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.
Saturday, May 29, 2010
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.
Sunday, November 29, 2009
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.
Subscribe to:
Posts (Atom)