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Brother/Sister, can you spare a sprinkler head?

This week, I continue my ruminations on all things relating to outpatient care sites (Quick question: Is there anyone out there who doesn’t have responsibility for any outpatient care locations? I hope not, because this is probably getting a little tedious, though I guess in that hope it means that your existence has become more complicated over time, but if you don’t, you probably will). At any rate, this week’s tidbit revolves around the requirements for all (and I do mean “all”) properties having sprinkler heads to have a list of the sprinkler heads installed in the property, with the list being posted in the sprinkler cabinet. I think everyone is familiar with the requirements to have a stock of spare sprinklers, which would include all the types and ratings installed, with the number of spares guided by the following algorithm:

6.2.9.5 The stock of spare sprinklers shall include all types and ratings installed and shall be as follows (this also shows up in NFPA 25-2011 in Chapter 5) :

(1) For protected facilities having under 300 sprinklers – no fewer than 6 sprinklers

(2) For protected facilities having 300 to 1000 sprinklers – no fewer than 12 sprinklers

(3) For protected facilities having over 1000 sprinklers – no fewer than 24 sprinklers

By the way, the information contained in this week’s missive is sourced from the 2010 edition of NFPA 13 Standard for Installation of Sprinkler Systems, which came into play when CMS adopted the 2012 edition of the Life Safety Code® (LSC). As a cautionary note, now this information “lives” in NFPA 25 Standard for the Inspection, Testing & Maintenance of Water-Based Fire Protection Systems, so if you happen to have a state authority having jurisdiction that’s using a more recent edition of the LSC, then NFPA 25 is where you’ll find this stuff.

At any rate, back to that all-important list (and kudos to those of you who have your lists in place), bopping back to NFPA 13, we find the following:

6.2.9.7.1* The list shall include the following:

(1) Sprinkler identification number (SIN) if equipped; or the manufacturer, model, orifice, deflector type, thermal sensitivity, and pressure rating

(2) General description

(3) Quantity of each type to be contained in the cabinet

(4) Issue or revision date of the list

The Appendix provides a little more info:

A.6.2.9.7.1 The minimum information in the list contained in the spare sprinkler cabinet should be marked with the following:

(1) General description of the sprinkler, including upright, pendent, residential, ESFR, and so forth

(2) Quantity of sprinklers to be maintained in the spare sprinkler cabinet

Where the rubber meets the road, so to speak, is the requirement for an annual verification of all this stuff:

NFPA 25-2011: 5.2.1.4 The supply of sprinklers shall be inspected annually for the following:

(1) The correct number and type of sprinklers as required by 5.4.1.4 and 5.4.1.5

(2) A sprinkler wrench for each type of sprinkler as required by 5.4.1.5.6

5.4.1.5* A supply of at least six spare sprinklers shall be maintained on the premises so that any sprinklers that have operated or been damaged in any way can be promptly replaced.

A.5.4.1.5 – A minimum of two sprinklers of each type and temperature rating installed should be provided.

5.4.1.5.1 The sprinklers shall correspond to the types and temperature ratings of the sprinklers in the property.

5.4.1.5.2 The sprinklers shall be kept in a cabinet located where the temperatures will at no time exceed 100 degrees F.

5.4.1.4.2.1 Where dry sprinklers of different lengths are installed, spare dry sprinklers shall not be required, provided that a means of returning the system to service is furnished.

So that’s the partial skinny on sprinklers; the primary reason for plunking this down in front of you is because this showed up as a finding (mostly the list, but the other stuff is fair game) in a recent survey (not The Joint Commission, but these things tend to move through the various regulatory tribes).

I did want to leave you with a final thought for the week. I subscribe to a weekly email newsletter from James Clear (the following lives here); I find the newsletter interesting and much more often than not, useful, so I give you:

“What is the real goal?

  • The real goal is not to ‘beat the market.’ The goal is to build wealth.
  • The real goal is not to read more books. The goal is to understand what you read.
  • Don’t let a proxy become the target. Don’t optimize for the wrong outcome.”

Stay well and stay safe—that’s all I need you to do!

Probably not the final word on outpatient clinic settings

Sometimes I have a difficult time finding a unifying “thread” for the weekly chronicle and other times the way forward is fairly clear. This week may be more towards the former, but I think I can tie things together with a little bit of judicious “bridging.”

First we’ll start with what can only be described as “old news,” though the topic (CMS continues to make frowny faces towards the various accrediting organizations, coupled with the odd glare or two) is as old as the hills. At any rate, if one were an accreditation organization (AO), one might look at the ongoing skirmishes ’twixt the Federales and their deemed status minions as an existential threat (the exact degree of the threat is tough to figure out: Can CMS “fire” all the AOs and still be able to ride herd on healthcare? I’m not so sure). It can’t be pleasant to be berated on a regular basis, reminded of one’s failings, etc., so the natural tendency would be to try to get out from underneath. And the one sure way of making that happen is to work towards generating lots and lots (and lots!) of findings, and if you can tie those findings to various levels of criticality, then you can demonstrate your value to the process. Certainly, the various AOs have generated a lot of findings within the hospital settings over the last few years and (at least for our friends at TJC) there’s been some branching out into the “field.”

One of the trends I’ve noticed as this “shift” has been occurring is a fair number of findings relating to eyewash stations  in all sorts of areas and I think a recently updated (June 26, 2020) TJC FAQ for hospital and hospital clinic settings may be instructive as a function of setting the stage (or the table—you pick) for increased focus on those instances in which surveyors feel you need an eyewash station and perhaps you do not have a risk assessment prepared that would indicate otherwise. As we have discussed in the past (you can find pretty much all of those mentions here), eyewash stations (or the lack thereof, of the care and feeding of) tend to generate findings, but (as long as you do the math) you only have to have them under certain very specific circumstances—circumstances with which surveyors are sometimes only passingly familiar.

That said, one other trendy thing I’ve noticed is that glutaraldehyde is starting to creep back into the healthcare safety landscape, which poses its own fair share of complexities when it comes to managing risks (some useful thoughts on that subject on Tim Richards’ blog). And sometimes, just sometimes, when one is discussing the far reaches of an organization, the creeping of something like glutaraldehyde can be much less noticeable than if it were under the white hot lights of the main campus (or the mothership, if you prefer). Sooooo, particularly for those of you with lots of offsite locations (or even only a few), keep an eye out for those funky things that “show up” at generally less than useful times. You might find out it’s the difference between survey success and having to write plans of correction for weeks on end…

Hope you are all staying safe and staying positive. It’s looking like the first wave of COVID-19 is not quite done with us (and I don’t think we can have a second wave until the first one is done), but I know you folks are keeping a lid on things: Keep up the good work!

And it makes me wonder…sure does!

And it’s not just a bustle in your hedgerow, so alarm might be warranted…

Lately, I’ve been using this space to muse on the potential for changes to the survey process, particularly as a function of the inclusion of outpatient clinic settings and the impact of life safety surveyor attention to these facilities might have on survey results. If your immediate thought was “more findings in the physical environment,” I fear you are more correct than you might have wanted to be.

While I don’t have access to the official results just yet (the wheels of bureaucracy grind ever slowly), I was able to be front and center last week for a full federal Conditions of Participation survey. The most notable aspect of the survey (for me) was the attention paid to outpatient clinics being managed as business occupancies by the life safety portion of the survey process. There was a lot of focused document review for these offsite locations, with the expectation that the degree/level of exactitude in the documentation for your main campus is to be extended to the outpatient settings. Inventory lists of devices, making sure sensitivity testing is being done (with specific values—not just a pass/fail note for each); focused attention on how spare sprinkler heads are being managed—including ensuring that the correct wrench or wrenches are in place; quarterly fire drills (and yes, you read that correctly; it seems that the days of annual fire drills in business occupancies is drawing to a close), etc.

Those of you managing your outpatient settings through your own processes will have a leg up on the process, but if you rely on documentation provided by landlords, etc., you probably want to start kicking those tires and having the discussions now. The other piece of this is that the expectation is that any requested documentation would be readily (pretty darn close to immediately) available for review by the surveyor, so you may want to consider how you are managing that process. Do you have site-based binders or do you provide electronically? The surveyors definitely don’t want to hear that (for whatever reason) the documentation is not available.

As a final thought for this week, in light of this week’s coverage, you may want to give some thought as to how you might memorialize the ligature resistance risk assessment in the outpatient areas (don’t forget to make it thoughtful). As you can see from the link, the FAQ is aimed at the “hospital and hospital clinics” settings, so I think we can see where this could (and, let’s face it, probably will) go.

Until next time, I hope this finds you well and somehow managing the current currents—not sure what it will look like when we finally get past these rapids, but I hope that we all get through together!

We advance, masked!

In the topsy turvy world of Personal Protective Equipment (aka PPE), there are some developments on the decontamination/reprocessing of masks that I wanted to bring to your attention, if you’ve not already scoped them out.

First up, a little more information from our friends at the Occupational Safety & Health Administration, where we find that the guidance issues to surveyors is to be somewhat judicious in how they chase issues relating to PPE, but the basic expectations of employers look like this:

  • Make a good-faith effort to provide and ensure workers use the most appropriate respiratory protection available for the hazards against which workers need to be protected. Efforts should be consistent with flexibilities outlined in OSHA’s previous COVID-19 enforcement memoranda.
  • When respirators must be decontaminated to facilitate their reuse in ways consistent with OSHA’s previous COVID-19 enforcement memoranda and the U.S. Centers for Disease Control and Prevention (CDC) Strategies for Optimizing the Supply of N95 Respirators, ensure that decontamination is accomplished according to the methods described above and detailed in CDC’s Decontamination and Reuse of Filtering Facepiece Respirators using Contingency and Crisis Capacity Strategies.
  • Ensure users perform a user seal check each time they don a respirator. Employers should not permit use of a respirator on which the user cannot perform a successful user seal check. See 29 CFR § 1910.134, Appendix B-1, User Seal Check Procedures.[11]
  • Train employees to follow appropriate precautionary measures prior to using a decontaminated filtering facepiece respirator (FFR). See cdc.gov/coronavirus/2019-ncov/hcp/ppe-strategy/decontamination-reuse-respirators.html.
  • Train employees using decontaminated respirators to understand that if the structural and functional integrity of any part of the respirator is compromised, it should not be used by that individual as respiratory protection. The inability to achieve a successful user seal check could be an indicator that the integrity of the respirator is compromised.
  • Visually inspect, or ensure that workers visually inspect, the FFRs to determine if the structural and functional integrity of the respirator has been compromised. Over time or as a result of the decontamination process, components such as the straps, nose bridge, and nose foam material may degrade, which can affect the quality of the fit and seal.
  • Train employees on the procedures for the sequence of donning/doffing to prevent self-contamination. See cdc.gov/niosh/npptl/pdfs/PPE-Sequence-508.pdf.
  • If no manufacturer or third-party guidance or procedures are available to support the specific decontamination method(s) employed, avoid the use of decontaminated FFRs when healthcare personnel perform surgical procedures on patients infected with, or potentially infected with, SARS-CoV-2 or perform or are present for procedures expected to generate aerosols or procedures where respiratory secretions are likely to be poorly controlled (e.g., cardiopulmonary resuscitation, intubation, extubation, bronchoscopy, nebulizer therapy, sputum induction). If decontamination methods degrade FFR performance, including filtration and fit, or otherwise affect structural integrity, the decontaminated FFR may not provide the level of protection needed or expected during aerosol-generating procedures.

I suspect that, in general, folks are being sufficiently attentive to their PPE (perhaps more than has ever been the case) that they are checking for integrity (though they may not be as familiar with the User Seal Check Procedure—could be a teachable moment). And the missive covers some decontamination methodologies that may be of interest, particularly in light of the FDA’s altered stance on decontamination and reprocessing of masks.

I guess the questions become those related to available supplies of PPE. I get the sense that some folks are still relying to a fair degree on the use of masks that are not NIOSH-approved and so this latest development could potentially mean that, in the absence of being able to decontaminate and reprocess, the supply chain is going to have to be considerably more robust in either providing more non-NIOSH masks or more NIOSH masks that can be appropriately decontaminated, etc. I’d be curious to hear of any experiences (good or not so) that you’ve had in this regard. It seems likely that, even as we try to get to the “new normal,” we’re going to be dealing with this for a while, so we might as well share the good, the bad, and the ugly.

Speaking of which (sort of), as a closing thought for this week, now that I am hanging out in airports again, one thing that I’ve noticed is the phenomenon of the smile that doesn’t reach someone’s eyes. Pre-mask, I don’t know that I analyzed transient interactions with folks, but I find myself responding to folks based on their “eye language” and I’ve found that it can turn what would typically be a (more or less) neutral transaction into a positive or negative. I suspect that most customer service training involves reminding folks to smile, but now that our smiles have been temporarily removed from the occasion, the eyes are all we have for first impressions. Don’t know if that’s useful to you, but something to ponder.

Be well and stay safe ’til next time!

A little mo’ from the Mighty O (ccupational Safety & Health Administration)

As they are wont to do, the folks at OSHA periodically issue safety alerts and it would seem that the ongoing challenges of managing the ongoing occupational health and safety aspects of COVID-19 is ripe for alerting. You can find the complete list of alerts on OSHA’s COVID-19 homepage.

Interestingly enough, OSHA has not (as of this writing) issued an alert specific to hospitals, but they did recently issue an alert aimed at nursing homes and long-term care facilities, the elements of which are, at the very least, instructive for other folks in the healthcare demographic; you can find the alert in its entirety here. I just wanted to plant a seed relative to a few of these:

  • Maintain at least 6 feet between workers, residents, and visitors, to the extent possible, including while workers perform their duties and during breaks.
  • Stagger break periods to avoid crowding in breakrooms.
  • Always follow good infection prevention and control practices. Consult OSHA’s COVID-19 guidance for healthcare workers and employers.
  • Provide handwashing facilities and alcohol-based hand sanitizer with at least 60% alcohol throughout facilities.
  • Regularly clean and disinfect shared equipment and frequently touched surfaces in resident rooms, staff work stations, and common areas.
  • Use hospital-grade cleaning chemicals approved by the Environmental Protection Agency (EPA) from List N or EPA-approved, hospital grade cleaning chemicals that have label claims against the coronavirus.
  • Ensure workers have and use any personal protective equipment (PPE) they need to perform their jobs safely.
  • Continually monitor PPE stocks, burn rate, and supply chains. Develop a process for decontamination and reuse of PPE, such as face shields and goggles, as appropriate. Follow CDC recommendations for optimization of PPE supplies.
  • Train workers about how to protect themselves and residents during the pandemic.
  • Encourage workers to report any safety and health concerns.

I don’t know that there’s anything on the list that doesn’t make sense, but I do think it might be useful/beneficial to keep an eye on these (and the other elements) to ensure you and your folks are not at elevated risk for exposure. Admittedly, there is still a lot we don’t know about the epidemiological aspects of COVID-19 and it may result in additional levels of guidance and/or protection (remember those halcyon days when masks were not required—seems like only months ago—oh, wait, I guess it was…). I also think it’s important to hear folks out if they voice frustrations with process, etc. A fair amount of this stuff is learning as we go—and making the best decisions we can based on the available information—in full recognition that being a leader in healthcare can mean having to put up with some unpleasant feedback. I think some folks in the field remain super concerned and super attentive to the decisions others are making on their behalf, so it’s important to keep things on an even keel.

Until next time, continue to stay safe—and keep rocking it!

They’re baaaack: TJC returns to the fray!

Last week, our friends in Chicago announced that they will be resuming the survey grind in June (in all candor, I too will be heading out on the highways and byways of the consulting world, though I can’t help but think how “neatly” June sets up, June 1 being a Monday and all—I know nature likes symmetry, etc., but this seems almost too convenient. But I digress).

While it is not yet completely clear how things will be different, it does sound like there will be a fair amount of analysis and communications with facilities being surveyed to ensure that the survey process goes as smoothly as possible from an operational perspective. To that end, if you happen to be at a facility “in the queue” for survey, the account executive coordinating the process will be reaching out to your organization to determine the impact the pandemic has had on your operations and what things look like in their “current state.”

It is also clear that social distancing will be in full force for the next little while (again, I’ll have a chance to weigh on some of those particulars as I recommence client visits), including limiting the number of individuals “present” in group sessions (audio and/or video conferencing will take on much wider application—I know some of your EOC/EM committees have a lot of moving parts); minimizing participants in tracer activities; appropriate use of PPE (as provided for each organization’s requirements—TJC expects you to provide whatever is appropriate); driving in separate cars for off-site location and/or home visits, etc.

The announcement also indicated that the focus of the process will be a thorough assessment, but not a retroactive review of compliance (I am curious as to how that will manifest itself, particularly in terms of inspection, testing and maintenance activities, and other elements of compliance in place prior to the onset of the pandemic). The announcement also indicates that implementation of your emergency operations plan will not be the focus of the survey so much as the development of an understanding of how your organization has adapted to the pandemic and look at current practices to evaluate the extent to which safe care, and a safe working environment are being provided.

 

Possibly making the impossible, possible…

As I look back over the years, particularly my time as a consultant, I continue to be fascinated by requests to safety/facility professionals to (channeling Jean-Luc Picard) “make it so,” even when the “so” they are requesting was not considered in the design of whatever system/process that is the target of the request. Just last week, I fielded a question from a facility manager who had been requested to make an OR procedure room negative for procedures on COVID patients. Unfortunately, it wasn’t a direct reach-out so I wasn’t able to dialogue with this individual, so I’m not sure of the particulars (availability of negative pressure procedure rooms in the facility, etc.), but it did get me to thinking about how many impossible things have been done over the last eight to 10 weeks in hospitals all over the country.

As of this writing, the first week in June is bringing about my first onsite client visit since mid-March and I am keen to see what’s been happening “in the field.” Fortunately, through the 1135 waiver process, there have been some instances in which we’ve been able to “bend” the regulatory statutes to some degree, but I think (hope?) we can all agree that there have been (and likely will continue to be) gray areas that are not (at least currently) covered by a waiver and may be so funky in the execution that you could never do more than ask forgiveness when this is all done (recognizing that directly targeted permission has not been abundant). My consultative advice is to keep track of some of the more ingenious (and you can read that as “a little crazy”) solutions to challenges you’ve experienced at your facility—the worst thing that could happen would be for all this stuff to get lost in the slipstream of “getting back to normal” and never get shared with the world at large.

I suspect you are all way too busy to be thinking about this now, but (as an amateur student of history) a response to an unprecedented event would make for an interesting and compelling story for future generations. I hope that we’re not bound for a repeat any time soon, but there are lessons (or, dare I say, teachable moments) for all of us. And with the slow decline of the oral storytelling medium, I want to make a case for capturing this…

Until next time, please stay well and safe—and keep rocking it!

The trouble with normal: Some things to consider as we ease back into recovery

I think we can all agree that there are a lot of stressors in motion as we navigate the unknowns of the pandemic; some of which one might not normally encounter and others are just an amped-up version of “business as usual.” As we near the end of May, it does seem like there is a little bit of movement towards a return to normalcy (recognizing that we’ve probably bid adieu to the “old” normal), which has prompted some consideration of the demands placed on our facilities’ systems and how best to position ourselves to safely engage the recovery phase of this historic emergency response.

Another point of agreement (hopefully) would be that elements relating to infection control are going to be scrutinized more than ever as the accrediting organizations get back to it. I suspect that at least part of that scrutiny will involve the overarching management of utility systems and their components. Fortunately, there is much to be learned from/shared by folks I consider to be excellent sources of information and insight.

As was the case before the onset of COVID-19, I think the management of building water systems is going to come into play and, particularly if you’ve had to reduce usage in some areas of your facility, bringing things back online represent some real challenges. Certainly, the focus on managing the risks associated with waterborne pathogens goes back more than just a few months, but the following should be enough for you to get ahead of the curve.

The first two articles, penned by Matt Freje from HCInfo, focus on some key planning/prevention considerations that, at the very least, should be a part of your planning risk assessment going forward. It’s all completely sensible and clear in direction, particularly as work towards appropriate management of environmental conditions for our most at-risk patient populations, and both articles are definitely work a look. They cover building water systems and Legionella concerns.

Finally, for this week, we have a webinar covering potential Legionella risks as we ramp our buildings up to normal speed, sponsored/presented by the good folks at the ScalingUp!H2O podcast. Lots of good information presented by Dr. Janet Stout of Special Pathogens Laboratory. There’s a slide presentation, hence its availability on YouTube, but (again) worth the 35 or so minutes of your time to check it out.

Please continue to stay safe and productive during the pandemic. Thank you for your hard work and dedication to keeping things on an even keel!

CMS provides yet a little more flexibility for the management of the physical environment

In the ever-unfolding saga of pandemic response, the folks at CMS have issued another couple of waivers relating to the physical environment. Of course, these continue to be published with rest of the granted waivers, so I’ve copied and pasted the new stuff here:

  • Alcohol-based Hand-Rub (ABHR) Dispensers: We are waiving the prescriptive requirements for the placement of alcohol based hand rub (ABHR) dispensers for use by staff and others due to the need for the increased use of ABHR in infection control. However, ABHRs contain ethyl alcohol, which is considered a flammable liquid, and there are restrictions on the storage and location of the containers. This includes restricting access by certain patient/resident population to prevent accidental ingestion. Due to the increased fire risk for bulk containers (over five gallons) those will still need to be stored in a protected hazardous materials area. Refer to: 2012 LSC, sections 18/19.3.2.6.  In addition, facilities should continue to protect ABHR dispensers against inappropriate use as required by 42 CFR §482.41(b)(7) for hospitals; §485.623(c)(5) for CAHs; §418.110(d)(4) for inpatient hospice; §483.470(j)(5)(ii) for ICF/IIDs and §483.90(a)(4) for SNF/NFs.
  •  Fire Drills: Due to the inadvisability of quarterly fire drills that move and mass staff together, we will instead permit a documented orientation training program related to the current fire plan, which considers current facility conditions. The training will instruct employees, including existing, new or temporary employees, on their current duties, life safety procedures and the fire protection devices in their assigned area. Refer to: 2012 LSC, sections 18/19.7.1.6.
  •  Temporary Construction: CMS is waiving requirements that would otherwise not permit temporary walls and barriers between patients.

I’m going to guess that some folks have already “taken advantage” of these items (with the possible exception of the fire drills, more on that in a moment). It would seem more than likely that some additional hand sanitizer dispensers have sprouted up all over your facility (hopefully you’ve been keeping reasonable track on these locations). Once this is over, you’ll probably need to either do an analysis of how much you’ve got floating around or remove them before you run afoul of allowable amounts. I also can’t imagine that temporary walls haven’t sprouted up (lots of sprouts this week!) in all sorts of spots. Those are probably a little simpler to track, but there is one instructive element to this allowance, that being the interpretive difference between TJC and CMS when it comes to temporary barriers: While TJC allows them to be smoke-tight, the feds are really looking for temporary barriers to be fire-rated, particularly for construction separations. Something about which to be mindful when things get back to “normal.”

As to the fire drill waiver, I absolutely understand the first part of the statement—inadvisable is as good a descriptor for trying to conduct fire drills at the moment, particularly as a function of moving and massing staff together. But I’m not exactly sure what they mean by the latter portion, but I think we can parse this for a bit. Especially if the physical space has been altered in efforts to provide “new” pressure relationships for some units, then, in all likelihood, there are elements of egress that have been impacted and, in some instances, that impact is to a degree that probably requires modification of existing unit-based fire response plans. I think it’s good to be able to alert folks to the “reality” that if the alarm goes off “this is not a drill,” but how do we make sure that folks can take full advantage of the compartmentalization features of our facilities? And then, how do we “document” that education? I don’t think it needs to be particularly complex (in fact, I suspect the less complex, the better) and could perhaps be communicated through whatever lines of communication are in place with your incident command structure. If anyone has any thoughts they’d be inclined to share, that would be delightful.

And for you folks who might be interested in what’s happening in the fulcrum of state and federal response, you can find your state’s waiver requests, etc., here.

I won’t say it’s good reading, but one can never have too much insight into the process during times of chaos.

Stay well and take care!

In the grand scheme of things, this helps—but how much?

A few weeks back we chatted about efforts to engage the 1135 Waiver process as a function of fire and life safety systems inspection, testing & maintenance, particularly as a function of ASHE’s efforts to facilitate a coordinated response. Apparently, this part of the waiver picture was not a priority for the folks at regional CMS, so there were a number of rejection notices sent to folks.

I’m not exactly sure what may have transpired (other than the passing of time, but if there were folks with access to CMS ears that continued to advocate, a debt of gratitude is owed), but some items related to certain inspection, testing & maintenance activities have finally made it to the slate of blanket waivers. You can find the information here, on page 23 of the linked document. Unfortunately, it appears that the blanket waiver announcement is being released in cumulative form, so you have to dig a little bit to find the applicable passage. Because of that, I’ve copied and pasted the information below.

As near as I can tell, the areas of greatest concern for the moment are those activities for which waivers were not granted:

  • Sprinkler system monthly electric motor-driven and weekly diesel engine-driven fire pump testing.
  • Portable fire extinguisher monthly inspection.
  • Elevators with firefighters’ emergency operations monthly testing.
  • Emergency generator 30 continuous minute monthly testing and associated transfer switch monthly testing.
  • Means of egress daily inspection in areas that have undergone construction, repair, alterations, or additions to ensure its ability to be used instantly in case of emergency.

In looking at the list, I think that it is both reasonable and very practical from a safety perspective. Clearly, as busy as it is, there are critical processes/protections that need to be assured, so hopefully you haven’t missed any of those noted activities and, if you have, you probably need to start working on preparing your organizational leaders for some likely survey findings.

As a closing thought, lately while walking I’ve been checking out some new (to me) podcasts, one humor-based (Conan O’Brien Needs A Friend—generally pretty good—a couple of good “laughs out loud” per episode) and one not so much so, which is my shareable moment for you. Lately, the Freakonomics Radio podcast has been covering subjects relating to the pandemic, with the episode I listened to today being “How Do You Reopen A Country?” One of my favorite aspects of this program is their tendency to come at topics in a calm, measured fashion, but generally from a somewhat unusual angle, but I don’t want to spoil it for you be jabbering too much. If you’re interested in something thoughtful, but not crazily scary, you might enjoy the episode.

Hope this finds you safe and well – until next time…

CMS Blanket Waiver Information

Inspection, Testing & Maintenance (ITM) under the Physical Environment Conditions of Participation: CMS is waiving certain physical environment requirements for Hospitals, CAHs, inpatient hospice, ICF/IIDs, and SNFs/NFs to reduce disruption of patient care and potential exposure/transmission of COVID-19. The physical environment regulations require that facilities and equipment be maintained to ensure an acceptable level of safety and quality.

CMS will permit facilities to adjust scheduled inspection, testing and maintenance (ITM) frequencies and activities for facility and medical equipment.

  • Specific Physical Environment Waiver Information:

o 42 CFR §482.41(d) for hospitals, §485.623(b) for CAH, §418.110(c)(2)(iv) for inpatient hospice, §483.470(j) for ICF/IID; and §483.90 for SNFs/NFs all require these facilities and their equipment to be maintained to ensure an acceptable level of safety and quality. CMS is temporarily modifying these requirements to the extent necessary to permit these facilities to adjust scheduled inspection, testing and maintenance (ITM) frequencies and activities for facility and medical equipment.

o 42 CFR §482.41(b)(1)(i) and (c) for hospitals, §485.623(c)(1)(i) and (d) for CAHs, §482.41(d)(1)(i) and (e) for inpatient hospices, §483.470(j)(1)(i) and (5)(v) for ICF/IIDs, and §483.90(a)(1)(i) and (b) for SNFs/NFs require these facilities to be in compliance with the Life Safety Code (LSC) and Health Care Facilities Code (HCFC). CMS is temporarily modifying these provisions to the extent necessary to permit these facilities to adjust scheduled ITM frequencies and activities required by the LSC and HCFC. The following LSC and HCFC ITM are considered critical are not included in this waiver:

  • Sprinkler system monthly electric motor-driven and weekly diesel engine-driven fire pump testing.
  • Portable fire extinguisher monthly inspection.
  • Elevators with firefighters’ emergency operations monthly testing.
  • Emergency generator 30 continuous minute monthly testing and associated transfer switch monthly testing.
  • Means of egress daily inspection in areas that have undergone construction, repair, alterations or additions to ensure its ability to be used instantly in case of emergency.

o 42 CFR §482.41(b)(9) for hospitals, §485.623(c)(7) for CAHs, §418.110(d)(6) for inpatient hospices, §483.470(e)(1)(i) for ICF/IIDs, and §483.90(a)(7) for SNFs/NFs require these facilities to have an outside window or outside door in every sleeping room. CMS will permit a waiver of these outside window and outside door requirements to permit these providers to utilize facility and non-facility space that is not normally used for patient care to be utilized for temporary patient care or quarantine.