Compliance News: Holiday Decorations

Compliance News:  Holiday Decorations 

by Robert Trotter, BS, MCP and David Stymiest, PE, CHFM, CHSP, FASHE

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.)”

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. Exception: Combustible decorations, such as photographs and paintings, in such limited quantities that a hazard of fire development or spread is not present.”

Compliance News: ECRI Institute Lists 2013's Top 10 Health Technology Hazards

Compliance News:  ECRI Institute Lists 2013's Top 10 Health Technology Hazards 

by David Stymiest, PE, CHFM, CHSP, FASHE

The ECRI Institute recently published a 25-page special report entitled “ECRI Institute 2013 Top 10 Health Technology Hazards” – available at www.ecri.org/2013hazards. 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.

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.

Compliance News: ASHE Publishes New Management Monograph "Managing Hospital Electrical Shutdowns"

Compliance News:  ASHE Publishes New Management Monograph "Managing Hospital Electrical Shutdowns" 

by David Stymiest, PE, CHFM, CHSP, FASHE 

ASHE recently published a new management monograph that provides guidance for managing safe electrical shutdowns. It is available free of charge as a downloaded protected PDF to all ASHE members at :

http://www.ashe.org/resources/management_monographs/mg2012stymiest.html.

Hard copies are also available to both ASHE members and non-members in the ASHE Online Store as ASHE catalog # 055978.

This 55-page monograph covers the following major topics in depth:

• Why electrical shutdowns should be planned
• Things to consider before planning a shutdown
• Planning a shutdown
• Electrical system considerations during a shutdown
• After the shutdown
• Planning for future shutdowns
• Numerous appendices with samples and templates to assist hospitals in their shutdown management activities

Our Compliance News readers are welcome to submit comments, suggestions and questions by email to: DStymiest@ssr-inc.com.

Compliance News: TJC Provides More Corridor Clutter Guidance

Compliance News:  TJC Provides More Corridor Clutter Guidance 

by David Stymiest, PE, CHFM, CHSP, FASHE 

  

TJC continued providing corridor clutter clarifications and expectations in the September 2012 edition of The Joint Commission Perspectives®, which is TJC’s official newsletter. In this issue TJC Department of Engineering Director George Mills followed up on his August 2012 column by addressing several additional issues including latching patient room doors, corridor walls, corridors and air supply, corridor projections. He also provided additional guidance related to the CMS waiver policy regarding certain provisions of the 2012 Life Safety Code.

Mr. Mills discussed the differences between the required patient room door latches and the self-closing or automatic closing devices that are not required for patient room doors. He discussed TJC’s expectation that accredited organizations are required to have in their fire response plans a process to ensure that patient room doors close and latch in a fire emergency. Because this requirement must be in the facility fire response plan, staff are accountable for checking patient room doors and closing the open ones during both fire drills and non-drill fire events.

Compliance News: NFPA 110-2013 Edition Addresses Generator Fuel Oil Management

By David L. Stymiest, PE, CHFM, CHSP, FASHE



The 2013 edition of NFPA 110 was recently released by the NFPA Standards Council. Chief among the changes in this edition were several changes, including informational Annex recommendations, intended to improve emergency power supply system (EPSS) reliability through better fuel oil management processes. The excerpts below are only partial excerpts, and readers should review the full text of the updated standard, which is available at www.nfpa.org/110. In the discussion below, note that all Annex language is not mandatory, rather it is advisory only and contains recommendations for user consideration.

Paragraph 7.9.1.3 was modified to stipulate that “tanks shall be sized so that the fuel is consumed within the storage life, or provisions shall be made to remediate fuel that is stale or contaminated or to replace stale or contaminated fuel with clean fuel.” Although these are not in NFPA 110, some popular remediation techniques incorporate filtering of the stored fuel through a series of water separators and media filters, periodic centrifuge cleaning/polishing with high pressure tank agitation and/or mechanical tank cleaning with auxiliary filtration.

Compliance News: Corridor Clutter Remains an Issue in Many Hospitals

By David Stymiest, PE, CHFM, FASHE


An article by TJC Director of Engineering George Mills in the August 2012 edition of EC News discussed at length the continuing issue of corridor clutter. This article is in the EC News “Clarifications and Expectations” column that is intended to increase accredited organizations’ awareness of the NFPA 101 Life Safety Code®.1 We recommend that you obtain and review this article and its follow-up article in the next issue of EC News.

Corridors need to be kept clear of clutter because of NFPA 101 Life Safety Code® requirements and also for ease of rapid patient movement in response to emergency conditions.

Crash carts and isolation carts may be stored in corridors while they are “in use” according to TJC. Crash carts must always be available and ready for use, so they are always “in use.” Isolation carts are in use as long as they are outside a patient room to which the patient for that cart has been assigned. An isolation cart outside a patient room is not in use after that patient has been discharged. If a hospital chooses to use door-hanging isolation cabinets rather than isolation carts, it is important to ensure that all NFPA 101 Life Safety Code® clear width requirements are maintained when the door is open. With the door closed the maximum six inch obstruction rule (reducing corridor width by not more than six inches) still applies even to that cabinet.

Compliance News: Weekly Generator Run Tests

By David Stymiest, PE, CHFM, FASHE



A question that I am commonly asked is whether weekly generator run tests are required. This question occurred almost a half dozen times at the recent ASHE Annual Conference.

NFPA 110 requires weekly Emergency Power Supply System (EPSS) inspections as stated in this excerpt from NFPA 110-2010 (The EPSS consists of the generators downstream to the transfer switch load terminals, inclusive):

“8.4 Operational Inspection and Testing.
8.4.1* EPSSs, including all appurtenant components, shall be inspected weekly and exercised under load at least monthly.”

However NFPA 110 does not require weekly emergency generator run tests. In fact NFPA 110 clarified this issue in the 2010 edition Annex as stated below:

Compliance News: Current Life Safety Plans

By David Stymiest, PE, CHFM, FASHE


In In his recent ASHE Annual Conference presentation, George Mills of TJC reminded attendees about the requirements for current LS plans. Much of this information is in a related February 2012 EC News article and is summarized below.


TJC Standard LS.01.01.01, EP 2, requires an organization to have a current Statement of Conditions™ (SOC™). EP2 is scoring category A with documentation required. In order to have a current SOC™ an organization must create and maintain an up-to-date and complete Basic Building Information (BBI). Since the BBI requires organizations to indicate the location of current LS drawings, not being able to supply those current LS drawings during a survey can result in a direct impact RFI against EP2.

TJC has stated that current LS drawings must address the following topics:

Compliance News: CMS Will Consider 2012 Life Safety Code in Notice-and Comment Rulemaking Process

By David L. Stymiest, PE, CHFM, FASHE





Last year CMS requested public comments about whether it should adopt the 2012 Life Safety Code® instead of the currently required 2000 edition. In its recently-issued final rule regarding revisions to the Conditions of Participation, CMS also addressed those public comments.

In response to the public comments that it received, CMS stated “We appreciate commenters’ suggestions regarding the LSC regulations set out under our ‘Physical environment’ CoP at §482.41. Suggestions received were outside the scope of this final rule and will be considered through separate notice-and-comment rulemaking in a LSC omnibus rule, targeted for publication in the near future.”

The discussion and response are on pages 113-114 of Final Rule CMS-3244-F, RIN 0938-AQ89, entitled “Medicare and Medicaid Programs; Reform of Hospital and Critical Access Hospital Conditions of Participation.” This document is available from CMS at http://www.ofr.gov/OFRUpload/OFRData/2012-11548_PI.pdf.

Compliance News: Discharge from Exits

By Robert Trotter, CBO, CFM - Koffel Associates





The Life Safety Code® mandates that exits terminate directly at a public way or at an exterior exit discharge. Yards, courts, open spaces, or other portions of the exit discharge must be of required width and size to provide all occupants with a safe access to a public way. However, this requirement does not apply to rooftop exit discharge where approved by the authority having jurisdiction. Exits are permitted to discharge to roofs or other sections of the building or an adjoining building where the following criteria are met:

(1) The roof construction has a fire resistance rating not less than that required for the exit enclosure.
(2) There is a continuous and safe means of egress from the roof.

Compliance News: OSHA Revises Hazard Communication Standard

By David L. Stymiest, PE, CHFM, FASHE




In its March 20, 2012 press release and conference call, OSHA announced revisions to its Hazard Communication Standard to align it with the United Nations’ global chemical labeling system, known as the Globally Harmonized System (GHS) of Classification and Labeling of Chemicals. OSHA stated that this change is intended to improve understanding and “will improve the quality, consistency and clarity of hazard information that workers receive, making it safer for workers to do their jobs and easier for employers to stay competitive in the global marketplace.”

According to OSHA, the standard will classify chemicals according to their health and physical hazards, and establish consistent labels and safety data sheets for all chemicals both made in the USA and imported from abroad.


Employers have until December 2013 to train employees to the new requirements. The new standard, informally known as HazCom 2012, will be fully implemented by 2016. OSHA noted that during the transition period to the effective completion dates noted in the standard, chemical manufacturers, importers, distributors and employers may comply with either 29 Code of Federal Regulations 1910.1200 (the final standard), the current standard or both.

How to obtain more information:

OSHA’s press release is available at:
http://www.dol.gov/opa/media/press/osha/OSHA20120280.htm

The voluminous final rule revising the standard is available at: http://s.dol.gov/P1
(That URL also contains links to an MP3 (audio) file of the conference call as well as further related information.)

The GHS is available from OSHA at: http://www.osha.gov/dsg/hazcom/ghs.html

A list of OSHA’s FAQ’s and responses is available at: http://www.osha.gov/dsg/hazcom/hazcom-faq.html

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:

Compliance News: Floor Level at Exit Doors

By Robert Trotter, CBO, CFM

According to the Life Safety Code® the elevation of the floor surfaces on both sides of a door shall not vary by more than 1/2 inch. The elevation must be maintained on both sides of the doorway for a distance not less than the width of the widest leaf. Thresholds at doorways may not exceed 1/2 inch in height. Raised thresholds and floor level changes in excess of 1/4 inch at doorways are to be bevelled with a slope not steeper than 1 in 2. However, in existing buildings where the door discharges to the outside or to an exterior balcony or exterior exit access, the floor level outside the door is permitted to be one step lower than the inside, but may not be in excess of 8 inches lower.

Compliance News: Loaded or Corroded Sprinklers

By Robert Trotter, CBO, CFM




The Life Safety Code® mandates that all automatic sprinkler and standpipe systems required by this Code must be inspected, tested, and maintained in accordance with NFPA 25, Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems. Section 2-2.1.1 of the 1998 edition states “Sprinklers shall be free of corrosion, foreign materials, paint, and physical damage and shall be installed in the proper orientation (e.g., upright, pendant, or sidewall). Any sprinkler must be replaced that is painted, corroded, damaged, loaded, or in the improper orientation.” The Appendix says that the conditions described above 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.

Compliance News: CMS Hospital Equipment Maintenance Requirements Clarified

By Dean Samet, CHSP



Hospitals are expected to maintain equipment inventories and documentation of their maintenance activities. Federal or state laws and regulations may require that equipment maintenance activities be performed in accordance with the manufacturer’s recommendations, or may establish other maintenance requirements. In such instances, hospitals must be in compliance with the most stringent maintenance requirements mandated. Absent such mandated requirements, the Centers for Medicare & Medicaid Services (CMS) is allowing hospitals to follow one of the following: The manufacturer’s recommended maintenance schedule; to schedule more frequent maintenance than the manufacturer recommends; or, in some cases of non-critical equipment, to schedule less frequent equipment maintenance than the manufacturer calls for.

Compliance News: Influenza Vaccination Standard Revised by TJC

By Dean Samet, CHSP




In their December 2011 edition of The Joint Commission Perspectives, TJC announced their Infection Prevention and Control (IC) Standard IC.02.04.01 would be revised, strengthened, and extended to all TJC accreditation programs in which the standard is not currently applicable. The revised IC changes for hospital, critical access hospital, and long term care accreditation programs will be effective July 1, 2012. The revised IC changes for ambulatory care, behavioral health care, home care, laboratory, office-based surgery, and Medicare/Medicaid certification-based long term care accreditation programs will be implemented in a phased approach commencing July 1, 2012.


Revised Standard IC.02.04.01 elements of performance (EPs) will require accredited organizations to:

Compliance News: Alcohol-Based Hand-Rub Dispenser Placement

By Robert Trotter, CBO, CFM




Health care organizations should already be familiar with the current code-based requirements of NFPA 101®, Life Safety Code® and The Joint Commission (TJC) regarding the placement of Alcohol-Based Hand-Rub (ABHR) Dispensers. TJC is now allowing ABHR dispensers to be placed according to the requirements of the 2009 and 2012 editions of NFPA 101®,Life Safety Code®. The primary change from previous TJC requirements is the reduction of the minimum measurements from the ignition source to the dispenser. LSC Sections 18/19.3.2.6 (7) state: Dispensers shall not be installed in the following locations: 

• Above an ignition source within 1 inch (25 mm) horizontal distance from each side of the ignition source.
• To the side of an ignition source within a 1 inch (25 mm) horizontal distance from the ignition source.
• Beneath an ignition source within a 1 inch (25 mm) vertical distance from the ignition source.

For ignition sources such as duplex receptacles and light switches the measurements are taken from the side edges of the ignition source coverplate as depicted in the diagram.