All Entries in the "Life Safety Code" Category

Gaining some Perspectives on The Doors of Perception

I’m going to guess that you all out in the audience do not necessarily place The Joint Commission’s Perspectives periodical on your list of must-reads, but for the May and June 2012 issues (and who knows beyond that), you really owe it to yourself to grab a copy and prepare for some hard-hitting door and barrier conversation with our esteemed colleague, one Mr. George Mills, Director of the Engineering Department at The Joint Commission.

At any rate, I think we can point to an increasing level of frustration on the part of the various and sundry regulatory agencies (and us, don’t forget us) relative to the number of findings in the life safety (LS) chapter and the omnipresence of these issues in the most frequently cited standards during surveys. How do we make this go away? The answer to that question, interestingly enough, is adopting a risk-based strategy for the ongoing inspection and maintenance of whatever building component is in play – this month its doors.

Now, those of you who’ve been hanging around the pea patch for one or two cycles will immediately recognize the concept as being almost eerily similar to the Building Maintenance Program of days gone by (OK, maybe not so gone by). That said, I think that I can safely say that if you can adopt the strategies contained in this month’s Perspectives (starting on page six), you will have the power (and data-driven power at that) to ensure that your organization will not have to endure another RFI for door issues on your final survey report (but remember that you may still have to use the post-survey clarification process to rid yourself of those pesky RFIs. Still, it is so worth it).

The article has recommendations, a lovely form to use, the philosophy and concept behind the whole thing – really, it’s the complete package. One word of caution: Stuff that appears in Perspectives is traditionally held to be equivalent to anything in the standards manuals and FAQs. For all intents and purposes it’s a requirement, so you’d better get to the adoption of this strategy or having a most compelling risk assessment to indicate that you are achieving an equivalent level of safety for your facility and its occupants. Failure to do so will make things very difficult when attempting post-survey clarifications.

As noted in the article (and this has been a frequent touchstone in my consulting practice), the stuff The Joint Commission is finding is mostly minor in nature: doors not latching, missing ratings labels, excessive gaps and undercuts, etc. These is not big ticket stuff by any stretch of the imagination. And, to my way of thinking—odd though it may be at times—there is no reason we should have to be burdened with having to clean up all these little survey messes (not that I’m advocating big messes as an alternative – no no no). I think we’ve been provided a very implementable strategy for keeping things on the side of compliance, which is never a bad thing.

What do you folks think?

Update: Link correction for CMS memorandum on LSC

I have been alerted that the link below did not work. I have corrected that link, but I’ll provide it here too:

Click here to directly access the CMS memorandum the changes regarding the Life Safety Code®.

(Ref: S&C-12-21-LSC)

There’s a light, a certain kind of light – and it’s not an oncoming train!

This one has the potential to be the game-changer we’ve been hoping (waiting) for – the emergence of the 2012 edition of the Life Safety Code® as a CMS-sanctioned regulatory standard.

Once you lay your hands on this plucky little document -  the official CMS memorandum – you will see that it appears) to represent a fair degree of flexibility when it comes to, among other things, corridor storage, and the amount of combustible decorations that are allowed. One thing this likely means is that everyone’s going to be inundating NFPA for their own personal copy of the 2012 Life Safety Code® – this is going to become a go-to resource from here on out.

Now, the first thing you will notice is that there’s a lot of mention of nursing homes, and not so much of hospitals, particularly on Page 1. To that end, let me direct you toward the bottom of page 2 of the document (under the section titled “Effective Date”), which specifically indicates that the memorandum and all its components are “in effect for all applicable healthcare facilities such as Hospitals and Nursing Homes.”

The other caveat, at least for the moment, is that it appears that the changes are only “accessible” through the CMS waiver request process, which will, in turn, result in a process in which “each waiver request will have to be evaluated separately in the interest of fire safety and to ensure that the facility has followed all LSC requirements and the equipment has been installed properly by the facility.” I’m not entirely certain whether this would drive anything more than a review of the waiver request, but I’m not entirely certain how they’d be able to ensure compliance with LSC requirements, etc., without eyeballing a facility. That said, there’s a whole heck of a lot of hospitals that would be pursuing this, so maybe there’s a process in place, maybe based on past TJC/DNV/HFAP and/or CMS survey results.

So, what it looks like we have here is some room for stuff in the corridors, including fixed furniture; and the presence of combustible decorations on “walls, doors and ceilings.”

That’s enough yapping from me for the moment; I encourage you to check out the document and let us know what you think. I think it’s very interesting.

And your bird can sing…

One of the topics that resurfaces every once in a little while concerns those most critical documents– your life safety drawings – and what should be contained therein. If you are still uncertain about what those suckers oughta look like, I would direct your attentions to the February 2012 edition of The Joint Commission’s EC News in the “Asked and Answered” section. The laundry list of items to be included on your life safety drawings is not particularly surprising by those among us who have been advocating for a certain contingent of information. So, if you were going to air out your “dirty” life safety drawings, some items for consideration might include:

• a legend that clearly identifies fire safety features of your building
• identification of those areas of the building that are fully sprinkled (if your building it partially sprinkled – no need for such detail if you’re fully sprinkled)
• the location of all of your hazardous storage areas (if you’re not sure what that entails, check out EP #2 under LS.02.01.30 and/or NFPA 101-2000: 18/19.3.2.1);
• the locations of all your rated barriers (yes, all of them – don’t leave any out)
• locations of all your smoke barriers
• the boundaries of any areas that have been designated as suites – and don’t forget to include the square footage of the suites – both sleeping (maximum 5,000 square feet) and non-sleeping (maximum 10,000 square feet)
• locations of your smoke compartments
• the locations of any chutes and/or shafts (as opposed to chutes and ladders – that’s kids’ stuff)
• any approved waivers or equivalencies.

A quick word about waivers and equivalencies: It’s always nice to share those ahead of time with your various “Authorities Having Jurisdiction.” A proactive approach to communications, as with most proactive approaches, will yield much goodwill. This whole thing works best as a collaborative process. No surprise on either side and you’ve got yourself a pretty good survey experience.

Breaker, breaker…

Recently I received a question from a colleague regarding a survey finding an RFI under EC.02.05.01, performance element numero 7, which requires hospitals to map the distribution of its utility systems. The nature of the finding was that there was an electrical panel in which the panel schedule did not accurately reflect the status of the breakers contained therein.

My guess is that there was a breaker labeled as a “spare” that was in the “on” position, which is a pretty common finding if one should choose to look for such a condition. At any rate, the finding went on to outline that staff were unaware of the last time the mapping of the electrical distribution was verified. The question thus became: How often do we need to be verifying panel schedules, since the standard doesn’t specify and there is no supporting FAQ, etc., to provide guidance.

Now, first, I don’t know that this would be the most appropriate place to cite this condition; my preference would be for EP #8, which requires the labeling of utility systems controls to facilitate partial or complete emergency shutdowns, but I digress. Strictly speaking, any time any work is done in an electrical panel, the panel schedule should be verified for accuracy, which means that any breaker that is in the “on” position should be identified as such on the panel schedule. This is not specifically a Joint Commission requirement, but I think that we can agree that the concept, once one settles the matter as a function of logic and appropriate risk management behavior, “lives” in NFPA 70 the National Electrical Code®.

As I noted above, unfortunately, this is a very easy survey finding if the surveyor looks at enough panels; it is virtually impossible to not have at least one breaker in the “on” position that is identified on the panel schedule as a spare or not identified at all. That said, if you get cited for this, you are probably going to have to wrestle with this at some point and your facilities folks are going to have to come up with a process for managing this risk, as it’s really not safe to have inaccurately labeled electrical panels.

As to a desired frequency, without having any sense of how many panels are involved, which would be a key indicator for how often the folks would be able to reasonably assure compliance (a concept not very far away from the building maintenance program [BMP] concept), it’s tough to predict what would be sufficient. That said, the key compliance element remains who has access to the electrical panels. From my experience, the problem with the labeling of the breakers comes about when someone pops a breaker and tries to reset it without reaching out to the facilities folks. Someone just goes flipping things back and forth until the outlet is working again (floor buffing machine operators are frequent offenders in this regard).

From a practical standpoint, I think the thing to do in the immediate (if it’s not already occurred) is to condcut a survey of all the panels to establish a baseline and go from there, paying particular attention to the breakers that are not properly labeled in the initial survey. Those are the breakers I’d try to secure a little better, just to make sure that they are not accessible by folks who shouldn’t be monkeying around with them. Another unfortunate aspect of this problem is that both EP 7 and EP 8 are “A” performance elements, so it’s a one-strike-and-you’re-out scenario. Certainly worth a look-see, perhaps during hazard surveillance rounds.

So many panels, so little time…

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Follow the leader

Another survey condition that has been surfacing of late—which you could say makes it a “sighted citation—” is the bundling of EC-LS-EM findings and generating a further finding under Leadership for not ensuring that the care environment was appropriately managed. Generally, this seems to occur when there are “enough” EC-LS-EM findings to drive a condition-level status as a function of the CMS Conditions of Participation. Unfortunately, at least at the moment, it is not clear how much “enough” is required to drive the finding to this precarious level.

Not having personally participated in the applicable surveys, I can’t tell whether or not there may have been mitigating circumstances that resulted in the survey team feeling that the organization was not appropriately mustering resources to manage risk in the physical environment. That said, I can certainly tell you that one of the things that seems to thread its way through these findings is a gap in correcting deficiencies identified during maintenance and testing, including timely follow-up testing for failed systems, and timely follow-up in general. It is absolutely imperative that we have a process for managing identified deficiencies, including the identification of any interim measures (these ain’t just for life safety folks any longer, boys and girls) that would be implemented to compensate for the deficiencies. It is clear to me that there has been a shift toward the ongoing management of deficiencies through a formal process, at least in terms of survey expectations.

Although it is well understood that healthcare is not swimming in money, our overall charge is to ensure that the care environment is appropriately managed at every moment of every day; people’s lives are potentially at risk here, and we have got to be absolutely certain that we are doing everything in our power to protect them.

Mac’s Brief on the September TJC Executive Briefings, Part 2

As promised, I continue going the standards The Joint Commission (TJC) unveiled as the top 10 most frequently cited standards for the first six months of survey year 2011 at the annual Executive Briefings meeting. Five (count ‘em) of those standards were in the environment of care (EC)/life safety (LS) world. Here are the last three:

TJC cited 47% of hospitals for LS.02.01.30 (whew, finally under 50%). This is where things went slightly awry for yours truly as it was apparently indicated that the findings (generally under EP #2, which refers to the fire protection features of hazardous areas) have to do with signage. At EB, an example was given of proper labeling of a vent stack from sterile processing that might have hazardous materials (isn’t that why we have EC.02.02.01?) Also mentioned was the concept of the risk assessment (did you really think that was ever going to go away?) to determine what soiled utility rooms should be locked or otherwise secured. Again, my thought was that this was covered under EC.02.02.01 or maybe EC.02.01.01, but in the Life Safety chapter? I didn’t see that one coming!

When it comes to standard EC.02.03.05 (of which 42% of hospitals were cited), I think the safety community has to come together and convince our maintenance and testing vendors that we are sick and tired of having our heads handed to us because they “buried” some deficiency on page 17 of a report only to have the surveyor find the stinking thing and say, “So, what about this?” We need to have a list of deficiencies identified during any maintenance and testing activity provided to us, before the vendors leave the building. We can no longer afford to wait a month or six weeks to get the report of findings; the clock starts ticking the moment these concerns are identified and we need to be jumping on them quickly and assertively, which may entail including the implementation of some sort of interim measure to ensure that we are not placing folks at risk. I absolutely understand that doing so is, in many ways, nothing but a pain in the tuchus; but until such time, as we are proactively managing this stuff, this is going to continue to be among the most frequently cited standards. I say we end it here—who’s with me? FREEDOM! Sorry, got a bit carried away there. Must be ‘cause I’m wearing my (metaphorical) kilt . . .

Finally, LS.02.01.35 (of which 36% of hospitals cited): This standard relates to all things sprinklers—the 18- inch rule, stuff hanging on sprinkler piping, cabling tied to sprinkler supports, all that stuff. Again, this is very much a numbers game. What’s the likelihood that somewhere, above some ceiling, the cable monkeys have run some conduit or other detritus over a sprinkler line or tied it to a support? Very bloody likely, I’d say, very bloody likely.

Getting back to this infection control thingy (as promised in my last post), it was announced that the life safety surveyors are receiving education relative to basic IC issues, including scope cleaning and the separation of clean and dirty scopes. The announcement brought up a thought—for those of you with not-so-generously-proportioned scope cleaning areas, particularly when the soiled and clean processes are separated only by distance and not by a physical barrier, you might want to consider a risk assessment to determine whether your processes are pristine. I know you are doing the best you can, but sometimes you have to take those types of decisions out, dust ‘em off, and look at them again to make sure they are still viable. It may be your only defense during a survey, and I say you can’t have too many of them, only not enough.

For those of you not so executively inclined: Mac’s Brief on the September TJC Executive Briefings

To the surprise of almost no one (as far as I can tell), when The Joint Commission (TJC) unveiled the top 10 most frequently cited standards for the first six months of survey year 2011 at the annual Executive Briefings meeting, five (count ‘em) of those standards were in the environment of care (EC)/life safety (LS) world. Each standard relates directly to the increasing coverage of the life safety surveyors. It also appears that their scope is going to be expanding into the realm of infection control (IC), but more on that in the next blog post (stay tuned).

While the EC/LS world had to settle for second place on the list with LS.02.01.20 (taking third: LS.02.01.10, fourth: LS.02.01.30, fifth: EC.02.03.05, and eighth: LS.02.01.35), it is clear there is a great deal of work yet to be done by hospitals to gain a little control over this deluge of deficiencies.

A whopping 57% of hospitals surveyed between January and June were cited on LS.02.01.20, which has everything to do with maintaining the integrity of egress. Hospitals were caught for a number of deficiencies: doors locked in a means of egress, projections, corridor clutter, and configuration/designation of suites.

My colleague Brad Keyes and I have spoken (some would say approaching ranting) about the importance of your life safety drawings and how they facilitate the survey process if they are accurately maintained. It appears the quality (or lack thereof) of life safety drawings are more frequently put to the test during survey, with not-so-glowing results. (I’m interpreting a 43% success rate as something less than A-level performance.) I suspect that a majority of the findings might still relate to corridor clutter (after all, how difficult is it to find two instances of unattended, unallowed stuff in the corridor, hmm?) Interestingly enough it was revealed that one cannot manage the corridor clutter LS deficiency through the plan for improvement (PFI) process, which is kind of stinky.

My opinion is that if you do your risk assessment for interim life safety measures (ILSM) to compensate for the LS deficiency represented by corridor clutter and actually resolve it in some way, then that is an appropriate use of the process. But, in this case—and so many others, it makes my head spin—my opinion matters not a whit. So egress woes top the list.

Moving on to LS.02.01.10, which also has a 57% rate of findings in hospitals for the first half of 2011. This one’s fairly straightforward: doors (not latching), doors (undercuts), doors (lacking closers), more doors (can anyone say door stops?), and then sealing around ductwork penetrating fire-rated barriers. Again, how difficult is it to find this stuff (and yes, I know that it is our job to make it difficult, but still…) Once again, accurate life safety drawings are the key; if your drawings say door is a fire door, then that’s how it will be surveyed, even if it’s a smoke door now since you’ve sprinkled your building–the drawings never lie!)

More top-cited standards will be discussed in the next blog post–stay tuned!

NFPA approves new versions of Life Safety Code®, NFPA 99

Boston’s buzzing today as hockey fans celebrate the Bruins winning their first Stanley Cup in 39 years, but that’s not the only action that took place here this week. Earlier in the week, the National Fire Protection Association (NFPA) held its 2011 Conference and Expo in Boston, which was followed by the NFPA Technical Meeting on Tuesday and Wednesday.

Of particular interest to healthcare facilities folks, at the Technical Meeting the association approved new versions of NFPA 101, Life Safety Code® (LSC), and NFPA 99, Standard for Health Care Facilities. The 2012 editions of each standard are expected to be published officially in the next few months.

Once the 2012 editions are published, CMS and The Joint Commission are expected to follow suit and adopt the 2012 editions. Currently, both require hospitals to comply with the 2000 edition of the LSC. The most recent edition of the LSC was published in 2009.

It could take up to 18 months before CMS adopts a newer edition of the LSC. Once that happens, The Joint Commission, Det Norske Veritas, and the Healthcare Facilities Accreditation Program will also adopt it, and then accredited hospitals must comply with the new requirements.

Visit the NFPA’s Conference blog for more information on the votes and see the upcoming issue of Healthcare Life Safety Compliance for details and analysis of these actions and what they’ll mean for your facility.