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.”
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