Regulatory’s Life - c.ymcdn.com · •If “yes,” does the ILSM evaluation require the ... Appendix A – Interim Life Safety Applicability Form If one or more of the ILSM triggers

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1 Proprietary & Confidential Creating a Sustainable Future for Healthcare Organizations

Quality: Exploring Regulatory’s Life Safety Chapter

Carol Tuminaro, MBA, BSN, RN, HRM Senior Manager

Quality, Safety, and Performance Improvement

2 Proprietary & Confidential

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Evaluate this Session!

• Please help us improve our educational sessions by completing an evaluation of this program. You will have two opportunities to complete an evaluation and receive a completion certificate: At immediate conclusion of webinar

Post event: within two business days of the webinar, you will receive an email containing links to the online evaluation and a recording of this webinar

• Upon completing the online evaluation, you will receive an email with a link to access your completion certificate.

• If you have questions or need assistance, please contact [email protected].


Today’s Presenter

Carol Tuminaro, MBA, BSN, RN, HRM Senior Manager, Quality, Safety, and Performance Improvement

With over 15 years of healthcare consulting, Carol’s clients value her in-depth knowledge of risk management, quality/process improvement, core measures, survey processes, regulatory requirements and accreditation standards. Carol identifies critical issues to help hospitals achieve compliance with state and Joint Commission accreditation standards, as well as CMS Medicare Conditions of Participation regulations. Carol provides health care organizations with practical suggestions and tools to help clients achieve compliance, maintain readiness for unannounced regulatory and accreditation surveys and respond to any identified deficiencies.

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Greetings and Introductions


Objectives

Participants will be able to:

Describe the survey process for accreditation compliance to the Life Safety standards, utilized by hospital accrediting agencies

Review the core chapters of the NFPA Life Safety Code, with which hospitals must comply

Discuss how the Life Safety Codes vary for Hospital Occupancy versus Business Occupancy

Analyze the "Deemed" status requirements for managing and sustaining compliance with Life Safety

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Topics in the Life Safety Codes

•General life safety design and building construction

•Means of egress, to include space design, travel distances, egress illumination, and signage

•Protection provided by: • Door features

• Fire windows

• Stairs and other vertical openings

• Corridors • Smoke barriers

• Interior finishes


Topics in the Life Safety Codes

• Fire alarm notification: audible and coded

• Suppression of fires, including sprinkler systems

• Building services, including elevators and chutes

• Decorations, furnishings, and portable heaters

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CMS Adopted the National Fire Protection Agency Codes for Critical and Acute Care Hospitals

• Adopted the NFPA codes and incorporated them into their Conditions of Participation for Hospitals as K-Tags

• All Hospitals under CMS State Regulations must follow K-Tags

• All “Deemed Status” Agents must comply

• Based on Regulations 101-2000 Other Codes Apply

Center for Medicare and Medicaid Services (CMS)

National Fire Protection Agency (NFPA) Codes for Life Safety


When Does the Hospital Utilize NFPA Life Safety Codes? The hospital manages

its environments during the provision

of daily care and service

Demolition

Deconstruction Renovation

New construction Planning new, altered,

or renovated space

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• Administration and management of the NFPA Life Safety Codes

• Management of identified and known deficiencies

• Systematic approach in providing a facility review and departmental assessments

• Hospital and business occupancy areas to include clinics, off-site areas

• Hospital-wide QA/PI Plan includes Indicators, inspection and testing for all areas

• QA/PI Committee Minutes for past 12 months reflect assessment and any defects, deficiencies and needs

Stakeholders within the Organization Must Support Life Safety Initiatives


• R Rescue (if patients, staff or visitors in the immediate area, remove to safety)

• A Alarm (to include location of fire)

• C Contain (closing of doors and windows)

• E Extinguish / Evacuate

• P - Pull the pin

• A - Aim low

• S - Squeeze the lever

• S - Sweep from side to side

• Staff must have Life Safety training (review of fire plan) at orientation and annually

Staff Training

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Staff Awareness

Location of alarms Location of extinguishers

Knowledge of types of extinguishers

Knowledge of chemicals, cleaning supplies, and other flammable supplies


Life Safety Deficiencies

Exit Access In: Minimum Clear Width

New hospitals and nursing homes 8 feet

New limited care facilities and psychiatric hospitals 6 feet

Patient areas in existing facilities 4 feet

Non-patient areas (new and existing) 3 feet 8 inches

Note: Six (6) inch projections above 40 inches from the floor are allowed per newer editions of NFPA 101

Minimum Corridor Aisle and Ramp Width

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Hospital vs Business Occupancy

Fire safety is similar in either type of occupancy

Differences are primarily in the:

Design, construction, and compartmentation

• Not less than a 2-hour fire resistance rating

• Corridors must have self-closing fire doors

• Must limit the spread of fire emergency to the room of fire origin

Provision for detection, alarm

and extinguishment

Fire prevention, planning, training,

and drilling programs for the isolation of fire,

transfer of occupants to areas

of refuge, or evacuation of the

building

NO space heaters in hospital occupancy


• The organization is responsible for protecting occupants during periods when the Life Safety Code can not be met or during periods of construction

Interim Life Safety Code

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• ILSM Plan / Fire Plan

• ILSM Risk Assessment

• Occupancy Determination Hospital

Business

Free-standing

Residential

Interim Life Safety Measures Must Be Developed and Implemented to Guide Compliance

Policy and Procedure Development

• Initiation of Processes

• Fire Drill Requirement

• Fire Watch Requirement

• Construction/Project Forms and Tools

• Termination of Processes and by Whom


• Emergency exits are obstructed, blocked, or non-working

• Fire alarm and related systems are inoperable or impaired for any reason

• When, for any reason, normal patient or public traffic must be rerouted

• Construction, renovations, modifications in, over, or adjacent to a patient care area or within the hospital

When Are Interim Life Safety Measures Applicable?

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• Is an ILSM evaluation required?

• If “yes,” does the ILSM evaluation require the implementation of ILSMs?

• If “yes,” what ILSMs apply?

Performing an Interim Life Safety Measure (ILSM) Evaluation Determines what ILSMs Are Necessary


• Provide increased inspections of the affected areas

• Provide temporary but equivalent fire alarm and detection systems for use when a system is interrupted or impaired

• Provide additional fire-fighting equipment

• Provide additional support for a fire watch

• Provide additional temporary construction barriers

Implementation of Interim Life Safety Measures

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Interim Life Safety Measures Interim Life Safety Measures (ILSM)

Fire Drill Log


Fire Watch “Decision Grid” Appendix C – Fire Watch Decision Grid

________________________________________ __________________________ _______________ Signed Title Date

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Interim Life Safety Measures

Description of Project or Deficiency: ___________________________________

_________________________________________________________________

Location : _________________________________________________________________

Description of ILSM Trigger Applicable?

Hot work Y N

Blocked exit Y N

Alternate egress Y N

Excessive combustible materials Y N

Removal of part or all of the fire detection system Y N

Removal of part of all of the extinguishing system Y N

Significant breach of smoke or fire wall Y N

Significant breach of smoke or fire door Y N

Appendix A – Interim Life Safety Applicability Form

If one or more of the ILSM triggers listed above are marked “Yes”, then interim life safety measures apply and must be evaluated using Appendix B, Interim Life Safety Measures _____ ILSM measures do not apply _____ ILSM measures do apply __________________________ _______________ ___________ Signed Title Date


Since 1991, the NFPA Life Safety Codes require all newly constructed, renovated, or modified healthcare facilities or areas to be fully protected by an approved sprinkler system

Based on building design, the organization’s structure is intended to protect occupants without evacuating

• Patient rooms

• Fire doors

• Fire walls

• Smoke compartments

• Building components

• Egress exits and signage

The Defend-in-Place Concept Must Be Understood for Full Compliance

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• Compartments

Structural

• Detection

Operational

• Suppression

Equipment

The Defend-in-Place Concept Is Adopted When Evacuation Is Not Always Possible

• Fire Protection for Hospitals

DEFEND IN PLACE

• Evacuation is not always an option for patients being served in all areas of the hospital


A Hazardous Vulnerability Assessment Assists in the Identification of Life Safety Risk

A tool utilized for inspecting, collecting, and evaluating information on hazards associated with the

Environment of Care and Life Safety accreditation codes and standards

The purpose of the hazard analysis or assessment is to develop a list of hazards that

hazards that are of such significance they are reasonably likely to cause injury or illness to patients

and/or staff if not effectively controlled

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• The hospital maintains the integrity of the means for egress

• Corridor storage

Crash carts

Linen carts

Isolation carts

Chemo carts

Compliance Findings in the Clinical Environment


Joint Commission Corridor Interpretations

8’ Width Egress Corridor

Staff Office

Exit

Stair

Permitted Storage

Space (if <50

sq ft)

44”

Egress Corridor Storage

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Joint Commission Corridor Interpretations

8’ Width Egress Corridor

Staff Office

Exit

Stair

Permitted Storage

Space (if <50

sq ft)

Egress Corridor Storage



Building and fire protection features are designed and maintained to minimize the effects of fire, smoke, and heat

Life Safety facility architectural drawings match current departments and their provision of patient care and service

• Location of storage areas

• Location of hazardous storage areas

• Location of smoke and fire barriers in proximity to patient care and service areas

• Location of smoke compartments

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• Departmental fire plans

• Alarm systems

• Roles and responsibilities Pull stations

Fire extinguishers

Medical gas shut-off valves

Clutter control

18” rule

Secured medical cylinders

Pressure relationships in the clinical settings

Alcohol-based hand rubs


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Compartment Deficiencies


Rated Fire Wall Penetration Examples

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How Can Organizations Be Successful in Meeting the Life Safety Standards in the Clinical Settings?

Educate and train directors and department managers in the EOC and Life Safety Standards

Hold them accountable for working collaboratively with facilities staff in assessing their areas and reporting their findings in a timely manner

Most important is to develop a “tracking mechanism” for all your assessment and departmental survey processes


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Upcoming Programs

Quality Update Webinars • Team Facilitation

July 29, 2016 10:30 am Central Time • Emotional Intelligence

August 26, 2016 10:30 am Central Time • TOPIC: TBD

September 30, 2016 10:30 am Central Time

Classroom Programs • Advanced Quality Director Forum

October 25-27, 2016 (Brentwood, TN)

Register at www.qhrlearninginstitute.com


Quorum Learning Institute Recordings and Videos: Come Visit Our Library

http://videos.qhr.com/

http://www.qhrlearninginstitute.com/

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• Thank you for joining us today. We value your feedback and hope that you will take a few minutes to evaluate this program so that we may continue to improve and bring you the quality educational programming you expect.

• As a reminder, you will have two opportunities to complete an evaluation and receive a completion certificate:

At immediate conclusion of webinar

Post event: within two business days of the webinar, you will receive an email containing links to the online evaluation and a recording of this webinar

• Upon completing the online evaluation, you will receive an email with a link to access your completion certificate.

• If you have questions or need assistance, please contact [email protected].

Program Evaluation


6/17/2016

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47 Proprietary & Confidential Creating a Sustainable Future for Healthcare Organizations

For More Information

Contact:

[email protected]

(800) 233-1470, ext. 4513


Creating a Sustainable Future for Healthcare Organizations

Intended for internal guidance only, and not as recommendations for specific situations. Readers should consult a qualified attorney for specific legal guidance.

Documents

Regulatory’s Life - c.ymcdn.com · •If “yes,” does the ILSM evaluation require the ... Appendix A – Interim Life Safety Applicability Form If one or more of the ILSM triggers