COMPLIANCE IN OPERATION
Charles Workman, CHFM, CHSP, CHEP
Director, Regulatory Programs
Hospital Corporation of America
1
Introduction
• Expected Outcomes from this presentation:
– The attendees should be able to understand these processes at the
conclusion of the presentation.
– Activities that have combined maintenance requirements and compliance
activities.
– Techniques and resources to align vendors with compliance activities.
– Methods to validate compliance on a continual basis.
• Please ask questions at any time during the presentation, or
• Save them for the end of the session.
2
CMS Memo 12-21: Intent and Content
Intent: to allow the 2012 NFPA 101, 18/19.2.3.4 to be adopted as long as the criteria is
met.
•
Smoke compartments are required to be fully sprinkled and automatic fire alarm system
installed.
Content:
• Projections into the corridor shall be permitted for wheeled equipment:
3
−
6 feet corridors must maintain 60 inches clearance
−
8 feet corridors must maintain 6 feet clearance
•
Fire plan addresses the relocation of the wheeled equipment
•
Limitations of the equipment: In use, Emergency equipment, Lift and Transport
•
Fixed equipment is allowed in the 8 foot corridors
To Implement or Not?
The decision must be made with the clinical staff and engineering so everyone
understands the implications.
Advantages
Disadvantages
• Free parking for wheeled equipment.
• Items will collect in the corridors!
• When implemented, NFPA 101, 7.1.10.1
will not apply, even though it is still in
the 2012 edition of the code.
• Obstructions to Fire Protection features
and medical gas shut off valves must be
prevented.
4
CMS Memo 13-58 Implementation
•
Medical Gas Master Alarms – Allows a Computer System to substitute for one of the Category 1
alarm panels.
•
Openings in Exit Enclosures – Mechanical room doors into stairwells.
•
EPSS Testing – Reduces the 2-hour to 1.5 hours.
–
Existing = 25% (30 Mins), 50% (30 Mins), 75% (1 hour). New = 50% (30 Mins), 75% (1 hour).
•
Doors – From single delayed door in an egress to multiple
•
Suites – Sleeping to 10,000 square feet
•
Extinguishing Systems
–
Electric Fire Pump to Monthly (Churn Test)
–
Waterflows to Semi-Annually
•
Clean Waste and Patient Record Containers – Capacity to 96 gallons from 32 gallons
•
Adoption of CMS Memo 12-21
5
Suite Adoption Issues – Dead End Corridors
Existing Building – no limitations on distance
Suite “A”
Dead End Corridor
Suite “B”
Utilizing 2000 LSC for 5000 SF suites
If Utilizing CMS Memo 13-58, distance must meet new occupancy requirements
6
Specifics of the Corridor
CMS Memo
•
Fixed furniture:
–
Must be secured to the floor.
–
Must be located on one side of the corridor.
–
Space must be located to allow direct supervision from the
nurse station.
–
Area cannot exceed 50 square feet.
•
This places the area under criteria for a Hazardous Area.
(18/19.3.2.1)
7
Process for Implementation
Key Actions
If adopted, the language must be included under the “Additional Comments” section of
the Basic Building Information (BBI) in the electronic Statement of Conditions (e-SOC).
• Mark the clearance in the corridor.
– Place colored tape on the ceiling tile framing to mark the threshold.
• Develop fire plans for the individual clinical areas.
• Assignment of person/s to remove equipment in the event of an emergency should be general
and not specific. For example:
– CNA’s on 3 South will move wheeled items to Nurse station.
– Charge nurse will assign staff to remove equipment and place in vacant patient room.
• Submit in the minutes of the EOC/Safety Committee the adoption of the Memo.
8
Fire Plan Example
Fire Plan must include:
9
•
Exit access,
•
Area to move wheeled equipment,
•
Areas of refuge (if meets the criteria of 7.2.12),
•
Access to a public way,
•
Elevator with firefighter service,
•
Two-way communication system, and
•
Must be protected by a 1-hour separation
Fire Alarm Devices and Components
EC.02.03.05
Includes EPs:
• 1: Supervisory signals
• 3: Duct detectors
• 4: Audio/visual devices
• 5: Off-site notification
• 13: Kitchen systems
• 14: CO2 systems
Other components are covered
in Fire Suppression Systems
10
• Testing and inspection requirements are detailed in NFPA 72,
Chapter 7. (These include inspection and testing frequencies and
procedures.)
• EP 25 was directly translated from NFPA 72, specifically:
– An inventory must be complete and accurate for all devices. (NFPA 72:
permanent records, 7-5.2.2 (7) – “Designation of the detector(s) tested, for example,
Tests performed in accordance with Section_____________.”)
• The example provided in NFPA 72, Figure 7-5.2.2 will not be
sufficient to satisfy an inventory.
Fire Alarm and Devices
Functionality
The testing of the devices must correspond to the output of the fire alarm system.
• It must be recorded that activation devices set off a sequence in the fire alarm system.
• Supervisory signals must be tested to show a “global” activation of the system.
(Requires action by occupants.)
• The following table from NFPA 72 shows how initiating devices correspond to the fire alarm
system and activate the notification devices.
11
12
Fire Suppression Inspections
Inspection of
Devices
The components of the fire suppression system are required to be inspected as to their
condition.
• Sprinklers are required to be inspected from floor level annually. (2-2.1.1*)
–
Sprinklers with corrosion, foreign materials, paint, physical damage, or having the incorrect orientation must
be replaced.
• Gauges in wet pipe systems are required to be inspected monthly. (2-2.4.1*)
–
–
Gauges must be in good condition.
Normal water supply pressure must be maintained.
• Gauges must be inspected Monthly and replaced or tested every 5 years. (2-2.4 and 2-3.2*)
–
13
Gauges testing outside 3 percent of the full scale must be recalibrated or replaced.
Fire Suppression Inspections (continued)
Inspection of
Devices
• Hydraulic nameplate must be inspected quarterly. (2-2.7*)
–
Must be legible and securely attached to the sprinkler riser.
• Sprinkler spares shall be inspected for quantity. (2-4.1.5) For protected facilities, required
quantities are:
–
–
–
(a) With less than 300 sprinklers — no fewer than 6 sprinklers
(b) With 300 to 1000 sprinklers — no fewer than 12 sprinklers
(c) With more than 1000 sprinklers — no fewer than 24 sprinklers
• A special sprinkler wrench for installing and removing sprinklers is required. (2-4.1.6*)
–
14
One sprinkler wrench for each type of sprinkler installed.
General Recommendations for Improvement
EC.02.03.05
The vendor must follow EP25 and the language from NFPA 72 (1999 edition):
• Test methods must be identified
(Table 7-2.2)
• Visible frequencies must be identified
(Table 7-3.1)
• Testing Frequencies must be identified
(Table 7-3.2 and CMS memo 13-58)
• EP25 is TJC trying to convey the language from NFPA 72, 7-5.2
• 15 items must be reviewed and documented (see NFPA 72 which states “designation of detector(s)”)
• Example inspection and testing form
(Figure 7-5.2.2)
If the vendor is not providing the information as per these references, they are in breach of the contract.
15
Utility Failure Policy and Matrix
• Policy reads “Follow the Utility Failure Matrix.”
• Matrix is located with the Administrator on Call, PBX Operator, and
Engineering
UTILITY FAILURE MATRIX
Call House Operator 24/7
House Operator makes announcement on Public Address System
House Operator calls "on duty" Engineering Mechanic using 2-Way radio
Failure
Code Red
Fire Alarm*
What to Expect
1) Switch to Security
Call XXXX. Defend in place
channel
or evacuation.
2) Call Fire Department
3) LiveProcess Msg
Many lights &
Electrical Power
equipment out. Only
Failure -Emergency
RED electrical
Generators Working
receptacles work
16
Operator to Contact
Code Yellow
1) Engineering
2) Clinical Engineering
Admin. On Call
Determine evacuation needs and
medical priorities.
Responsibility of Staff
Operator via (Comm tool)
Respond with tools to the impacted
scene. Radio to Operator and Fire
Panel. Switch to Security channel;
1) Click "call code"
Security to meet the Fire Department. 2) Select Code Red
One staff member to Fire Computer
Room, if available.
Ensure that life support systems
Have staff check that "life
are on emergency power (RED
support equipment" is plugged Outlets). Ventilate patients by
into Red Outlets.
hand. Complete cases in progress
ASAP.
1) Click "Communications"
2) Send a Notification
3) Type Message
4) Select group "Code Yellow Internal - Power
Failure with Generators Working"
General Recommendations for Compliance
Interim Life Safety
Measures (ILSM)
ILSM must be evaluated and documented.
• The ILSM evaluated box must be entered on
the electronic Statement of Conditions
(eSOC)
• Not all 11 elements in LS.01.02.01 are
applicable to all ILSM conditions
We need to develop more realistic measures!
17
Example
If penetrations are present in a fire or smoke assembly,
the integrity has been compromised. The Life Safety
Code was designed to provide a sequence of measures.
Measure: maintain the next lower protective level until
the penetrations are corrected (e.g., next smoke barrier
or smoke partition).
Evaluation of ILSM Made Simple
Criteria
Criteria
Job Length
Greater than 3 months
From 1 to 3 months
Less than 1 month
Less than 1 week
Points
20
15
10
0
0
Criteria
2) Impact on Patient Care
Work is in patient area
Near ambulatory patients
near visitor / staff areas
Near staff only
0
4) Hazards of Work Activity Methods
Open flame
Heat producing / elec welding
Low Hazards Only
Points
20
15
10
0
Score
15
Points
0
Criteria
2) Impact on Patient Care
Work is in patient area
Near ambulatory patients
near visitor / staff areas
Near staff only
0
4) Hazards of Work Activity Methods
Open flame
Heat producing / elec welding
Low Hazards Only
20
15
10
0
0
6) Impact on Exiting (Building Exit)
Exit blocked
Exit obstructed
Exit penetrated
None
25
20
15
0
15
0
0
8) Impact on Fire Alarms
Multiple zones
One zone
In zone - no working system
None
20
15
5
0
0
10) Storage Areas
Multiple storage areas in zone
One in zone + adjacent
Adjacent areas only
None
20
15
10
0
0
1) Job Length
Greater than 3 months
From 1 to 3 months
Less than 1 month
Less than 1 week
20
15
10
0
3) Hazards of Work Activity Materials
Hazards of Work Activity Materials
Unprotected flammable
Excessive combustible
Low Hazards Only
20
15
0
20
15
10
Unprotected flammable
Excessive combustible
Low Hazards Only
20
15
0
25
15
10
0
Impact on Exit Access (Corridors)
Redirect / reroute exit
Redirected exits not visible
Exit access width reduced
None
25
15
10
0
Temp Work Activity Partitions
Multiple partitions in zone
One partition
No partition necessary
Access to Emergency Department &
Building Exterior
Emergency Dept. blocked
Building exit blocked > 50'
Building exit blocked < 50'
None
20
15
0
ILSM Required?
25
20
15
0
0
8) Impact on Fire Alarms
Multiple zones
One zone
In zone - no working system
None
20
15
5
0
10) Storage Areas
Multiple storage areas in zone
One in zone + adjacent
Adjacent areas only
None
0
0
Missing
Significant Compromise
Minor Penetrations
None
0
Redirect / reroute exit
Redirected exits not visible
Exit access width reduced
None
25
15
10
0
9) Temp Work Activity Partitions
Multiple partitions in zone
One partition
No partition necessary
20
15
0
0
0
25
20
10
0
NOTE: 1) A score of 100 points or more on this
Preliminary Life Safety Assessment form will require a
more detailed review and evaluation by the Project
Manager, and may result in implementation of ILSM. 2)
A score greater than 0 in Criteria Sections 5, 6, 7, or 8
above will require an ILSM Evaluation regardless of
total points scored.
0
15
Building Exterior
Emergency Dept. blocked
Building exit blocked > 50'
Building exit blocked < 50'
None
25
20
10
0
15
NOTE: 1) A score of 100 points or more on this
Preliminary Life Safety Assessment form will require a
more detailed review and evaluation by the Project
Manager, and may result in implementation of ILSM. 2)
A score greater than 0 in Criteria Sections 5, 6, 7, or 8
above will require an ILSM Evaluation regardless of
total points scored.
0
Preliminary Life Safety
Assessment Score
30
0
0
NO
FALSE
Sum o f 5, 6, 7, 8
Impact o n egress?
ILSM Required?
18
25
15
10
0
7) Impact on Exit Access (Corridors)
20
15
10
0
Score
11) Access to Emergency Department &
Preliminary Life Safety
Assessment Score
Sum o f 5, 6, 7, 8
Impact o n egress?
0
6) Impact on Exiting (Building Exit)
Exit blocked
Exit obstructed
Exit penetrated
None
20
15
10
0
0
5) Fire / Smoke Separations
Fire / Smoke Separations
Missing
Significant Compromise
Minor Penetrations
None
Points
15
15
YES
TRUE
Building Maintenance Program?
• Do we need one and how do we implement one that is effective?
– Doors are verified during fire drills:
• Corridor doors positively latch
• Some barrier doors close upon activation of fire alarm
• Exits and hazardous areas self close and latch
– The inventory is assigned to each floor
– Smoke Barriers – Survey once a year
– Fire Barriers surveyed once a year
– The main focus is being Proactive – Above the ceiling access control
19
Above the Ceiling - Permit or Tagging
Pro-Active
• Purpose: Control activities that penetrate smoke and fire barriers.
• Being proactive is the only solution.
• Inspections are to measure the expectations of the barrier integrity.
• Process must be discussed with Infection Prevention Professionals to determine level of control
to access the ceiling spaces.
– Permit Process: Detailed description of activities and location of work
– Tagging Process: Identify the area on drawings, number tags, evaluate with ICRA
20
Permit Process
•
•
•
•
•
Detailed description of area.
Work being completed
All areas requiring inspection
Signature of Engineering representative
Retain the Permit?
• Once work is completed, there are No requirements
for record retention.
21
Permit
Tagging Process
• Tags are two-sided
• Tag number is identified
on a set of drawings
• Tag is effective for 24 hours only
• At the end of each day, tags
are returned
• If area involved Smoke/Fire
rated walls or partitions - Inspect
• If area did not involve Smoke/Fire
rated walls or partitions
• Discard the tag
22
ICRA and Tag Process
Above the Ceiling ICRA Process
Start
Obtain an Above the Ceiling Tag and
complete the log
Inspection Only?
Yes
Review the ICRA, Complete
log for ICRA review.
No
Determine Group level on ICRA form
No
Group I or II?
Complete ICRA form for Group III or
IV. Process with Infection Prevention
Fill in Group on back of tag. Close tag
and ICRA permit upon completion of
work.
Verify if Smoke or Fire Rated
Assemblies are impacted
Fire stopping must be provided by
contractor before permits are closed
out.
23
If work is Group I or II, fill in
group on back of tag
Yes
Drawings for Tagging Process
• Have a set of life safety drawings laminated
• Identify the area being accessed with erasable ink
• End of day once inspected/not inspected
• Erase the drawings at the end of the day
• Recommend a reward program for all staff for access to the ceiling
– Meal tickets
– Something from gift shop
24
After Work is Complete
No Inspection
25
3945
3945
Inspection
General Recommendations for Improvement
Medical Gas Systems
Per NFPA 99 (1999 edition):
• 4-3.1.2.14 Identification
• “Piping shall be identified by stenciling or adhesive markers”
• All locations where the piping is to be marked are listed
• If the medical gas testing company writes on their report that the systems were inspected and
tested in accordance with NFPA 99, they should identify missing labels
If the testing company does not list missing labels, they are in breach of the contract.
26
General Recommendations for Improvement
(cont’d.)
LS.02.01.30
Per NFPA 101, (2000 edition) 18/193.6.2:
• The smoke compartment must be identified as being sprinkled or non sprinkled
• The ceiling is allowed to terminate above the ceiling, in an existing building, the smoke
compartment must be sprinkled
• In new buildings, sprinklers are not optional; the building must be fully sprinkled
Identifying sprinkled area on drawings will alleviate the finding for corridor walls that Do Not go from
deck to deck.
27
General Recommendations for Improvement
(cont’d.)
EC.02.03.05
• Per NFPA 25 (1998 edition) 2-2.1.1, “Sprinklers shall be inspected from the floor level annually.”
• If the fire suppression vendor presents you with a document that they have performed sprinkler
testing and inspection or water-based fire protection system testing and inspection in accordance
with NFPA 25, they are in breach of their contract!
We must hold contractors accountable for the service they are to provide!
28
Physical Environment and Utility Systems
Physical Environment
Definition
Reference CMS
29
Utility Systems
Design and Operation
Conditions of Participation
Design
The Joint Commission
Standards
Operations
State Regulations
Variables to Consider
Conditions of Participation (COP)
CMS
• Language from the CMS COP:
− CMS COP 482.41 (Physical Environment) allows the hospital to decide on which Guideline they choose.
− Each operating room should have separate temperature control. Acceptable standards such as from the
Association of Operating Room Nurses (AORN) or the Facilities Guidelines Institute (FGI) should be
incorporated into hospital policy.
• Designation of the Guideline being utilized.
• A policy must be implemented reflecting the specific guideline
• Other Acceptable standards:
30
•
Association for the Advancement of Medical Instrumentation (AAMI)
•
American Institute of Architects (AIA)
Joint Commission Standards
Specific Standards
•
EC.02.05.01 EP 6:
–
–
•
•
3
The EP has this designation, indicating it is a Direct Impact for scoring
EC.02.06.01 EP 13:
–
The hospital maintains ventilation, temperature, and humidity levels suitable for the care, treatment, and
services provided.
–
Not a Direct impact!
EC.02.06.05 EP 1:
–
31
In areas designed to control airborne contaminants (such as biological agents, gases, fumes, dust), the
ventilation system provides appropriate pressure relationships, air-exchange rates, and filtration efficiencies.
Planning for New, altered or renovated spaces use: State rules and regulations, Facility Guidelines Institute
(FGI) or a reputable standard or guideline.
State Regulations
• Variance from State to State:
– Florida utilize a State Operations Manual developed and enforced by
Agency for Health Care Administration (AHCA)
– Texas utilizes a State Operations Manual developed and enforced by
the Department of State Health Services (DSHS). Texas Administrative
Code (TAC)
– Kentucky utilizes a State Operations Manual developed and enforced
by the Office of the Inspector General (OIG).
• The Kentucky State design laws state the use of the AIA 2006 edition
32
Utility Systems - Design
• Design: The parameters in which the HVAC systems were designed is
dependent on the State.
• Example standard from ASHRAE 170, Attachment D to 2010 FGI:
33
Utility System - Operation
Define the Needs
• The needs of the patient are a consideration:
– The primary reason for the lower temperatures are for the surgeons!
– During Cardiac cases, the physicians like to lower the temperature to stop the heart and reduce the
organs need for oxygen.
– Before closing, the physician wants the temperature raised to increase blood flow and reduce the
possibility of hypothermia.
– The colder temperature will keep the bacteria count down.
– Some consideration must be given to cardiac catheterization cases where all of the clinical staff are
wearing lead shielding to prevent excessive dosing from the “C” arm.
34
Variables in Operations
Variables: The system was designed for one range and the demand is much lower or
higher from the clinical staff!
•
If the temperatures and relative humidity fall out of range once the physicians request a lower
temperature, the HVAC system is not operating within the design parameters.
Next Steps:
• Present to the clinical staff the following:
• Once a parameter is requested outside of the design range, it is no
longer an engineering issue!
• The clinical staff must meet and decide if they are comfortable with
the operating room being out of parameters.
• The decision to continue the case must be with the clinicians.
35
Where are Eye Wash Stations Required?
36
Purpose
EC.02.02.01
•
Emergency first aid as required by OSHA.
•
The Material Safety Data Sheets (MSDS) describes the first aid actions.
•
Evaluate the MSDS and determine if flushing is required for a certain period of time.
•
If no time period is identified in the MSDS.
•
Flushing station is adequate until the person is taken to
the emergency room.
37
Questions?
• I can be reached at:
• Charles.workman@hcahealthcare.com
• 615.344.1187
Thank You
38