By Dean Samet, CHSP
In a July 2010 Environment of Care News article entitled, Ensuring Effective Fire Alarm and Automatic Sprinkler Systems, The Joint Commission says that there has been some confusion among health care organizations regarding the requirements for the master fire alarm panel location.
Monday, November 29, 2010
Compliance News: Manual Transmission of Fire Alarm Signals Permitted Under Certain Conditions by TJC
By Dean Samet, CHS
In the July 2010 Environment of Care News article Ensuring Effective Fire Alarm and Automatic Sprinkler Systems, The Joint Commission (TJC) reintroduced a manual method of fire alarm transmission policy. This policy is meant to be applied when the four traditional methods of transmitting fire alarm signals to the local fire department cannot be achieved per the 2000 NFPA 101, Life Safety Code® (LSC), Section 9.6.4 Emergency Forces Notification, which in turn references the 1999 NFPA 72, National Fire Alarm Code®.
Compliance News: Accreditation Survey Findings Report Includes TJC and CMS Findings
By Dean Samet, CHSP
In July of 2009 The Joint Commission modified its Accreditation Survey Findings Report to include both TJC and Medicare requirements which were identified as being less than fully compliant at the time of survey. This is primarily for organizations that use The Joint Commission accreditation for deemed status purposes. TJC has developed crosswalks of their requirements to Medicare Conditions of Participation (CoPs) as reflected in a new report format.
In July of 2009 The Joint Commission modified its Accreditation Survey Findings Report to include both TJC and Medicare requirements which were identified as being less than fully compliant at the time of survey. This is primarily for organizations that use The Joint Commission accreditation for deemed status purposes. TJC has developed crosswalks of their requirements to Medicare Conditions of Participation (CoPs) as reflected in a new report format.
Compliance News: More Days On-Site for Life Safety Code® Specialist surveyors
By Dean Samet, CHSP
TJC is giving their Life Safety Code® Specialist Surveyors additional days on site as reported in the October 20, 2010 Joint Commission Online and November 2010 The Joint Commission Perspectives®. Effective January 1, 2011, both hospitals and critical access hospitals will have an LSC Specialist on-site from one to three extra days, depending on the size of the hospital. The LSC Specialist surveyors will be assessing compliance against both Life Safety (LS) and Environment of Care (EC) chapters. Fire safety equipment and fire safety building features standard EC.02.03.05 and emergency power systems standard EC.02.05.07 will be particular areas for review and discussion as they have historically ranked as some of the more challenging standards with which to comply. The extra days should result in a more thorough and enhanced LS and EC assessment and opportunity for additional educational training.
Monday, November 1, 2010
Power Play: NFPA Updates Standards to Improve Emergency Systems
By David Stymiest, P.E., FASHE, CHFM
The National Fire Protection Association recently published the latest editions of NFPA 110 (Standard on Emergency Power Supplies) and NFPA 111 (Standard on Stored Electrical Energy Emergency and Standby Power Systems), each of which features changes of vital interest to health facility professionals.It is unlikely that the 2010 editions of these standards, for which the Technical Committee (TC) on Emergency Power Supplies has primary responsibility, will be imposed on accredited health facilities right away. Both the Centers for Medicare & Medicaid Services (CMS) and The Joint Commission (TJC) invoke earlier editions that are mandatory references through the 2000 NFPA 101 Life Safety Code®.
Read entire article here: Power Play
Wednesday, September 29, 2010
Compliance News: TJC Infection Control Standards for Medical Equipment, Devices and Supplies
By Dean Samet, CHS
For 2010, The Joint Commission (TJC) has made several changes to its infection control standard IC.02.02 .01 including a new “rationale” and revisions to elements of performance EP1 and EP2 which clarify requirements to reduce the risks associated with medical equipment, devices and supplies.
According to an October 2009 The Joint Commission Perspectives article, several significant issues have emerged related to the cleaning, disinfecting and sterilizing of medical equipment, devices, and supplies. TJC cites an example of the proper use of steam sterilizers as discussed in the July 2009 Perspectives. Medical technology and instrumentation is a rapid and ever-changing field where new devices and new or resistant pathogens are emerging at an unprecedented rate.
Compliance News: TJC Alert on Violence Rising at Health Care Facilities
By Dean Samet, CHSP
In a June 3, 2010 News Release, The Joint Commission introduced Sentinel Event Alert Issue 45: Preventing violence in the health care setting. Health care facilities are confronted with and facing increased rates of violent crimes including assault, rape and homicide. TJC defines a sentinel event as “an unexpected occurrence involving death or serious physical or psychological injury, or the risk thereof. Serious injury specifically includes loss of limb or function. The phrase, “or the risk thereof,” includes any process variation for which a recurrence would carry a significant chance of a serious adverse outcome. Such events are called “sentinel” because they signal the need for immediate investigation and response.”
The Joint Commission’s SEA Issue 45 suggested actions follow:
In a June 3, 2010 News Release, The Joint Commission introduced Sentinel Event Alert Issue 45: Preventing violence in the health care setting. Health care facilities are confronted with and facing increased rates of violent crimes including assault, rape and homicide. TJC defines a sentinel event as “an unexpected occurrence involving death or serious physical or psychological injury, or the risk thereof. Serious injury specifically includes loss of limb or function. The phrase, “or the risk thereof,” includes any process variation for which a recurrence would carry a significant chance of a serious adverse outcome. Such events are called “sentinel” because they signal the need for immediate investigation and response.”
The Joint Commission’s SEA Issue 45 suggested actions follow:
Compliance News: TJC Elminates 16 Hospital EPs
By Dean Samet, CHSP
The Joint Commission eliminated 16 elements of performance (EPs) from their hospital accreditation program with a July 1, 2010 effective date, as announced in the June 9, 2010 Joint Commission Online publication.
These and other EPs went through an extensive evaluation process as part of TJC’s internal Robust Process Improvement (RPI) initiative started in mid-2008. The RPI establishes a measurement ranking scale against which all standards for all of TJC programs will purportedly be evaluated going forward. As part of this evaluation, more than 300 hospitals were invited to provide their perceptions of what constitutes a “valuable” standard and which standards they believed contributed the least value towardquality and safety. TJC defines a valuable standard as one that:
The Joint Commission eliminated 16 elements of performance (EPs) from their hospital accreditation program with a July 1, 2010 effective date, as announced in the June 9, 2010 Joint Commission Online publication.
These and other EPs went through an extensive evaluation process as part of TJC’s internal Robust Process Improvement (RPI) initiative started in mid-2008. The RPI establishes a measurement ranking scale against which all standards for all of TJC programs will purportedly be evaluated going forward. As part of this evaluation, more than 300 hospitals were invited to provide their perceptions of what constitutes a “valuable” standard and which standards they believed contributed the least value towardquality and safety. TJC defines a valuable standard as one that:
Thursday, July 29, 2010
Compliance News: Fire Sprinkler System Main Drain Test
By Robert Trotter, CBO, CFM
The Joint Commission’s 2010 Hospital Accreditation Standards for the Environment of Care describes requirements for the main drain tests on sprinkler and standpipe systems. EC.02.03.05 Element of Performance 9 states, “For automatic sprinkler systems: Every 12 months, the hospital tests main drains at system low point or at all system risers. The completion date of the tests is documented.” For additional information refer to the 1998 edition of NFPA 25, Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems. Although The Joint Commission requires an annual test, NFPA 25 requires this test to be conducted quarterly. Section 9-2.6 states, “A main drain test shall be conducted quarterly at each water-based fire protection system riser to determine whether there has been a change in the condition of the water supply piping and control valves.”
Note: The test for standpipe systems should be done at the low point drain for each standpipe or the main drain test connection where the supply main enters the building.
The Joint Commission’s 2010 Hospital Accreditation Standards for the Environment of Care describes requirements for the main drain tests on sprinkler and standpipe systems. EC.02.03.05 Element of Performance 9 states, “For automatic sprinkler systems: Every 12 months, the hospital tests main drains at system low point or at all system risers. The completion date of the tests is documented.” For additional information refer to the 1998 edition of NFPA 25, Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems. Although The Joint Commission requires an annual test, NFPA 25 requires this test to be conducted quarterly. Section 9-2.6 states, “A main drain test shall be conducted quarterly at each water-based fire protection system riser to determine whether there has been a change in the condition of the water supply piping and control valves.”
Note: The test for standpipe systems should be done at the low point drain for each standpipe or the main drain test connection where the supply main enters the building.
Compliance News: New and Existing Elevators
By Robert Trotter, CBO, CFM
According to the 2000 edition of NFPA 101®, Life Safety Code® elevators in all occupancies must comply with Section 9.4 which addresses general requirements, code compliance, fire fighters’ service, number of cars, elevator machine rooms, elevator testing, and openings. The Joint Commission’s 2010 Hospital Accreditation Standards for Life Safety have specific Elements of Performance for new and existing healthcare occupancies and ambulatory healthcare occupancies. LS.02.01.50 EP 4 and LS.03.01.50 EP 1 require new elevators to be equipped with the following:
• Fire fighters’ service key recall
• Smoke detector automatic recall
• Fire fighters’ service emergency in-car key operation
• Machine room smoke detectors
• Elevator lobby smoke detectors
Existing elevators that have a travel distance of 25 feet or more above or below the level that best serves the needs of fire fighters shall also meet these requirements.
According to the 2000 edition of NFPA 101®, Life Safety Code® elevators in all occupancies must comply with Section 9.4 which addresses general requirements, code compliance, fire fighters’ service, number of cars, elevator machine rooms, elevator testing, and openings. The Joint Commission’s 2010 Hospital Accreditation Standards for Life Safety have specific Elements of Performance for new and existing healthcare occupancies and ambulatory healthcare occupancies. LS.02.01.50 EP 4 and LS.03.01.50 EP 1 require new elevators to be equipped with the following:
• Fire fighters’ service key recall
• Smoke detector automatic recall
• Fire fighters’ service emergency in-car key operation
• Machine room smoke detectors
• Elevator lobby smoke detectors
Existing elevators that have a travel distance of 25 feet or more above or below the level that best serves the needs of fire fighters shall also meet these requirements.
Compliance News: Relative Humidity Levels in Operating Rooms Reduced
By Dean Samet, CHSP
The American Society for Healthcare Engineering (ASHE) announced in May 2010 that effective the end of June 2010 the requirement for relative humidity levels in operating rooms has been reduced to a minimum of 20%. The new design range for ORs and short-term patient treatment stay areas is now 20-60% relative humidity (RH).
The above changes are a result of actions taken by the ANSI/ASHRAE/ASHE Standard 170: Ventilation of Health Care Facilities Standing Committee and were approved as issued in ASHRAE Standard 170, Addendum “d.” ASHRAE (American Society of Heating, Refrigerating and Air-Conditioning Engineers) 170 has been incorporated into The Facility Guidelines Institute’s 2010 edition of Guidelines for Design and Construction of Healthcare Facilities. According to ASHE, the publication of Addendum (d) “stresses the aspects of relative humidity in operating rooms in terms of clinical outcomes, comfort, and engineering concepts.”
The American Society for Healthcare Engineering (ASHE) announced in May 2010 that effective the end of June 2010 the requirement for relative humidity levels in operating rooms has been reduced to a minimum of 20%. The new design range for ORs and short-term patient treatment stay areas is now 20-60% relative humidity (RH).
The above changes are a result of actions taken by the ANSI/ASHRAE/ASHE Standard 170: Ventilation of Health Care Facilities Standing Committee and were approved as issued in ASHRAE Standard 170, Addendum “d.” ASHRAE (American Society of Heating, Refrigerating and Air-Conditioning Engineers) 170 has been incorporated into The Facility Guidelines Institute’s 2010 edition of Guidelines for Design and Construction of Healthcare Facilities. According to ASHE, the publication of Addendum (d) “stresses the aspects of relative humidity in operating rooms in terms of clinical outcomes, comfort, and engineering concepts.”
Compliance News: Polyurethane Expanding Foam
By Robert Trotter, CBO, CFM
The use of polyurethane expanding foam is expressly not permitted by The Joint Commission for sealing penetrations in fire-rated walls and floors. According to the 2010 Hospital Accreditation Standards LS.02.01.10 Element of Performance 9, "The space around pipes, conduits, bus ducts, cables, wires, air ducts, or pneumatic tubes that penetrate fire-rated walls and floors are protected with an approved fire-rated material." The Joint Commission included this specific note, "Polyurethane expanding foam is not an acceptable fire-rated material for this purpose." According to the 2000 edition of NFPA 101®, Life Safety Code® section 8.2.3.2.4.2 requires the space between the penetrating item and the fire barrier to be filled with a material that is capable of maintaining the fire resistance rating of the fire barrier or it must be protected by an approved device that is designed for the specific purpose.
The use of polyurethane expanding foam is expressly not permitted by The Joint Commission for sealing penetrations in fire-rated walls and floors. According to the 2010 Hospital Accreditation Standards LS.02.01.10 Element of Performance 9, "The space around pipes, conduits, bus ducts, cables, wires, air ducts, or pneumatic tubes that penetrate fire-rated walls and floors are protected with an approved fire-rated material." The Joint Commission included this specific note, "Polyurethane expanding foam is not an acceptable fire-rated material for this purpose." According to the 2000 edition of NFPA 101®, Life Safety Code® section 8.2.3.2.4.2 requires the space between the penetrating item and the fire barrier to be filled with a material that is capable of maintaining the fire resistance rating of the fire barrier or it must be protected by an approved device that is designed for the specific purpose.
Compliance News: Electrical Arc Flash Safety: How close is too close?
By David Stymiest, PE, FASHE, CHFM, GBE
NFPA 70E® defines a series of boundaries related to electrical safety near energized equipment. These boundaries can be based on the voltage; the available short-circuit current and the predicted fault duration. The definitions are not repeated here, but the following considerations are useful to gain an overview of the issues involved.
• Flash Protection Boundary – an imaginary boundary within which there is the potential for a second-degree burn injury. Fire resistive protection (also called PPE) is required. This is the first item that must be determined by an arc flash hazard analysis.
NFPA 70E® defines a series of boundaries related to electrical safety near energized equipment. These boundaries can be based on the voltage; the available short-circuit current and the predicted fault duration. The definitions are not repeated here, but the following considerations are useful to gain an overview of the issues involved.
• Flash Protection Boundary – an imaginary boundary within which there is the potential for a second-degree burn injury. Fire resistive protection (also called PPE) is required. This is the first item that must be determined by an arc flash hazard analysis.
Compliance News: CMS Corridor Obstructions Stance Revised
By Dean Samet, CHSP
In a May 14, 2010 Centers for Medicare & Medicaid Services memorandum, Ref: S&C-10-18-LSC, CMS announced changes to previous policies regarding the use of corridor wall-mounted computer touch screens in healthcare facilities.
In a May 14, 2010 Centers for Medicare & Medicaid Services memorandum, Ref: S&C-10-18-LSC, CMS announced changes to previous policies regarding the use of corridor wall-mounted computer touch screens in healthcare facilities.
CMS is now allowing certain wall-mounted technologies and other items to be wall-mounted in corridors as long as they don’t project out more than six inches from the corridor wall or conflict with other sections of the National Fire Protection Association’s Life Safety Code®.
Saturday, May 29, 2010
Compliance News: Locks on Doors in Means of Egress
By Robert Trotter, CBO, CFM
According to the 2000 edition of NFPA 101®, Life Safety Code®, “Experience indicates that panic seldom develops, even in the presence of danger, as long as occupants of buildings are moving towards exits that they can see…” However, the stoppage of egress travel such as an exit door locked with a padlock (as shown on a marked exit door in an industrial occupancy of a hospital) is potentially conducive to panic. Healthcare occupancies as well as business, industrial and storage occupancies are required to comply with the means of egress provisions for locks, latches and alarm devices for doors. Section 7.2.1.5.1 of the Life Safety Code® states, “Doors shall be arranged to be opened readily from the egress side whenever the building is occupied.” It is also important that locks, if provided, “shall not require the use of a key, tool, or special knowledge or effort from the egress side.”
According to the 2000 edition of NFPA 101®, Life Safety Code®, “Experience indicates that panic seldom develops, even in the presence of danger, as long as occupants of buildings are moving towards exits that they can see…” However, the stoppage of egress travel such as an exit door locked with a padlock (as shown on a marked exit door in an industrial occupancy of a hospital) is potentially conducive to panic. Healthcare occupancies as well as business, industrial and storage occupancies are required to comply with the means of egress provisions for locks, latches and alarm devices for doors. Section 7.2.1.5.1 of the Life Safety Code® states, “Doors shall be arranged to be opened readily from the egress side whenever the building is occupied.” It is also important that locks, if provided, “shall not require the use of a key, tool, or special knowledge or effort from the egress side.”
Compliance News: Labeling Utility System Controls
By Robert Trotter, CBO, CFM
Accurate labeling of utility system controls is essential during routine and emergency shutdown situations. Hospitals are required by The Joint Commission 2010 Hospital Accreditation Standards for the Environment of Care to manage risks associated with its utility systems. EC.02.05.01 Elements of Performance 1 through 13 describe the specific requirements. In regard to the electrical utility, hospitals should pay particular attention to labeling of electrical panelboards as required by EC.02.05.01 EP 8, “The hospital labels utility system controls to facilitate partial or complete emergency shutdowns.”
While The Joint Commission has recently been finding these deficiencies under the Environment of Care Standard it is possible the same finding could be noted under the Life Safety Standard relative to building services. For additional information refer to the 1999 edition of NFPA 70®, National Electrical Code Article 384-13, “All panelboard circuits and circuit modifications shall be legibly identified as to purpose or use on a circuit directory located on the face or inside of the panel doors.”
Accurate labeling of utility system controls is essential during routine and emergency shutdown situations. Hospitals are required by The Joint Commission 2010 Hospital Accreditation Standards for the Environment of Care to manage risks associated with its utility systems. EC.02.05.01 Elements of Performance 1 through 13 describe the specific requirements. In regard to the electrical utility, hospitals should pay particular attention to labeling of electrical panelboards as required by EC.02.05.01 EP 8, “The hospital labels utility system controls to facilitate partial or complete emergency shutdowns.”
While The Joint Commission has recently been finding these deficiencies under the Environment of Care Standard it is possible the same finding could be noted under the Life Safety Standard relative to building services. For additional information refer to the 1999 edition of NFPA 70®, National Electrical Code Article 384-13, “All panelboard circuits and circuit modifications shall be legibly identified as to purpose or use on a circuit directory located on the face or inside of the panel doors.”
Compliance News: NFPA® Codes Available On-Line (Free)
By Pete Kendrick, CHFM, CPMM
Have you ever desired to review a National Fire Protection Association (NFPA®) code that is not part of your facility library? If so, it might be useful to know that you can do so for free on the NFPA® website, and the service is available to both members and non-members. There are some limitations which will be addressed below, but here is how to find a code. Let’s look up NFPA 99 Standard for Healthcare Facilities just for fun.
First, go to the website at http://www.nfpa.org/. Click on Codes & Standards which is just below the “sign-in” box. On the left you will see a second link for a “List of NFPA codes & standards” and you should select that. For an example, scroll down and click on NFPA 99 under the Code No. in the center of the page. Select “View the document online (read only).”
Have you ever desired to review a National Fire Protection Association (NFPA®) code that is not part of your facility library? If so, it might be useful to know that you can do so for free on the NFPA® website, and the service is available to both members and non-members. There are some limitations which will be addressed below, but here is how to find a code. Let’s look up NFPA 99 Standard for Healthcare Facilities just for fun.
First, go to the website at http://www.nfpa.org/. Click on Codes & Standards which is just below the “sign-in” box. On the left you will see a second link for a “List of NFPA codes & standards” and you should select that. For an example, scroll down and click on NFPA 99 under the Code No. in the center of the page. Select “View the document online (read only).”
Compliance News: Damaged Sprinkler Heads
By Robert Trotter, CBO, CFM
Damaged sprinkler heads can have a detrimental effect on the performance of sprinklers by affecting water distribution patterns, insulating thermal elements, delaying operation, or otherwise rendering the sprinkler inoperable or ineffectual. According to The Joint Commission’s 2010 Hospital Accreditation Standards for Life Safety, hospitals must provide and maintain systems for extinguishing fires. LS.02.01.35 Element of Performance 5 states, “Sprinkler heads are not damaged and are free from corrosion, foreign material, and paint.” The standard offers the following: (For full text and any exceptions refer to NFPA® 25-1998: 2-2.1.1.) Section 2-2.1.1 of NFPA® 25, Standard for the Inspection, Testing and Maintenance of Water-Based Fire Protection Systems states, “Any sprinkler shall be replaced that is painted, corroded, damaged, loaded, or in the improper orientation.” Note that sprinklers installed in concealed spaces such as abovesuspended ceilings do not require inspection.
Damaged sprinkler heads can have a detrimental effect on the performance of sprinklers by affecting water distribution patterns, insulating thermal elements, delaying operation, or otherwise rendering the sprinkler inoperable or ineffectual. According to The Joint Commission’s 2010 Hospital Accreditation Standards for Life Safety, hospitals must provide and maintain systems for extinguishing fires. LS.02.01.35 Element of Performance 5 states, “Sprinkler heads are not damaged and are free from corrosion, foreign material, and paint.” The standard offers the following: (For full text and any exceptions refer to NFPA® 25-1998: 2-2.1.1.) Section 2-2.1.1 of NFPA® 25, Standard for the Inspection, Testing and Maintenance of Water-Based Fire Protection Systems states, “Any sprinkler shall be replaced that is painted, corroded, damaged, loaded, or in the improper orientation.” Note that sprinklers installed in concealed spaces such as abovesuspended ceilings do not require inspection.
Compliance News: Electrical Arc Flash Safety: Why is it important?
By David Stymiest, PE, FASHE, CHFM, GBE
With the release of the 2009 edition of NFPA 70E®, Standard for Electrical Safety in the Workplace®, increased attention is being focused on electrical power system safety and the dangers associated with electrical arc flashes.
According to CDC’s National Institute of Occupational Safety & Health (NIOSH), electricalhazards cause more than 300 deaths and 4,000 injuries in the workplace each year. Someelectrical injuries are instantly fatal, while up to 40% of electrical injuries are ultimately fatalaccording to a paper written by three critical care physicians and referenced in a recent electrical industry magazine article. A research and consulting firm specializing in workplace injuries hascompiled often-quoted statistics indicating that five to ten reported electrical equipment arc flash explosions occur per day in the USA.
With the release of the 2009 edition of NFPA 70E®, Standard for Electrical Safety in the Workplace®, increased attention is being focused on electrical power system safety and the dangers associated with electrical arc flashes.
According to CDC’s National Institute of Occupational Safety & Health (NIOSH), electricalhazards cause more than 300 deaths and 4,000 injuries in the workplace each year. Someelectrical injuries are instantly fatal, while up to 40% of electrical injuries are ultimately fatalaccording to a paper written by three critical care physicians and referenced in a recent electrical industry magazine article. A research and consulting firm specializing in workplace injuries hascompiled often-quoted statistics indicating that five to ten reported electrical equipment arc flash explosions occur per day in the USA.
Compliance News: Measures of Success and Scoring Category Changes
By Dean Samet, CHSP
According to the April 28, 2010 Joint Commission Online, a number of Measures of Success (MOS) requirements have been deleted effective April 26, 2010 and several Elements of Performance (EPs) will change from a “C” to an “A” scoring category effective July 1, 2010. Compliance with affected Elements of Performance is still expected. If your organization is currently completing the MOS data submission for the affected EPs based on your last survey, go to The Joint Commission Connect extranet and enter “MOS requirement removed” in the text box and submit.
Before showing the recent changes, let’s review the particulars of what an MOS is and what the scoring categories are.
According to the April 28, 2010 Joint Commission Online, a number of Measures of Success (MOS) requirements have been deleted effective April 26, 2010 and several Elements of Performance (EPs) will change from a “C” to an “A” scoring category effective July 1, 2010. Compliance with affected Elements of Performance is still expected. If your organization is currently completing the MOS data submission for the affected EPs based on your last survey, go to The Joint Commission Connect extranet and enter “MOS requirement removed” in the text box and submit.
Before showing the recent changes, let’s review the particulars of what an MOS is and what the scoring categories are.
Saturday, May 1, 2010
Opening Day: Transitioning from Construction to Survey-Ready Operation
By David l. Stymiest, P.E., FASHE, CHFM (in Health Facilities Management)
Construction project turnover time is hectic. Facility activation and move-in are usually foremost and it is often difficult to get all of the compliance work done on time. Lacking a solid process for transitioning from construction to operations and survey-ready compliance at occupancy can put a hospital at risk during an early survey.
Challenges and Limitations
There are many challenges in health care facility activation. Among them are managing economic, operational, patient safety and compliance risks. The challenge in this complex undertaking is to minimize the duration while meeting all regulatory compliance requirements by initial occupancy.
Challenges and Limitations
There are many challenges in health care facility activation. Among them are managing economic, operational, patient safety and compliance risks. The challenge in this complex undertaking is to minimize the duration while meeting all regulatory compliance requirements by initial occupancy.
Read entire article here: Opening Day
Monday, March 29, 2010
Compliance News: Minimum Clear Width for Doors
By Robert Trotter, CBO, CFM
Egress doors in existing healthcare occupancies should comply with the 2000 edition of NFPA 101®, Life Safety Code® section 19.2.3.5 which states, “The minimum clear width for doors in the means of egress from hospitals; nursing homes; limited care facilities; psychiatric hospital sleeping rooms; and diagnostic and treatment areas, such as x-ray, surgery, or physical therapy, shall be not less than 32 in. wide.” There is an exception for existing 34-inch doors, and existing 28-inch corridor doors in facilities where the fire plans do not require evacuation by bed, gurney, or wheelchair. Excluding any of the four exceptions, egress doors in new healthcare occupancies must meet the requirements prescribed in 18.2.3.5. The minimum clear width for doors in the means of egress from sleeping rooms, diagnostic and treatment areas, such as x-ray, surgery, or physical therapy, and nursery rooms in hospitals and nursing homes is 41.5 inches and 32 inches in psychiatric hospitals and limited care facilities.
Egress doors in existing healthcare occupancies should comply with the 2000 edition of NFPA 101®, Life Safety Code® section 19.2.3.5 which states, “The minimum clear width for doors in the means of egress from hospitals; nursing homes; limited care facilities; psychiatric hospital sleeping rooms; and diagnostic and treatment areas, such as x-ray, surgery, or physical therapy, shall be not less than 32 in. wide.” There is an exception for existing 34-inch doors, and existing 28-inch corridor doors in facilities where the fire plans do not require evacuation by bed, gurney, or wheelchair. Excluding any of the four exceptions, egress doors in new healthcare occupancies must meet the requirements prescribed in 18.2.3.5. The minimum clear width for doors in the means of egress from sleeping rooms, diagnostic and treatment areas, such as x-ray, surgery, or physical therapy, and nursery rooms in hospitals and nursing homes is 41.5 inches and 32 inches in psychiatric hospitals and limited care facilities.
Compliance News: Access to Electrical Switchboards
By Robert Trotter, CBO, CFM
Electrical wiring and equipment are required by NFPA 101®, Life Safety Code® to be in accordance with the 1999 edition of NFPA 70, National Electrical Code. While there are specific requirements for access to electrical switchboards, here is an overview of the requirements. Sufficient access and working space should be provided and maintained about all electric equipment to permit ready and safe operation and maintenance of such equipment. The depth of the working space in the direction of access to live parts should not be less than 36 inches and the width of the working space in front of the electric equipment should be the width of the equipment or 30 inches, whichever is greater. The work space should be clear and extend from the grade, floor, or platform to the minimum height of six and one-half feet. The working space required by the NEC is not permitted to be used for storage (as pictured).
Electrical wiring and equipment are required by NFPA 101®, Life Safety Code® to be in accordance with the 1999 edition of NFPA 70, National Electrical Code. While there are specific requirements for access to electrical switchboards, here is an overview of the requirements. Sufficient access and working space should be provided and maintained about all electric equipment to permit ready and safe operation and maintenance of such equipment. The depth of the working space in the direction of access to live parts should not be less than 36 inches and the width of the working space in front of the electric equipment should be the width of the equipment or 30 inches, whichever is greater. The work space should be clear and extend from the grade, floor, or platform to the minimum height of six and one-half feet. The working space required by the NEC is not permitted to be used for storage (as pictured).
Compliance News: Smoke Alarms in Doctors’ Sleeping Rooms
By Pete Kendrick, CHFM, CPMM
As part of the preparations for your next The Joint Commission survey, you may have decided to claim several occupancy classifications in accordance with NFPA 101® (2000 Edition) Sections 18/19.1.1.1.4 which state in part that, in the opinion of the governing body of the facility and the agency having jurisdiction, if patients or visitors are capable of self-preservation, sections of the building can comply with other occupancy chapters. Besides ambulatory, business, and assembly, what other occupancies need to be considered?
If you have doctors’ sleeping rooms, do you know if they are equipped with approved single-station smoke alarms? Such rooms are required to meet a small section of some other chapters you possibly aren’t familiar with. Open your NFPA 101® to Chapter 26, Lodging and Rooming Houses. You may not know it but you might actually be the proprietor of a rooming house. Look at 26.1.1.1, which states that, “This chapter applies to buildings that provide sleeping accommodations for a total of 16 or fewer persons on either a transient or permanent basis, with or without meals, but with separate cooking facilities for individual occupants…” Does this apply to your doctors’ sleeping rooms? Probably.
As part of the preparations for your next The Joint Commission survey, you may have decided to claim several occupancy classifications in accordance with NFPA 101® (2000 Edition) Sections 18/19.1.1.1.4 which state in part that, in the opinion of the governing body of the facility and the agency having jurisdiction, if patients or visitors are capable of self-preservation, sections of the building can comply with other occupancy chapters. Besides ambulatory, business, and assembly, what other occupancies need to be considered?
If you have doctors’ sleeping rooms, do you know if they are equipped with approved single-station smoke alarms? Such rooms are required to meet a small section of some other chapters you possibly aren’t familiar with. Open your NFPA 101® to Chapter 26, Lodging and Rooming Houses. You may not know it but you might actually be the proprietor of a rooming house. Look at 26.1.1.1, which states that, “This chapter applies to buildings that provide sleeping accommodations for a total of 16 or fewer persons on either a transient or permanent basis, with or without meals, but with separate cooking facilities for individual occupants…” Does this apply to your doctors’ sleeping rooms? Probably.
Compliance News: Maintaining Smoke Barriers
By Dean Samet, CHSP
Smoke barriers serve a very important purpose, especially in healthcare occupancies. During a fire, protection of patients and staff is of paramount concern. If possible, patients intimate with the fire should be moved to safety immediately. For others, “defending patients in place” is often the first step in a number of actions established to keep patients out of harm’s way from a fire and the products of combustion. If and when it is determined that patients must be evacuated to an area of safe refuge, it is typically horizontally, on the same floor level, through smoke barriers to an adjacent smoke compartment. If the fire escalates, patients may have to be relocated from that smoke compartment or floor and moved vertically via stairs or elevators (if possible and permitted).
Smoke barriers serve a very important purpose, especially in healthcare occupancies. During a fire, protection of patients and staff is of paramount concern. If possible, patients intimate with the fire should be moved to safety immediately. For others, “defending patients in place” is often the first step in a number of actions established to keep patients out of harm’s way from a fire and the products of combustion. If and when it is determined that patients must be evacuated to an area of safe refuge, it is typically horizontally, on the same floor level, through smoke barriers to an adjacent smoke compartment. If the fire escalates, patients may have to be relocated from that smoke compartment or floor and moved vertically via stairs or elevators (if possible and permitted).
Compliance News: Det Norske Veritas Healthcare (DNVHC) Hospital Accreditation
By Dean Samet, CHSP
Effective September 26, 2008, the Centers for Medicare & Medicaid Services (CMS) announced their decision to approve Det Norske Veritas Healthcare, Inc. (DNVHC) for recognition as a national accreditation organization for hospitals seeking to participate in the Medicare or Medicaid programs. This has provided another alternative for roughly 80% or more of the country’s hospitals that have looked primarily to The Joint Commission (TJC) for their hospital accreditation for over 50 years.
Accreditation by an accreditation organization is voluntary and is not required for Medicareparticipation. A hospital may opt for routine surveys by a state survey agency to determine whether it meets the Medicare requirements.
Effective September 26, 2008, the Centers for Medicare & Medicaid Services (CMS) announced their decision to approve Det Norske Veritas Healthcare, Inc. (DNVHC) for recognition as a national accreditation organization for hospitals seeking to participate in the Medicare or Medicaid programs. This has provided another alternative for roughly 80% or more of the country’s hospitals that have looked primarily to The Joint Commission (TJC) for their hospital accreditation for over 50 years.
Accreditation by an accreditation organization is voluntary and is not required for Medicareparticipation. A hospital may opt for routine surveys by a state survey agency to determine whether it meets the Medicare requirements.
Friday, January 29, 2010
Compliance News: Supervision of Fire Sprinkler Control Valves
By Robert Trotter, CBO, CFM
Fire sprinkler valves controlling connections to water supplies and to supply pipes to sprinklers in new and existing health care occupancies are required by NFPA 101®, Life Safety Code® to be electrically supervised. Any valve that controls automatic sprinklers in the entire building or portions of the building, sectional and floor control valves, OS&Y valves (as pictured) located within the building or building exterior, and post indicating valves located outside on the property are included in the requirement. Electrically supervised means supervisory signals must sound and be displayed either at a location within the protected building that is constantly attended by qualified personnel or at an approved, remotely located receiving facility to indicate a condition that would impair the satisfactory operation of the sprinkler system. A chain and/or padlock are not acceptable means of valve supervision. The Joint Commission verifies these requirements through the 2010 Hospital Accreditation Standards for Life Safety. LS.02.01.35 Element of Performance 5 states, “The fire alarm system monitors approved automatic sprinkler system components.”
Compliance News: Stairway Doors Held Open
By Robert Trotter, CBO, CFM
Stairway doors are an integral part of the egress system and they protect openings of vertical enclosures. The Joint Commission mandates specific requirements when stairway doors are held open (as pictured). In accordance with the 2010 Hospital Accreditation Standards for Life Safety, hospitals must maintain the integrity of the means of egress.
Regarding health care occupancies, LS.02.01.20 Element of Performance number 9 states, “When stairway doors are held and the sprinkler or fire alarms system activates the release of one door in a stairway, all doors serving that stairway close.” This requirement is also found in the 2000 edition of NFPA 101®, Life Safety Code® 18/19.2.2.2.7.
Likewise for ambulatory health care occupancies LS.03.01.20 Element of Performance number 5 states, “When stairway doors are held and the sprinkler or fire alarms system activates the release of one door in a stairway, all doors serving that stairway close.” This requirement is also found in the 2000 edition of NFPA 101®, Life Safety Code® 20/21.2.2.4.
Compliance News: Emergency Instructions for Occupants
By Robert Trotter, CBO, CFM
Most people are familiar with evacuation plans and fire safety information located on hotel room doors. This information is not required in hospitals under normal conditions; however, they must protect occupants during periods when NFPA 101®, Life Safety Code® is not met or during periods of construction. One of the administrative activities prescribed for Interim Life Safety Measures as required by the 2010 Hospital Accreditation Standards for Life Safety is LS.01.02.01 which states, “The hospital posts signage identifying the location of alternate exits to everyone affected.”
While there are no prescriptive requirements for the arrangement or information provided on the signs, here are a few suggestions to consider:
Compliance News: Re-entry from the Stair Enclosure
By Robert Trotter, CBO, CFM
The stair enclosure in a facility is an essential component of the means of egress. It serves as a primary way of protecting occupants during their egress from the building. Under certain circumstances, health care organizations have the need to secure stair doors from re-entry to the interior of the building. Where this need exists you should consider the applicable re-entry provisions found in the 2000 edition of NFPA 101®, Life Safety Code®.
Compliance News: 2010 TJC Accreditation Decision Changes
By Dean Samet, CHSP
The Joint Commission has made additions to their 2010 Conditional Accreditation decision rules. Unchanged is where Conditional Accreditation will still result when a health care organization fails to resolve the requirements of a Provisional Accreditation status, or was in substantial noncompliance with applicable TJC standards. As always, the organization must remedy the identified problem area(s) through an Evidence of Standards Compliance (ESC) submission and subsequently undergo an on-site follow-up survey.
New for 2010, “Conditional Accreditation may result when an organization fails to meet requirements for the timely submission of data and information to The Joint Commission; or survey findings demonstrate systematic patterns, trends or repeat findings from previous surveys; or there is credible evidence indicating that possible fraud or abuse has occurred at a health care organization.” (Refer to The Joint Commission Online August 5, 2009.) The new language related to survey findings has been made to bring the decision in line with TJC’s Standards Improvement Initiative (SII). The new wording related to possible fraud or abuse has been created to meet Centers for Medicare and Medicaid Services (CMS) requirements.
Also new for 2010 and related to TJC’s application to CMS for continued hospital-deeming authority, TJC has adopted a new type of follow-up survey called “Medicare Condition-Level Deficiency Follow-Up Survey.” This new survey will be required after an organization has one or more Medicare Conditions of Participation (CoPs) assessed by CMS as a “Condition-Level Deficiency.” This new regulation requires that an organization remedy the identified CoPs and then undergo an on-site follow-up survey by TJC. This follow-up survey is in addition to the above mentioned TJC Conditional Accreditation decision rules.
Compliance News: Transitioning from Construction to Survey-Ready Compliance - Part 3
By David Stymiest, PE, FASHE, CHFM
Part 1 appeared in the September/October 2009 issue of Compliance News.
Part 2 appeared in the November/December 2009 issue of Compliance News.
Schedules (policies and procedures, forms, lists, etc.) would have to be established for the following types of items (listing is not all-inclusive):
• Fire drills, safety rounds, safety monitoring and security monitoring of EC
• Ongoing testing, inspections and maintenance
• Inspections of all ‘previous’ Building Maintenance Plan (BMP) components – (smoke and corridor walls; fire, smoke and corridor doors; exit signs and egress lights, trash and linen chutes, grease producing devices, and means of egress free of blockage such as ice and snow)
• Inspections of fire walls
• Inspections of fire and smoke dampers, including the special one-year inspection
• Fire alarm systems, devices and equipment; fire protection systems, devices and equipment; fire extinguishers
• Eyewash stations
• Emergency power, medical gas and vacuum, and other systems
Labeling would be expected for hazardous materials and waste, utility system controls to facilitate partial or complete emergency shutdowns, medical gas and vacuum system valves, both permanent and temporary signage, and maps if they are used. Standard labels may not meet all of the AHJ requirements.
Project record documentation that meets the AHJ requirements for mapping of utility systems would be acceptable if it is available during survey. The utility systems include normal and emergency power, steam, chilled water, domestic water, sanitary piping, fire protection, medical gas and vacuum, fire alarm and emergency communications, telecom, and any other systems included in the Utility Systems Management Plan scope.
Utility maintenance documentation is required to be accessible during survey. This includes documentation generated both internally and by outside services. The organization needs to have processes (and contract provisions) to obtain, store and access all such documentation during both equipment failures and unannounced surveys. The decision process for the types of maintenance (preventive, predictive, reliability-centered, corrective, or metered) to be performed on all new equipment should also be documented and available during survey.
Similar requirements apply to maintenance documentation for other types of equipment, including equipment serviced by both internal biomedical engineering departments and external service organizations.
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