1 COMPLIANCE IN OPERATION Charles Workman, CHFM, CHSP, CHEP Director, Regulatory Programs Hospital Corporation of America.

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COMPLIANCE IN OPERATION

Charles Workman, CHFM, CHSP, CHEP Director, Regulatory ProgramsHospital Corporation of America

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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.

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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.

• Projections into the corridor shall be permitted for wheeled equipment:

− 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

Content:

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To Implement or Not?

• Free parking for wheeled equipment.

• When implemented, NFPA 101, 7.1.10.1 will not apply, even though it is still in the 2012 edition of the code.

Advantages

• Items will collect in the corridors!

• Obstructions to Fire Protection features and medical gas shut off valves must be prevented.

Disadvantages

The decision must be made with the clinical staff and engineering so everyone understands the implications.

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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

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Suite Adoption Issues – Dead End Corridors

Suite “A”

Suite “B”

Existing Building – no limitations on distance

Utilizing 2000 LSC for 5000 SF suitesIf Utilizing CMS Memo 13-58, distance must meet new occupancy requirements

Dead End Corridor

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Specifics of the Corridor

• 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)

CMS Memo

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Process for Implementation

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.

Key Actions

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Fire Plan Example

Fire Plan must include:

• 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

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Includes EPs:

• 1: Supervisory signals

• 3: Duct detectors

• 4: Audio/visual devices

• 5: Off-site notification

• 13: Kitchen systems

• 14: CO2 systems

Fire Alarm Devices and Components

EC.02.03.05

• 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.

Other components are covered in Fire Suppression Systems

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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.

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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*)

– Gauges testing outside 3 percent of the full scale must be recalibrated or replaced.

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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*)

– One sprinkler wrench for each type of sprinkler installed.

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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.

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Utility Failure Policy and Matrix

• Policy reads “Follow the Utility Failure Matrix.”• Matrix is located with the Administrator on Call, PBX

Operator, and EngineeringUTILITY FAILURE MATRIX

Call House Operator 24/7House Operator makes announcement on Public Address SystemHouse Operator calls "on duty" Engineering Mechanic using 2-Way radio

Failure What to Expect Operator to Contact Admin. On Call Responsibility of Staff Operator via (Comm tool)

Code Red Fire Alarm*

Call XXXX. Defend in place or evacuation.

1) Switch to Security channel 2) Call Fire Department3) LiveProcess Msg

Determine evacuation needs and medical priorities.

Respond with tools to the impacted scene. Radio to Operator and Fire Panel. Switch to Security channel; Security to meet the Fire Department. One staff member to Fire Computer Room, if available.

1) Click "call code"2) Select Code Red

Electrical Power Failure -Emergency Generators Working

Many lights & equipment out. Only RED electrical receptacles work

Code Yellow 1) Engineering2) Clinical Engineering

Have staff check that "life support equipment" is plugged into Red Outlets.

Ensure that life support systems are on emergency power (RED Outlets). Ventilate patients by hand. Complete cases in progress ASAP.

1) Click "Communications" 2) Send a Notification3) Type Message4) Select group "Code Yellow Internal - Power Failure with Generators Working"

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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!

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).

Example

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Evaluation of ILSM Made SimpleCriteria Points Criteria Points ScoreJob Length 2) Impact on Patient CareGreater than 3 months 20 Work is in patient area 20From 1 to 3 months 15 Near ambulatory patients 15 15Less than 1 month 10 near visitor / staff areas 10Less than 1 week 0 0 Near staff only 0

Hazards of Work Activity Materials 4) Hazards of Work Activity MethodsUnprotected flammable 20 Open flame 20Excessive combustible 15 Heat producing / elec welding 15Low Hazards Only 0 0 Low Hazards Only 10 0

Fire / Smoke Separations 6) Impact on Exiting (Building Exit)Missing 25 Exit blocked 25Significant Compromise 15 Exit obstructed 20Minor Penetrations 10 Exit penetrated 15None 0 0 None 0 0

Impact on Exit Access (Corridors) 8) Impact on Fire AlarmsRedirect / reroute exit 25 Multiple zones 20Redirected exits not visible 15 One zone 15Exit access width reduced 10 In zone - no working system 5None 0 0 None 0 0

Temp Work Activity Partitions 10) Storage AreasMultiple partitions in zone 20 Multiple storage areas in zone 20One partition 15 One in zone + adjacent 15No partition necessary 0 0 Adjacent areas only 10

None 0 0Access to Emergency Department & Building Exterior

Emergency Dept. blocked 25

Building exit blocked > 50' 20Building exit blocked < 50' 10None 0 0

Preliminary Life Safety Assessment Score

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Sum of 5, 6, 7, 8 0

Impact on egress? 0 NO

ILSM Required? FALSE

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.

Criteria Points Criteria Points Score1) Job Length 2) Impact on Patient Care

Greater than 3 months 20 Work is in patient area 20From 1 to 3 months 15 Near ambulatory patients 15 15Less than 1 month 10 near visitor / staff areas 10Less than 1 week 0 0 Near staff only 0

3) Hazards of Work Activity Materials 4) Hazards of Work Activity MethodsUnprotected flammable 20 Open flame 20Excessive combustible 15 Heat producing / elec welding 15Low Hazards Only 0 0 Low Hazards Only 10 0

5) Fire / Smoke Separations 6) Impact on Exiting (Building Exit)Missing 25 Exit blocked 25Significant Compromise 15 Exit obstructed 20Minor Penetrations 10 Exit penetrated 15 15None 0 0 None 0 0

7) Impact on Exit Access (Corridors) 8) Impact on Fire AlarmsRedirect / reroute exit 25 Multiple zones 20Redirected exits not visible 15 One zone 15Exit access width reduced 10 In zone - no working system 5None 0 0 None 0 0

9) Temp Work Activity Partitions 10) Storage AreasMultiple partitions in zone 20 Multiple storage areas in zone 20One partition 15 One in zone + adjacent 15No partition necessary 0 0 Adjacent areas only 10

None 0 011) Access to Emergency Department &

Building Exterior

Emergency Dept. blocked 25

Building exit blocked > 50' 20Building exit blocked < 50' 10None 0 0

Preliminary Life Safety Assessment Score

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Sum of 5, 6, 7, 8 15

Impact on egress? 15 YES

ILSM Required? TRUE

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.

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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

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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

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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.

Permit

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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

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ICRA and Tag ProcessAbove 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

Fill in Group on back of tag. Close tag and ICRA permit upon completion of

work.

Complete ICRA form for Group III or IV. Process with Infection Prevention

If work is Group I or II, fill in group on back of tag

Group I or II? Yes No

Verify if Smoke or Fire Rated Assemblies are impacted

Fire stopping must be provided by contractor before permits are closed

out.

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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

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After Work is Complete

39453945

No InspectionInspection

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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.

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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.

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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!

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Physical Environment and Utility Systems

Physical Environment

Definition Reference CMS

Conditions of Participation

The Joint Commission Standards

State Regulations

Utility Systems Design and Operation

Design

Operations

Variables to Consider

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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:

• Association for the Advancement of Medical Instrumentation (AAMI)

• American Institute of Architects (AIA)

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Joint Commission Standards

Specific Standards

• EC.02.05.01 EP 6:

– 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.

– 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:

– Planning for New, altered or renovated spaces use: State rules and regulations, Facility Guidelines Institute (FGI) or a reputable standard or guideline.

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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

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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:

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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.

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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.

• 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.

Next Steps:

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Where are Eye Wash Stations Required?

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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 tothe emergency room.

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Questions?

• I can be reached at:

• [email protected]• 615.344.1187

Thank You