcwfDYxGxgVnLu-65aem3oNmMkb_dckVuQAMBRrQQZSn3pUtcTk2LUF1kH8_knkzRUmALWC0THpD2liVQgXWYBKaaB7z-CnNw9pjhaELp61B5tXrlTQSKtLaSPeWNkhgz0lKI/s200/ECRI+Fire.bmp" width="200" /></span></a>
<li><span style="font-family: Arial, Helvetica, sans-serif;">Alarm hazards</span></li>
<li><span style="font-family: Arial, Helvetica, sans-serif;">Medication administration errors using infusion pumps</span></li>
<li><span style="font-family: Arial, Helvetica, sans-serif;">Unnecessary exposures and radiation burns from diagnostic radiology procedures</span></li>
<li><span style="font-family: Arial, Helvetica, sans-serif;">Patient/data mismatches in EHRs and other health IT systems</span></li>
<li><span style="font-family: Arial, Helvetica, sans-serif;">Interoperability failures with medical devices and health IT systems</span></li>
<li><span style="font-family: Arial, Helvetica, sans-serif;">Air embolism hazards</span></li>
<li><span style="font-family: Arial, Helvetica, sans-serif;">Inattention to the needs of pediatric patients when using “adult” technologies</span></li>
<li><span style="font-family: Arial, Helvetica, sans-serif;">Inadequate reprocessing of endoscopic devices and surgical instruments</span></li>
<li><span style="font-family: Arial, Helvetica, sans-serif;">Caregiver distractions from smartphones and other mobile devices</span></li>
<li><span style="font-family: Arial, Helvetica, sans-serif;">Surgica</span><span style="font-family: Arial, Helvetica, sans-serif;">l fires</span></li>
</ol>
<br />
<br />
<div style="text-align: justify;">
<span style="font-family: Arial, Helvetica, sans-serif;">ECRI is not alone in highlighting the problematic issue of </span><span style="font-family: Arial, Helvetica, sans-serif;">medical device alarm fatigue. The Association for the Advancement of Medical Instrumentation (AAMI) Foundation’s Healthcare Technology Safety Institute also tackled this issue in 2012, building on priorities identified at the high level multi-organization Fall 2011 Medical Device Alarms Summit. The Joint Commission surveyed its accredited organizations in 2012 to assess its own future activities, and the US Food and Drug Administration is also addressing challenges related to medical device alarm fatigue.</span></div>
<div style="text-align: justify;">
<br /></div>
<div style="text-align: justify;">
<span style="font-family: Arial, Helvetica, sans-serif;">Medication administration errors using infusion pumps can be reduced, according to ECRI, by “integrating infusion pumps with electronic ordering, administration, and documentation systems.” </span><span style="font-family: Arial, Helvetica, sans-serif;">ECRI further cautions that this will “require considerable involvement from clinical engineers, IT staff, and other technology managers.” The report also addresses other recommended activities.</span></div>
<div style="text-align: justify;">
<br /></div>
<div class="separator" style="clear: both; text-align: justify;">
<a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhdpJWBJEn2nm-USofO9MAHQPtIMMMrXJhkZbHEL3GjaGbc-FZvTtPwTvrIEGMPzjBpkkd6n5I6669xIxhcqw7yAcP2jy_CQOT7VnW-EADtpWGTAc1j50QJOAjqzhh2eQaF9Ddt1dsjtIA/s1600/ECRI.bmp" imageanchor="1" style="clear: left; float: left; margin-bottom: 1em; margin-right: 1em;"><img border="0" height="204" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhdpJWBJEn2nm-USofO9MAHQPtIMMMrXJhkZbHEL3GjaGbc-FZvTtPwTvrIEGMPzjBpkkd6n5I6669xIxhcqw7yAcP2jy_CQOT7VnW-EADtpWGTAc1j50QJOAjqzhh2eQaF9Ddt1dsjtIA/s320/ECRI.bmp" width="320" /></a></div>
<div style="text-align: justify;">
<span style="font-family: Arial, Helvetica, sans-serif;">In its discussion of unnecessary exposures and radiation burns from diagnostic radiology procedures, ECRI goes beyond earlier discussions regarding CT procedures to any diagnostic imaging procedure. In the report, ECRI recommends attention to staffing; quality assurance and quality control procedures with peer review; attention to installation, acceptance testing, commissioning and maintenance of systems; and several other areas.</span></div>
<div style="text-align: justify;">
<br /></div>
<div style="text-align: justify;">
<span style="font-family: Arial, Helvetica, sans-serif;">The issue of inadequate reprocessing of endoscopic devices and surgical instruments has been an ECRI focus in past years as well. This issue is also targeted by TJC and has been one of the commonly-cited areas during 2012 TJC surveys. Although not mentioned in the ECRI report, even reprocessing area ventilation pressure relationships have been cited by TJC.</span></div>
<div style="text-align: justify;">
<br /></div>
<div style="text-align: justify;">
<span style="font-family: Arial, Helvetica, sans-serif;">ECRI stated that surgical fires are on its 2013 top 10 list because ECRI receives at least one report of a surgical fire each week despite previous focused attention. TJC’s Sentinel Event Alert Issue 29 entitled Preventing Surgical Fires also addressed this topic in detail. ECRI states that “virtually all surgical fires can be avoided” and recommends enhanced training and communication about the risks and roles of oxidizers, ignition sources and fuels in the OR. ECRI’s report also has additional recommendations for changes in practices to reduce or eliminate the risk of surgical fires moving forward.</span></div>
SSR Compliance and Facilities Managementhttp://www.blogger.com/profile/08001053767242037976noreply@blogger.com0