Compliance News: CMS Eases Hospital Corridor Clutter Waiver Process

By David Stymiest, PE, CHFM, FASHE


CMS issued new Survey and Clarification Memo # S&C-12-21-LSC, which applies to both hospitals and nursing homes, on March 9, 2012. CMS is easing its process for obtaining waivers in order to take advantage of four provisions in the NFPA 101 Life Safety Code© 2012 edition. CMS will now “allow providers to implement these four changes by considering waivers of the current LSC requirements found in the 2000 edition of the LSC without showing ‘unreasonable hardship’.” The four 2012 Life Safety Code© portions referenced by CMS are 18/19.2.3.4 under Capacity of Means of Egress; 18/19.3.2.5.2, 18/19.3.2.5.3, 18/19.3.2.5.4 and sections 18/19.3.2.5.5 under Cooking Facilities; 18/19.5.2.3(2), (3) and (4) under Heating, Ventilating, and Air Conditioning; and 18/19.7.5.6 under Furnishings, Mattresses, and Decorations. CMS stated “Due to the complex nature of some of the requirements, each waiver request will have to be evaluated separately in the interest of fire safety and to ensure that the facility has followed all LSC requirements and the equipment has been installed properly by the facility.”

ASHE members should have already received both an ASHE Advocacy Alert and Issue Brief regarding this topic. Since CMS waivers are issued after adverse findings during validation surveys, our recommendation is that organizations stay tuned and follow the development of this issue. As of this writing The Joint Commission has not commented publically.

Compliance News: The NFPA 110 Installation Acceptance Test

By David Stymiest, PE, CHFM, FASHE





Many hospitals are installing new or replacement emergency power systems. NFPA 110 requires a special testing sequence before the system may be used. 

Although the NFPA 110-2005 edition is referenced by the 2010 FGI Guidelines for Design and Construction of Healthcare Facilities, readers should review the updated and considerably improved Installation Acceptance Test in Section 7.13 of NFPA 110-2010 (www.nfpa.org/110). The 2010 update was rewritten to clarify the intent of the testing. If a project team is considering deviating from verbatim NFPA 110 requirements because of facility-specific differences, all necessary authority having jurisdiction (AHJ) approvals should be obtained.

Some of the major requirements of the NFPA 110-2010 Installation Acceptance Test include:

Transfer Switch Location Battery Lighting

QUESTION:  Where is the requirement for battery lights at transfer switch locations?  When did that requirement first appear?

Maintenance Repair Shop

Why do Maintenance repair shops need sprinkler systems?

Cooking Appliances

Do we need approval or an inspection to move our cooking appliances?

Penetrations in 2-HR Fire Barriers

What does a penetration in a 2-hour fire barrier have to be sealed with in order to maintain fire resistance?

Mural Painted Exit Access Doors

Life Safety Tip from Bob Trotter, CBO, CFM, MCP

Mural Painted Exit Access Doors

Be careful about where painted murals are located.  Exit access and exit doors with painted murals for decorative effect are not acceptable, as casual occupants might not be aware of such means of egress even though it is visible. The 2000 edition of NFPA 101^®, Life Safety Code^® 7.5.2.2 states “Exit access and exit doors shall be designed and arranged to be clearly recognizable”.

Improper Exit Arrangement

Life Safety Tip from Bob Trotter, CBO, CFM, MCP

Improper Exit Arrangement

If a temporary partition is installed to separate an area undergoing construction, repair, or improvement operations, alternate EXITS need to be identified. According to LS.01.02.01 Element of Performance 2 of the 2012 Hospital Accreditation Standards “The hospital posts signage identifying the location of alternate exits to everyone affected”. The appropriate action for this scenario would be to cover or remove the EXIT sign and post the (floor plan) signage indicating the location(s) of alternate EXITS.

Separation of E-Cylinders

Is there a standard that notes that full e-cylinders need to be separated from empty cylinders?  

In Case of Fire, Resolve to Make a Plan in 2012

"In Case of Fire, Resolve to Make a Plan in 2012" 

This article first appeared in the February 2012 issue of Nashville Medical News.

By Robert Trotter, CBO, CFM, MCP


In a February 2009 report, the National Fire Protection Association (NFPA) identified that during 2003-2006, municipal fire departments responded to an estimated 3,750 structure fires in medical, mental health, and substance abuse facilities, annually. These fires resulted in one civilian death, 57 civilian injuries, and $26.9 million in direct property damage. While no amount of money can account for the loss of a loved one, the United States Consumer Product Safety Commission (CPSC) assigns a statistical value per life of $5 million; and according to its Injury Cost Model, the estimated cost of a fire-related injury is about $56,000 per incident. Therefore, the average total estimated cost of these healthcare facility fires was $34.2 million.

Every well-managed healthcare organization should have, in effect and available to all supervisory personnel, written copies of a plan for the protection of all persons in the event of fire, for their evacuation to areas of refuge, and for their evacuation from the building when necessary.


To read the entire article, please click here.

Temporary Electrical Wiring

Life Safety Tip from Bob Trotter, BS, MCP

Temporary Electrical Wiring
  
According to NFPA 70, National Electrical Code, 1999 edition temporary wiring is defined as “Approved wiring for power and lighting during a period of construction, remodeling, maintenance, repair, or demolition, and decorative lighting, carnival power and lighting, and similar purposes”. The NEC requires temporary wiring to be removed immediately upon completion of construction or purpose for which the wiring was installed.

Continuous Compliance - Maintaining a constant state of regulatory readiness

Continuous compliance - Maintaining a constant state of regulatory readiness

This article first appeared in the May 2011 issue of HFM Magazine.

By David L. Stymiest, P.E., CHFM, FASHE

Continuous compliance also has been called continuous survey readiness. It involves proactively maintaining a safe health care environment conducive to high-quality patient care. It essentially means having staff at all levels doing the right things for the right reasons because they understand those reasons.


Just about all accrediting agencies conduct unannounced surveys or inspections. Even when organizations think they know approximately when the next unannounced survey is due, there is the potential for random unannounced surveys or a for-cause survey. Thus, continuous survey readiness is crucial. Ongoing training and thorough staff involvement in compliance activities are essential because key managers might be unavailable when the surveyors arrive.


To read the entire article, please click here

Daily checks on Airborne Infectious Isolation (AII) rooms

CDC is often listed as the source of guidelines for daily checks on Airborne Infectious Isolation (AII) rooms.

The document with the CDC guidelines is "Centers for Disease Control and Prevention. Guidelines for Preventing the Transmission of Mycobacterium tuberculosis in Health-Care Settings, 2005. MMWR 2005;54(No. RR-17)" and is at the following link: 

http://www.cdc.gov/mmwr/pdf/rr/rr5417.pdf

If you go to the CDC website and download the linked document, you will see the following wording in the right column on page 19 (PDF) or 17 (DOCUMENT PAGE #):

"Settings with AII Rooms

Health-care personnel settings with AII rooms should

• keep doors to AII rooms closed except when patients,

HCWs, or others must enter or exit the room (118);

• maintain enough AII rooms to provide airborne precautions

of all patients who have suspected or confirmed TB

disease. Estimate the number of AII rooms needed based

on the results of the risk assessment for the setting;

• monitor and record direction of airflow (i.e., negative pressure)

in the room on a daily basis, while the room is being

used for TB airborne precautions. Record results in an

electronic or readily retrievable document;"

Continuation not inserted here.  Refer to the referenced document for all guidelines.

 

Styrofoam Sound Barrier

Life Safety Tip from Bob Trotter, BS, MCP

Styrofoam Sound Barrier

The Styrofoam™ sheets applied to the walls of this mechanical room being use as a sound barrier must meet the interior wall and ceiling finish requirements of the 2000 edition of NFPA 101^®, Life Safety Code^®. For Health Care Occupancies Section 19.3.3.2 states the following: 

19.3.3.2  Interior wall and ceiling finish materials complying with 10.2.3 shall be permitted as follows: (1)   Existing materials — Class A or Class B. 

Exception:  In rooms protected by an approved, supervised automatic sprinkler system, existing Class C interior finish shall be permitted to be continued to be used on walls and ceilings within rooms separated from the exit access corridors in accordance with 19.3.6. 

It is expected that this type exposed product for this application will not meet the interior finish requirements.

Conflicting Exit Signs

Life Safety Tip from Bob Trotter, BS, MCP

Conflicting Exit Signs

This scenario exists at the bottom of an EXIT stair enclosure. The original EXIT sign did not indicate the direction of egress travel. Therefore the more modern EXIT sign was installed with the left Chevron indicating the direction of egress travel. However, the original sign should have been removed to eliminate the conflict that could pose risk to life safety.