CMS Impact on Recent Joint Commission Surveysc.ymcdn.com/sites/ Impact on Recent Joint Commission Surveys ... requirements and with all other 2000 LSC electrical ... staff instead

CMS Impact on Recent Joint Commission

Surveys

Environment of Care & Life Safety Code Concerns

SMS, Inc. 2015 1

Objectives

!  Review the top findings in Environment of Care and Life Safety Code for Hospital surveys

!  Discuss Compliance Strategies

!  Discuss Key Issues in Joint Commission Compliance

!  Review the Categorical Waivers available from The Center for Medicare & Medicaid Services (CMS)

!  Discuss the differences in the 2000 vs 2012 Life Safety Code

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Most Common Plant & Engineering Findings Top Standards Compliance Issued for the First Half of 2014

Hospitals

53% EC.02.05.01 Manages risks associated with utility systems

52% LS.02.01.20 Maintains the integrity of means of egress

51% EC.02.06.01 Establishes and maintains safe, function environment

50% EC.02.03.05 Maintains fire safety equipment and fire safety building features

50% IC.02.02.01 Reduces the risk of infections associated with medical equipment, devices and supplies

49% LS.02.01.10 Building & fire protection features are designed and maintained to minimize the effects of fire, smoke, and heat

49% RC.01.01.01 Maintains complete and accurate medical records for each patient

46% LS.02.01.30 Provides and maintains building features to protect individuals from hazards of fire and smoke

44% LS.02.01.35 Provides and maintains systems for extinguishing fire

36% EC.02.02.01 Manages risk related to hazardous material and waste SMS Inc. 2015 3

Utility System Risks EC.02.05.01

!  Pressure Relationships and Air Exchanges

!  Ventilation system is unable to provide appropriate pressure relationships, air-exchange rates and filtration efficiencies, specific areas lack:

! Negative or positive pressures in relationship to adjacent areas (Operating Room, Labor & Delivery Rooms, Central Sterile Processing)

! The correct number of air changes per hour

!  Improper filtration

! MERV = minimum efficiency reporting value ! EC.02.05.01 EP 6 will generate a CONDITION LEVEL DEFICIENCY

o  Condition Level Deficiency requires a verification survey

o  Can be downgraded to Standard Level Deficiency depending on manner & degree

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Means of Egress LS.02.01.20

!  The hospital maintains the integrity of means of egress: Corridor Clutter

!  Anything in the egress corridor more than 30 minutes is storage

!  Dead end corridor may be used for storage if less than or equal to 50 sq.ft.

!  Carts Allowed

–  Crash Carts

–  Isolation Carts

–  Chemo Carts

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Most Common PE Findings

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Most Common PE Findings

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Safe and Functional Environment EC.02.06.01 !  Ventilation, temperature & humidity levels suitable for care

!  Medical Gas Cylinders

!  Unsecured Cylinders

!  Storage of Cylinders

!  <300 cu.ft. open to the corridor per smoke compartment

!  300 – 3,000 cu.ft. stored in room (lockable doors)

!  “In storage” vs. “in use”

! Properly racked is “in storage”

! Secured to a gurney is “in use”

! Empty cylinders are not “in storage”

! Full and empty cylinders must be stored (racked) separately

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Maintenance of fire safety equipment & fire safety building features EC.02.03.05 !  Features of fire protection

!  Inventory required to ensure all devices are tested

!  Lack of an inventory (written, electronic or other) results in a finding at the EP

!  Documentation (not documented=not done)

!  EP #25, 02.03.05.25 (Fire System Testing)

1. Name of the Activity

2. Date of the Activity

3. Required Frequency of the Activity

4. Name and Affiliation of Person Conducting Activity 5. NFPA Standard Referenced for the Activity

6. Result of the Activity

Leadership finding possible SMS Inc. 2015 9

Fire Protection Feature Maintenance LS.02.01.10

§  Building Construction Type

-  Type I (443) (332) Type II (222)-unlimited height (>4) w/o Sprinkler (existing healthcare)

-  Exterior bearing walls, structural frame, floor slab

§  Fire Door & Frame Ratings

§  Door Latching

§  Penetrations of Fire Walls

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Fire Protection Feature Maintenance

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Protection from Fire and Smoke LS.02.01.30 ! Hazardous Areas (Door rating and Latching):

! Boiler Rooms ! Laundry ! Flammable Liquid Storage Room ! Laboratories ! Maintenance Shops ! Piped Oxygen Tank Rooms ! Soiled Linen/Trash Collection Rooms ! Storage Rooms >50 square feet

! Existing Healthcare-smoke tight with sprinkler or 1 hour construction ! New Healthcare-sprinkler system required and 1 hour construction ! Smoke Barriers & Doors-Penetrations and Latching

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Maintenance of Fire Extinguishing Systems LS.02.01.35

!  Piping for the AASS is not used to support any other item

!  Nothing may be supported on sprinkler system piping

!  No “Tying Off” No Decorations

!  Sprinkler heads are not damaged and are free from corrosion, foreign materials and paint

!  Missing escutcheons, missing signage (NFPA 13)

!  Ceiling tiles misplaced in rooms

!  Quick response sprinklers mixed with other types in patient sleeping smoke compartments

§  Blocked access to fire extinguishers

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Management of Hazardous Material & Waste EC.02.02.01

!  Personal Protective Equipment and the process to manage hazardous materials and waste handling and exposures

!  Eye Wash Stations:

! Include areas such as power plant and lab

! Stations must be placed within 10 seconds or 55 feet from where corrosive chemicals are used

! Weekly flushing required

! Annual inspection for system functionality required

! Mixing valve recommended for achieving tepid water or a risk assessment should be done

!  Hazardous energy source-Hot Lab isotopes, Lead aprons

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Eye Wash Station: Recommended locations (i.e. OSHA)

!  Medical services and first aid 1910.151(c) !  The eyes or body of any person may be exposed to injurious corrosive materials, suitable

facilities for quick drenching or flushing of the eyes and body shall be provided within the work area for immediate emergency use

!  Formaldehyde 1910.1048(i)(3) !  If there is any possibility that an employee's eyes may be splashed with solutions containing

0.1 percent or greater formaldehyde, the employer shall provide acceptable eyewash facilities within the immediate work area for emergency use

!  Battery charging and changing 1917.157(i) !  Facilities for flushing the eyes, body and work area with water shall be provided wherever

electrolyte is handled, except that this requirement does not apply when employees are only checking battery electrolyte levels or adding water

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How Are We Doing? Not So Good!!!

Standards 2014 2013 2012 2011

EC.02.05.01: Utility Systems Risks #1 #4 #10 #13

LS.02.01.20: Means of Egress #2 #1 #2 #2

EC.02.06.01: Built Environment #3 #8 #7 #11

EC.02.03.05: Fire Safety Systems #4 #7 #5 #5

LS.02.01.10: General B’ldg Req’s #6 #3 #3 #3

LS.02.01.30: Protection #8 #6 #6 #4

LS.02.01.35: Extinguishment #9 #9 #9 #10

EC.02.02.01: HazMat & Waste #10 #11 #11 #15

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Key Issues in TJC Compliance

!  Immediate Threat To Life (ITL)

!  Loss of Accreditation and Participation in CMS

!  Significant Compromise of the Fire Alarm System

! Significant Compromise of the Sprinkler System

! Significant Compromise of the Emergency Power System

! Significant Compromise of the Medical Gas Master Panel

! Significant Compromise of Exits

! Other Situations of Extreme Danger

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Key Issues in TJC Compliance

!  Life Safety Drawings Must Show –  Sprinklered Areas In Partially Sprinklered Buildings

–  Hazardous Storage Areas

–  Rated Barriers

–  Smoke Barriers

–  Suite Walls and Sizes

–  Location and Designation of Smoke Compartments

–  Chutes and Shafts

–  Approved Equivalencies or Waivers

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Recent Changes and Key Issues

!  Categorical Waivers: CMS S&C 13-58-LSC,12-21-LSC & 14-46-LSC

!  Relative Humidity

!  Exit Enclosure Openings

!  Suites

!  Door Locking

!  96 Gallon Recycling Containers

!  Corridor Projections (Wheeled Equipment)

!  Corridor Fixed Seating

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!  Categorical Waivers (cont’d) !  Corridor Cooking

!  Fire Places

!  Combustible Decorations

!  Medical Gas Master Alarm

!  Reduced Generator Load Bank Test Time

!  Reduced Fire Pump Churn Test Frequency

!  Reduced Water Flow Alarm Test Frequency

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Categorical Waivers

!  If the organization decides to adopt any of the categorical waivers they must ! Ensure full compliance with the appropriate code reference

! Document the decision to adopt the categorical waiver

! Document Life Safety Code items in the Statement of Conditions

! Environment of Care items have to be documented in Safety Committee Minutes

! Tell the surveyor at the start of the survey

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!  CMS issues new Categorical Waiver for RPTs

!  S&C: 14-46-LSC

! CMS is permitting a categorical waiver to allow for the use of power strips in existing and new health care facility patient care areas, if the provider/supplier is in compliance with all applicable 2012 LSC power strip requirements and with all other 2000 LSC electrical system and equipment provisions

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!  S&C 12-07-Hospital Superseded

!  A hospital may adjust its maintenance, inspection, and testing frequency and activities for facility and medical equipment from what is recommended by the manufacturer, based on a risk-based assessment by qualified personnel, unless:

! Other Federal or state law; or hospital Conditions of Participation (CoPs) require adherence to manufacturer’s recommendations and/or set specific requirements, for example:

Ø All imaging/radiologic equipment must be maintained per manufacturer’s recommendations; or

Ø The equipment is a medical laser device; or

Ø New equipment without a sufficient amount of maintenance history has been acquired

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CMS S&C 14-07

The organization inspects, tests & maintains new medical equipment or operating components of

utility systems in accordance with manufacturers’ recommendations with insufficient maintenance

history to support the use of alternative maintenance strategies

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! Endoscopy Air Pressure Requirements ! No Requirements For Endoscopy If: “an organization has

made a documented decision based on risk assessment to no longer monitor Endoscopy Procedure Rooms per ASHRE Guidelines, 2013 edition

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! Open Electrical Boxes (arc flash and fire risk) !  EC.02.03.01

!  If surveyor finds two or more open boxes it will result in a direct impact finding (C category

findings)

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! EC.02.03.03 ! When quarterly fire drills are required, at least 50% are

unannounced. Fire drills are held at unexpected times and under varying conditions

! When drills are conducted between 9:00p.m. and 6:00 a.m., the hospital may use alternative methods to notify staff instead of activating audible alarms

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!  Effective December 15, 2014 Ambulatory Surgery Centers

!  Life Safety Code Survey to join Survey Team for One Day

!  Duties will be similar to Hospital survey:

!  Document Review

!  Building Tour and Assessment

!  Environment of Care System Tracer

!  Emergency Management System Tracer

!  Education, consultation, team support

!  Special issue resolution

!  Document findings

!  Interim exit

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!  Single observations at C category EPs will be included in a separate section of the accreditation report

!  The new section will be titled “Opportunities for Improvement”

!  OFIs will not require an Evidence of Standards Compliance

!  Organizations will not be able to use the clarification process on OFIs

!  Effective July 1, 2014 all open, accepted Plan For Improvements will be imported into the final survey report

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2000 – 2012 Life Safety Code

!  CMS Proposed Rule

- 482.41

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2000 – 2012 Life Safety Code

!  Changes Definition of Health Care Occupancy

!  Allows ABHR’s

!  OR Smoke Vents

!  36” Window Sill Height

!  Many Other Issues Currently Covered By Categorical Waivers

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2000 – 2012 Life Safety Code !  Multiple intervening rooms are allowed if the travel distance within the suite to the

exit access door does not exceed 100 ft.

!  A suite that requires 2 means of egress is permitted to have 1 means of egress into another suite

!  Tentative Interim Amendment (2006 LSC): Projections 6 in. from the corridor wall, above the handrail height, shall be permitted for hand-rub dispensing units, now written in code

!  In-use wheeled equipment and not in-use emergency equipment must be arranged to allow 5 ft. of clearance at all times. Equipment must be moved in an emergency

!  Fixed furniture is allowed to extend 24 in. into the corridor

!  Stairway signage required for >3 stories (>5 stories)

!  Cooking equipment in corridors 4/7/15 SMS Inc. 2015 43

Summary

§  Better Survey Preparation for EOC and LSC standards

§  Understanding of the Categorical Waiver Process

§  Understand the differences in Life Safety Code version 2000 & 2012

§  Hot topics of the survey process

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Contact Information

Robert H. Bartels, CHFM CHSP CHEP FASHE

President

Safety Management Services, Inc. 1502 N. Arlington Heights Road

Arlington Heights, IL 60004

847-577-6550

[email protected]

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Documents

CMS Impact on Recent Joint Commission Surveysc.ymcdn.com/sites/ Impact on Recent Joint Commission Surveys ... requirements and with all other 2000 LSC electrical ... staff instead