STEVE FOX, CHFM

FACILITY MANAGER FOR THE PALOMAR HEALTH SYSTEM IN ESCONDIDO CA, ALONG WITH SERVING AS THE PRESIDENT OF THE SAND DIEGO CHAPTER OF CALIFORNIA SOCIETY FOR HEALTHCARE ENGINEERING (CSHE).

I HAVE BEEN FORTUNATE TO OVERSEE THE FACILITY OPERATIONS IN MULTIPLE HOSPITALS, SKILLED NURSING FACILITIES, CLINICS AND MEDICAL OFFICE BUILDINGS. HE HAS BEEN WITH PALOMAR HEALTH SINCE OCTOBER 2007 AND HAS PARTICIPATED IN NUMEROUS JOINT COMMISSION, CMS SURVEYS AND INSPECTIONS.   

Life Safety and You

You don’t want this to be your Hospital

Definition of Life Safety

Life Safety is comprised of: Codes Standards Regulations Documentation LIFE-SAFETY-Refers to the joint consideration of

both the life and physical well-being of individuals.

Life Safety Code

The publication Life Safety Code, known as NFPA 101, is a consensus standard widely adopted in the United States. It is administered, trademarked, copyrighted, and published by the National Fire Protection Association and, like many NFPA documents, is systematically revised on a three year cycle.

History

The Life Safety Code was originated in 1913 by the Committee on Safety to Life.

The Committee on Safety to Life was restructured in 1963 and the first publication in 1966 was a complete revision. The title was changed from Building Exits Code to Code for Safety to Life from Fire in Buildings and Structures. The final revision to all "code language" was made and it was decided that the Code would be revised and republished on a three-year schedule.

Foundation for any Facility

Life Safety Code and NFPA code are some of the most critical building blocks for the protection of your patients, visitors and staff.

You cannot compromise or take short cuts with anyone’s life.

Your time and dedication are critical to the success of having complete Life Safety documents and good surveys.

Life Safety Must have’s

Good set of Life Safety Drawings Understand what needs to be included and

what should be taken off Have an updated EBBI and e-SOC

Make sure the EBBI reflects your LS drawings Update the e-SOC on TJC website

Have good testing records Know what is expected by TJC and CMS

All Life Safety documents organized Be able to produce your records quickly

Understand your facility and the occupancies

Business Occupancy (BO) Lab, pharmacy, central sterile supply,

central storeroom, receiving, kitchen, cafeteria, administration, gift shop, etc.

Radiology, CT scan, etc. (usually) Clinics, dialysis (usually) Most areas where there’s no anesthesiaRequires 2-hour separation from HCO

Ambulatory Health Care Occupancy (AHCO)

Emergency Department Radiology/CT scan (rarely) Endoscopy (sometimes) Outpatient SurgeryRequires 2-hour separation from HCO, 1-

hour separation from BO

Health Care Occupancy (HCO)

Areas with patient sleeping accommodations for four or more patients

Areas intended to provide services simultaneously to four or more inpatients on gurneys (e.g., Inpatient ORs)

ILSM

Standard LS.01.02.01, EP 3: The hospital has a written interim life safety measure (ILSM) policy that covers situations when Life Safety Code deficiencies cannot be immediately corrected or during periods of construction. (Situational Decision Rules, Category “A”) Policy should list the 11 measures (EP 4-14) Make sure you have the current measures-

somewhat changed Policy should state that ILSM applies to all LSC

deficiencies, not just construction (specifically all e-PFI items)

ILSM cont.

Standard LS.01.02.01, EP 3: The policy includes criteria for evaluating when and to what extent the hospital follows special measures to compensate for increased life safety risk. (Category “A”) Criteria must be written Most common method is matrix showing

which measure are implemented for which deficiencies

TJC has published a matrix for this in EC News a number of times.

ILSM cont.

Failure to implement ILSM is one of two deficiencies in the Environment of Care that can lead to Contingent Accreditation under Accreditation Decision Rules.

LS EP standards to followLife Safety (LS) - Elements of Performance (EP)

Standard EC.02.03.05 The hospital maintains fire life safety

equipment and fire safety building features

EP standards to follow

EP-1 Supervisory Devices EP-2 Tamper Switches / Water-flow Devices EP-3 Duct/Heat/Smoke/Pulls EP-4 Visual/Audio Devices EP-5 Off Premises Transmission EP-6 Weekly Fire Pump Churn Test(changing)

EP-7 Water Tank Level Alarms EP-8 Water Tank Cool Weather Tests EP-9 Sprinkler Main Drain Test EP-10Fire Department Connections EP-11 Fire Pump Test (Full Flow) EP-12 Stand Pipe Test (5 year)

EP standards to follow cont.

EP-13 Kitchen Extinguishing System EP-14 CO2 / Other Gaseous Systems EP-15 Extinguisher Checks – Monthly EP-16 Portable Extinguishers – Annual EP-17 Occupant Hoses EP-18 Smoke/Fire Dampers EP-19 Air Handler Shutdown EP-20 Vertical / Horizontal Doors And there are many more………………..

Common LS violations

Challenge Inappropriate Findings

LSC Specialist Surveyors are often not LSC experts.

What LSC surveyor tells you on site is not final, and may not be correct.

Don’t hesitate to (respectfully) request clarification: “To make sure we get the correction right, can you show us where this is in LSC?”.

If you’re still not satisfied, challenge finding after completion of the survey.

Best Practices

Documented rounding Having zone responsibilities Having a game plan ready

Forms that work

Forms that work

Show maps for rounding Show how a specific documented route

can show surveyors what you do Any employee will follow the same

process

Floor Plan Rounding

Questions

Thank You