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.

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).

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.

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®.

While existing health care occupancies are exempt from the re-entry provisions, Annex A of the Life Safety Code® states, “Doors to the enclosures of interior stair exits should be arranged to open from the stair side at not less than every third floor so that it will be possible to leave the stairway at such floor if fire renders the lower part of the stair unusable during egress or if occupants seek refuge on another floor.”

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.

Compliance News: Combustible Decorations

By Dean Samet, CHSP

It’s that time of the year again when there is a propensity to cover walls, doors and hang decorations from ceilings in celebration of the particular holiday season. Typically these decorations are not flame retardant; therefore they could contribute to the development or spread of a fire. Per Section 19.7.5.4 of the 2000 NFPA 101® Life Safety Code®, “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.”

It is a judgment call when determining if the hazard for fire development or spread is present; however, newer editions of the Life Safety Code do state that, “…consideration should be given to whether the building or area being evaluated is sprinklered.”

Policies and procedures (P&Ps) that prohibit and strictly limit the use of any combustible decorations should be in place and enforced. Send memos to each department, especially nursing units, and follow up with a safety/security personnel visit to discuss and answer questions regarding the P&Ps.

Just a reminder, fire safety is each and every staff member’s responsibility.

Compliance News: Fireplaces in Hospitals

By Robert Trotter, CBO, CFM

Prescriptive requirements for fireplaces in new and existing healthcare occupancies are found in the NFPA 101®, Life Safety Code®. Likewise the 2009 Hospital Accreditation Standards of The Joint Commission has three Elements of Performance in the Life Safety Chapter relative to fireplaces. They are:

• LS.02.01.50 EP 1. Fireplaces are not permitted in patient sleeping areas. Where allowed, fireplaces are separated from patient sleeping spaces by one-hour or more fire-rated construction.

• LS.02.01.50 EP 2. Fireplaces are equipped with a fireplace enclosure guaranteed against breakage up to a temperature of 650° F and constructed of heat-tempered glass or other approved material.

• LS.02.01.50 EP 3. The hearth of newly installed fireplaces is raised at least four inches above the floor.

Compliance News: CMS Clarifies LSC Application for Off-Site Buildings

By Dean Samet, CHSP

There are many instances when hospitals have off-site spaces or on-campus buildings physically separated or separated by rated construction where they provide ambulatory surgery or a variety of outpatient services. There are occasions when inpatients are transported to one of these buildings for services or treatment not available in the hospital. Does the occupancy designation change because some inpatients are being treated? What chapter(s) of the Life Safety Code® should be applied? In a July 30, 2008 e-mail to CMS regional personnel, the Centers for Medicare & Medicaid Services (CMS) Life Safety Code Specialist, James Merrill, P.E., provided the “Survey Process” criteria below that summarize the Life Safety Code® chapters to be applied to off-site buildings owned or leased by hospitals for outpatient department services, ambulatory surgical services, nursing homes, etc. This reconfirms and updates a Health Care Finance Administration (HCFA) directive written in March of 1993. This criteria may be used as a first step in determining appropriate LSC application for those instances when hospitals have off-site spaces or those separated by one-hour or two-hour construction between occupancies where they provide ambulatory surgical or other outpatient services.

Survey Process:

1. If inpatients receive treatment or services routinely, on a 24-hour basis (sleeping in the building), then Chapter 18/19 (Health Care Facilities) should be applied.

2. If outpatients (and/or inpatients, but the inpatients do not sleep in the building overnight) receive treatment or services in the outpatient building (a separate building), and if they are incapable or are rendered incapable, of self-preservation or receive general anesthesia, then Chapter 20/21 (Ambulatory Health Care) should be applied.

3. If outpatients receive treatment (and/or inpatients, but only on an occasional basis and they do 3. not sleep in the building overnight), and if they are capable of self-preservation and do not receive general anesthesia, then Chapter 38/39 (Business Occupancies) should be applied.

4. If there is more than one occupancy in a building without a two-hour separation between occupancies, the most stringent occupancy chapter applies.

While the above-listed CMS survey process for occupancies outside of a healthcare occupancy is summarized, the nature of the medical services provided and to whom they are rendered must be considered as should the LSC definitions provided in the 2000 NFPA 101® Life Safety Code®.

Compliance News: CMS Categorical Waiver for Damper Testing Cycle

By Dean Samet, CHSP

On October 30, 2009, the Centers for Medicare & Medicaid Services (CMS) issued a “categorical waiver” whereby hospitals may apply the 2007 NFPA 80 and NFPA 105 six-year testing interval for fire and smoke dampers in heating and ventilating systems in hospitals without special application to CMS. This action brings CMS in line with The Joint Commission and other state agencies and authorities having jurisdiction (AHJs) across the country.

The CMS Survey and Certification Group October 30, 2009 memorandum states: “After due consideration of State survey agency findings and conclusions of the National Fire Protection Association (NFPA), we are issuing a categorical waiver pursuant to 42 CFR 482.41(b)(2) to permit a testing interval of six years rather than four years for the maintenance testing of fire and smoke dampers in hospital heating and ventilating systems, so long as the hospital’s testing system conforms to the requirements under 2007 edition of NFPA 80: Standard for Fire Doors and Other Opening Protectives and the 2007 edition of NFPA 105: Standard for the Installation of Smoke Door Assemblies. The six-year testing interval shall commence on the date of the last documented damper test.

“While the 1999 edition of NFPA 80: Standard for the Installation of Air-Conditioning and Ventilating Systems specified a four-year testing cycle, the NFPA more recently determined that an increase to a six-year interval did not lower the fire protection of hospitals but could instead lower the incidence of infections that may be spread when the ventilation system was shut down and restarted at shorter time intervals. There is also some indication of cost savings to institutions when maintaining these dampers on a longer time interval.

“Under this categorical waiver, a hospital that conforms to the above requirements will not need to apply in advance for a waiver nor will it need to wait until being cited for a deficiency in order to apply for a waiver. At the time of a CMS onsite life-safety code survey, the hospital must notify the survey team that it has elected to operate under this categorical waiver and is in conformance with the testing requirements of the above-cited 2007 NFPA edition. The survey team will note this attestation in its records and apply the 2007 testing cycle requirements in the course of its survey.”

Compliance News: Transitioning from Construction to Survey-Ready Compliance - Part 2

By David Stymiest, PE, FASHE, CHFM

Part 1 appeared in the September/October 2009 issue of Compliance News.

The management plans, policies and procedures for renovations or expansions on an existing campus should reflect the impacts of the project on the existing facility. These impacts can include changes to facilities and areas, changes to infrastructure equipment and systems, new operational and infrastructure-related processes, and department locations or relocations.

Risk assessments may be required for safety, security, fire, and where the facility intends to permit patient smoking. Additional risk assessments may be done for input to the Emergency Operations Plan (EOP) and hazard vulnerability analysis (HVA), as well as hazardous chemicals, hazardous energy sources (including radiation, lasers, batteries), hazardous medications, hazardous gases and vapors, and radioactive materials. Other types of risk assessments apply to Life Safety Code™ deficiencies and Interim Life Safety Measure (ILSM) documentation, preconstruction risk assessments (PRA), and infection control risk assessments (ICRA).

Some of these risk assessments might be used to establish written inventories in the following areas as subsets based upon risk:

• Hazardous materials and waste

• Medical equipment (evaluation prior to initial use)

• Operating components of utility systems (evaluation of new component types prior to initial use)

Many of the systems and equipment, including life safety building features or components, must be commissioned and/or tested prior to initial use. It is not practical to list all of these item types here. Presumably project record documentation that includes all of the information required by the AHJ would be acceptable as long as it is available during survey.

The Project Record Documentation can be helpful in providing the complete list of components for ongoing testing provided that it is available early enough to be useful. The following systems and components require ongoing testing, and there would have to be policies, procedures, schedules, requirements, and forms that detail this testing:

• Fire safety equipment, fire safety building features, fire alarm, fire protection and sprinklers, fire extinguishers and extinguishing systems

• Smoke and fire dampers, air handling unit shutdown, elevator recall, etc.

• Door operation, exit door and corridor door resistance

• Medical equipment on the inventory

• Operating components of utility systems on the inventory

• Emergency power, medical gas, and vacuum systems and equipment

• Pathogenic biological agents in cooling towers, hot water and cold water systems

• Temporary systems required for ILSM

Project testing and certification reports would have to be on file and easily accessible during unannounced surveys. Types of project-related testing and certification reports could include, but are not limited to, the following:

• Contractor documentation and commissioning (Cx) agent documentation

• Documentation of typical AHJ inspections and approvals: Local, State, NRC, DOT, FAA, etc.

• Helipads and separator tank, elevators, fuel tanks, pressure vessels, fire protection water systems, lightning protection systems

• Building automation or building management system

• Low voltage systems, both medical and otherwise

Shock Resistant: Preventing Arc-Flash Hazards in the Hospital Setting

By David L. Stymiest, P.E., CHFM, FASHE (in Health Facilities Management)

With the 2009 edition release of the National Fire Protection Association's 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. Why is there ever- increasing emphasis on electrical system safety?

According to the Centers for Disease Control and Prevention's (CDC's) National Institute of Occupational Safety & Health (NIOSH), electrical hazards cause more than 300 deaths and 4,000 injuries in the workplace each year. Some electrical injuries are instantly fatal, while up to 40 percent of electrical injuries are ultimately fatal, according 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 has compiled often-quoted statistics indicating that five to 10 reported electrical equipment arc-flash explosions occur per day in the United States.

Read entire article here: Shock Resistant